Group I

RN-Heals 2013
Tondo Medical Center

Mark Wilson Pascual Bernadette Ramilo

Mark Peralta Rani Marie Jane Reodica
Marilie Sheena Pereda Aguemarie Reolada
Quincy Mae Pingkian Dorcelyn Reyes
Sheryl Po Sheryl Ricafort
Suselle Poblete Hyacinth Lucero
Joann Rabano Michael Khevin Marasigan
 Table of Content
I. Introduction

A. Background of the Study

B. Rationale for Choosing the Case

C. Significance of the Study

D. Scope and Limitation of the Study

II. Clinical Summary

A. General Data
B. Chief Complaint:
C. History of Present Illness:
D. Past Medical History
E. Familial History
F. Physical Assessment
G. Patterns of Functioning (GORDON’S)
H. Activities of Daily Living
I. Patients Concept about Health, Illness and Hospitalization
J. Laboratory and Diagnostic Examination
K. Impression/Diagnosis
L. Ecologic Model

III. CLINICAL DISCUSSION OF THE DISEASE

A. Anatomy and Physiology
B. Drug Study

IV. NURSING PROCESS

A. Long Term Objective

B. Problem List
C. Nursing Care Plan
 D. Discharge Planning

Case Presentation on Pulmonary Tuberculosis

I INTRODUCTION

A. Background of the Study

Pulmonary tuberculosis, a chronic sub-acute or acute respiratory disease commonly affecting the lungs characterized by the formation
of tubercles in the tissues which tend to undergo cessation, necrosis and calcification. It is also known as poor man’s disease or consumption disease.
The causative agent in this disease is Mycobacterium Tuberculosis, a rod shaped bacteria. The disease is transmitted by deliberate inoculation of
microorganisms by droplet. This disease is transmitted to other people through the inhalation of organisms directly into the lungs from contaminated air.
The Philippines is one of the highest tuberculosis (TB) burden countries in the world with nationwide coverage of directly observed treatment,
short-course (DOTS) achieved in 2003. This study reports on the National TB Control Programme (NTP) surveillance data for the period 2003 to 2011.
During this period, the number of TB symptomatics examined increased by 82% with 94% completing the required three diagnostic sputum microscopy
examinations. Of the 1 379 390 cases diagnosed and given TB treatment, 98.9% were pulmonary TB cases. Of these, 54.9% were new smear-positive
cases, 39.3% new smear-negative cases and 4.7% were cases previously treated. From 2008 to 2011, 50 030 TB cases were reported by non-NTP
providers. Annual treatment success rates were over 85% with an average of 90%; the annual cure rates had an eight-year average of 82.1%. These
surveillance data represent NTP priorities – the large proportion of smear-positive cases reflected the country’s priority to treat highly infectious cases to
cut the chain of transmission. The performance trend suggests that the Philippines is likely to achieve Millennium Development Goals and Stop TB
targets before 2015.
Tuberculosis (TB) is the sixth leading cause of morbidity and mortality in the Philippines; the country is ninth out of the 22 highest TB-burden
countries in the world and has one of the highest burdens of multidrug-resistant TB. Directly observed treatment, short-course (DOTS)4 strategy for TB
control commenced in 1997 and nationwide coverage was achieved in 2003.5 The prevalence of TB in 2007 was 2.0 per 1000 for smear-positive TB
and 4.7 per 1000 for culture-positive TB. Compared with 1997, there was a 28% and 38% decline in prevalence for smear-positive and culture-positive
TB, respectively. ( world health organization)
This disease is can be acquired easily by person being in contact with an infected one, when you are living in a crowded area like the squatter’s
area and when you have poor nutrition. It is commonly present in third world or developing countries like the Philippines.

B. Rationale for Choosing the Case

The researchers decided to choose this case because they wanted to acquire more knowledge about Pulmonary Tuberculosis. They wanted to
use the knowledge that they have acquired in promoting awareness to the people especially to the poor that they should seek for medical care in order to
prevent the development and progression of PTB. The researchers also wanted to focus on preventive measures. PTB can cause Tuberculosis meningitis,
a very rare and fatal disease and the researchers would not want that to happen, so they will focus more on information campaign as part of primary
prevention of health. Presently our country has so many cases of PTB.

C. Significance of the Study

 This study will help the nursing profession by providing information about the proper management and care for PTB patient. It will also
educate the people, especially those with PTB and vulnerable individuals to seek medical care in order to prevent TBM. It will increase awareness about
the importance of having a healthy lifestyle and clean environment.
This study will elaborate the inter relatedness of environment, life style habits and acquiring Pulmonary Tuberculosis.

D. Scope and Limitation of the Study

This study is focused on the nursing aspect of care to those patients who have Pulmonary Tuberculosis. This study will only be used in the
nursing profession. The researchers only focused their attention on the medications, diagnostics, care plan, pathophysiology and discharge planning.
This study is not limited to the PTB patients only, but it is for all people who are interested in PTB. We are more focused on primary prevention
through health education because primary prevention is the true prevention.

II CLINICAL SUMMARY

A. General Data
 Name: PATIENT I
 Age: 46 y/o
 Birthplace: Pulangi, Albay
 Sex: Female
 Religion: Roman Catholic
 Civil Status: Married
 Address: P. Cadorniga st Navotas city
 Date Admitted: December 13, 2013
 Time Admitted: 2:10 am
 Attending Physician: Dr. Arthur Gonzales

B. Chief Complaint

The patient was admitted at Tondo Medical Center last December 13, 2013 at 2:10 in the morning due to the complaint of difficulty of
breathing (DOB). She was attended at the Emergency department and had taken a clinical history and physical assessment. She was transferred at the
Medical Ward particularly in the pulmonary ward of the hospital for further evaluation of the condition. She was attended by Dr. Arthur Gonzales, a
resident physician of the said hospital.

C. History of Present Illness

 Patient’s condition started about 6 months prior to consultation, as onset of cough, non-productive and an intermittent fever usually in the
afternoon, moderate grade temperature which are not documented. According to her it was relieved by an intake of paracetamol.
One week prior to admission the patient experienced worsening of the condition, she had productive cough non-bloody with whitish secretions.
There is also difficulty of breathing and vomiting. The patient can’t eat properly because she has no appetite for food. She also experience stabbing pain
on her chest according to the assessment it is 6/10 and it radiates to his back. The patient only took paracetamol for her fever. On the day of December
13, 2013 she was rushed to the hospital because of difficulty of breathing. Previously when she started experiencing these conditions, she does not seek
for any medical care from the physician because according to her it is still tolerable.

D. Past Medical History

The patient had upper respiratory tract infection when she was a child, she cannot remember. Previously she was not hospitalized. She does not
have complete immunizations because according to her it is not available in their place during those days, She has no history of hypertension and
Diabetes mellitus. Whenever she had any flu or cough, she uses herbal plants. She does not have any regular medical and dental check-ups. She does not
have allergies to what ever kind of foods and medications as far as she knows. Whenever she had fever she takes Paracetamol and Bioflu. She does
experience any severe accidents.

E. Familial History
 Telesporo Cia, 75 Eugenia Chavez 65
Deceased Deceased
CVA VA

Carlito, 75 Flusofida, 48 Josephine, 42

Litsilda, 50 PATIENT I, 46 Junior, 44 Gaudiocio, 40 Blencio, 38
PTB

Arsenio, 50

Allan,25 Analyn, 23 Anabel, 22 Analiza, 19 Ana Marie, 15

Arnold, 10

Legends

Male

Female

PTB Pulmonary Tuberculosis

CVA Cerebro Vascular Attack
F. Physical Assessment
VA Upon
Vehicular Accident
Admission : Date: December 13, 2013

GCS-15 oriented to 3 spheres-(E4M6V5) Height: 62 inches

V/S: BP- 90/60 mmHg, CR: 84 bpm, RR: 36 cpm, T-38.1 C Weight: 31.5 kilograms
LOC: Oriented BMI: 12.5 (Severe Malnutrition)
 AREA
A. SKULL
1. Size, shape and symmetry of
the skull
2. Presence of nodules, masses,
and depressions
3. Facial Features
4. Presence of edema and
hollowness in the eye.
C. HAIR
1. Evenness of growth,
thickness, or thinness of hair
2. Texture and oiliness over
the scalp
3. Presence of infection and
TECHNIQUE NORMS
Inspection Rounded (normocephalic
Palpation
and symmetrical, with
frontal, parietal, and
occipital prominences);
Smooth skull contour
Palpation Smooth, uniform
Inspection
consistence; absence of
nodules or masses
Inspection Symmetric or slightly
Palpation
asymmetric facial features;
palpebral fissure equal in
size; symmetric nasolabial
Inspection No edema and hollowness
Inspection Evenly distributed and
Palpation
covers the whole scalp;
Maybe thick or thin
Inspection Silky; resilient hair
Palpation
Inspection No infection and infestation
Palption
FINDINGS
Rounded(normocephalic);
smooth skull contour
Has no tenderness; no masses
nor nodules
Symmetrical and palpebral
fissure equal in size,
nasolabial folds are
symmetrical
Has Hollowness
Evenly distributed with no
patches of hair loss; thick
hair
Silky, smooth and resilient
hair
Presence of lice
ANALYSIS and INTERPRETATION
Normal
Normal
Normal
Abnormal, Volume deficiency of fat within the orbit
(the space inside of the bony eye socket). This
condition of the patient is related to his nutritional
status, she is malnourished. Her BMI is 12.5.
(http://www.drmeronk.com/hollowed/under-eye-hollows.html)
Normal
Normal.
Abnormal, There is pediculosis, a type of parasitic
infestation
D. FACE
Facial features, symmetry of
facial movements
IV. EYES
A. EYEBROWS
Hair distribution, alignment,
skin quality and movement
B. EYELASHES
Evenness of distribution and
direction of curl
C. EYELIDS
Surface characteristics and
position (in relation to the
cornea, ability to blink, and
frequency of blinking)
Inspection Symmetric or slightly
asymmetric facial features;
palpebral fissures equal in
size; symmetric nasolabial
folds
Inspection Symmetrical and in line
with each other; maybe
black, brown or blond
depending on race; evenly
distributed
Inspection Evenly distributed; turned
Palpation
outward
Inspection Upper eyelids cover the
small portion of the iris,
cornea, and sclera when
eyes are open; eyelids meet
infection. Lice may be contracted from infcetd clothes
and direct contact with an infected person. The idea is
that an oily substance, such as oil, smothers the lice and
they may die. (Kozier, Fundamentals of Nursing 7th ed. Page 733)
Symmetrical facial features Normal
while talking or elevating the
eyebrow. Equal palpebral
fissure, symmetrical
nasolabial folds.
Symmetrical and aligned Normal
with each other; black;
evenly distributed.
Movements are symmetrical.
Turned outward eyelashes; Normal
hair equally distributed
Able to close the eyes and Normal
has the ability to blink.
 completely when the eyes
are closed; symmetrical

D. CONJUNCTIVA

1. Color, texture, and the Inspection Pinkish or red in color;
Palapation
presence of lesions in the with presence of small
bulbar conjunctiva capillaries; moist; no
foreign bodies; no ulcers
Pale color; smooth in texture Abnormal, pale conjunctiva may be related to the low
RBC level of the patient. (Fundamentals of Nursing 5th
edition by Taylor, page 642)

2. Color, texture, and the Inspection
Palpation
presence of lesions in the
palpebral conjunctiva
Pinkish or red in color; Pale Abnormal, pale conjunctiva may be related to the low
with presence of small RBC level of the patient. (Fundamentals of Nursing 5th
capillaries; moist; no edition by Taylor, page 642)
foreign bodies; no ulcers

E. SCLERA

Color and clarity Inspection White in color; clear; no White sclera with some Normal
yellowish discoloration; visible capillaries, anicteric
some capillaries maybe sclera.
visible

F. CORNEA

Clarity and texture Inspection No irregularities on the Clear and smooth in texture Normal
surface; looks smooth;
clear or transparent

G. IRIS

Shape and color Inspection Anterior chamber is Dark brown in color; Normal
transparent; no noted transparent anterior chamber
visible materials; color
depends on the person’s
 race

H. PUPILS

1. Color, shape, and symmetry Inspection Color depends on the Pupil size is 3mm. Normal
of size person’s race; size ranges
from 3-7 mm, and are equal
in size; equally round

2. Light reaction and
accommodation
Inspection Constrict briskly/sluggishly
when light is directed to the
eye, both directly and
consensual
Dilates when looking at far Normal
objects and constricts when
looking at near objects.
Constricts when there is
light.

I. VISUAL ACUITY

1. Near vision Inspection Able to read newsprint Nearsightedness (Myopia) Abnormal, it is a refractive defect of the eye in which
collimated light produces image focus in front of the
retina when accommodation is relaxed. It is caused by
an eyeball that is longer than normal, which may be a
familial trait. Transient mayopia occurs due to
influenza, steroids, sever dehydration and large intake
of antacids. (Black, Medical Surgical Nursing7th edition, page
1963).
J. LACRIMAL GLAND

Palpability and tenderness of Palpation No edema or tenderness No tenderness and edema Normal
the lacrimal gland over lacrimal gland noted.

K. EXTRAOCULAR
MUSCLES

Eye alignment and Inspection Both eyes coordinated, Moves in Unison Normal
coordination move in unison, with
 parallel alignment

L. VISUAL FIELDS

Peripheral visual fields Inspection When looking straight Can see objects in the Normal
ahead, client can see periphery.
objects in the periphery

V. EARS

A. AURICLES

1. Color, symmetry of size,
and position
Inspection Color same as facial skin;
symmetrical; auricle
aligned with outer canthus
of eye, about 10 degrees
from vertical
Same color as the facial skin; Normal
tip of auricle aligned at the
outer canthus of the eye.

2. Texture, elasticity and areas Palpation Mobile, firm, and not Smooth in texture, flexible Normal
of tenderness tender; pinna recoils after it and elastic pinna; no
is folded tenderness

C. HEARING ACUITY
TESTS

1. Client’s response to normal Inspection Normal voice tones audible Can hear normal volume Normal
voice tones tones or words.

VI. NOSE

1.Any deviations in shape, Inspection Symmetric and straight; no Symmetric and straight; Abnormal, Nasal flaring suggests airway obstruction.
size, or color and flaring or discharge or flaring; Uniform color with nasal Nasal discharge shows the presence of mucus
discharge from the nares Uniform color flaring. secretions in the air tract.

2. Nasal septum (between the Inspection Nasal septum intact and in Nasal septum intact and in Normal
nasal chambers) Palpation midline midline

3. Patency of both nasal Inspection Air moves freely as the Only left nares is patent. Abnormal, not patent right nares show the presence of
cavities client breathes through the Right nares is with secretion. mucus secretions and would suggest there is an
nares infection in the respiratory system.

4. Tenderness, masses, and Palpation Not tender; no lesions Nor tenderness nor lesions. Normal
displacements of bone and
cartilage

VII. SINUSES

Identification of the sinuses Inspection Not tender Not painful when palpated Normal
and for tenderness

VIII. MOUTH

A. LIPS

Symmetry of contour, color Inspection Palpation Uniform pink color; soft, Pink in color, dry and Abnormal, May suggest cellular dehydration. (Black,
and texture moist, smooth texture; cracked lips Medical Surgical Nursing7th edition, page 208).
symmetry of contour;
ability to purse lips

B. BUCCAL MUCOSA

Color, moisture, texture, and Inspection Uniform pink color; moist, Pink color and dry. Abnormal, May suggests dehydration. (Black, Medical
the presence of lesions smooth, soft, glistening, Surgical Nursing7th edition, page 208).
and elastic texture
C. TEETH
Color, number and condition
and presence of dentures
D. GUMS
Color and condition
E. TONGUE/FLOOR OF
THE MOUTH
1. Color and texture of the
mouth floor and frenulum.
2. Position, color and texture,
movement and base of the
tongue
3. Any nodules, lumps, or
excoriated areas
F. PALATES and UVULA
1. Color, shape, texture and the
presence of bony prominences
Inspection 32 adult teeth; smooth,
white, shiny tooth enamel;
smooth, intact dentures
Inspection Pink gums; no retraction
Inspection pink color; moist; slightly
rough; thin whitish coating;
moves freely; no tenderness
Inspection Central position; pink
color; smooth tongue base
with prominent veins
Palpation Inspection Smooth with no palpable
nodules, lumps, or
excoriated areas
Inspection Palpation Light pink, smooth, soft
palate; lighter pink hard
Has 31 adult teeth. The
patient has yellowish teeth.
Have bad breath. Have tooth
decay in the lower right
second molars.
Pink gums; has no visible
retractions
Pink and moist. Tongue
moves freely and no pain
felt.
Located and positioned in the
center.
No tenderness nor masses
The hard palate has a lighter
color than the soft palate; has
Abnormal, most unpleasant odors are known to arise
from proteins trapped in the mouth which are processed
by oral bacteria. The most common location for mouth-
related halitosis is the tongue.
(http://en.wikipedia.org/wiki/Halitosis). It is also
related to dental carries and frequency of tooth
brushing.
Normal
Normal
Normal
Normal
Normal

2. Position of the uvula and
mobility (while examining the
palates)
G. OROPHARYNX and
TONSILS
1. Color and texture
2. Size, color, and discharge of
the tonsils
3. Gag reflex
X. THORAX
A. ANTERIOR THORAX
1. Breathing patterns
2. Temperature, tenderness,
masses
palate , more irregular quite rough texture
texture
Inspection Positioned in midline of Positioned at the center of the Normal
soft palate oropharynx
Inspection Pink and smooth posterior Dry, pinkish in color. Abnormal, May suggests dehydration. (Black, Medical
wall Surgical Nursing7th edition, page 208).
Inspection Pink and smooth; no Has no discharge; pinkish Normal
discharge; of normal size
Inspection Present Present Normal
Inspection Quiet, rhythmic, and Difficulty of breathing Abnormal, labored breathing is a common
effortless respirations manifestation affecting clients with cardiac and
pulmonary disorders. It is related to obstructed airway.
It also related to the decreased size of the lungs due to
PTB. (Black, Medical Surgical Nursing7th edition,
page 1566).
Palpation Skin intact; uniform Has an intact skin; has equal Abnormal. The patient is febrile with temperature of
temperature; chest wall

3. Anterior thorax auscultation
B. POSTERIOR THORAX
1. Shape, symmetry, and
comparison of anteroposterior
thorax to transverse diameter
2. Spinal alignment
3. Temperature, tenderness,
and masses
7. Posterior thorax auscultation
XI. CARDIOVASCULAR
intact; no tenderness; no
masses
Auscultation Bronchovesicular and
vesicular breath sounds
Inspection Palpation Anteroposterior to
transverse diameter in ratio
1:2; Chest symmetric
Inspection Spine vertically aligned
Palpation Skin intact; uniform
temperature; chest wall
intact; no tenderness; no
masses
Auscultation Vesicular and
bronchovesicular breath
sounds
warmth to touch. No masses.
Has crackles sounds on the
upper thorax & lower thorax
Has a anteroposterior to
transverse diameter ratio of
1:2, elliptical in shape and
symmetrical chest
Has a vertical alignment
No masses nor tenderness;
has equal warmth.
Has crackles heard on the
anterior and middle part of
right and left lungs.
Diminished lung sound on
the posterior right lung.
38.1 due to the disease process.
(Fundamentals of Nursing)
Abnormal, crackles or rales are audible when there is a
sudden opening of small airways that contain fluid. It is
usually heard during inspiration. (Black, Medical
Surgical Nursing7th edition, page 1756).
Normal
Normal
Abnormal. The patient is febrile with temperature of
38.1 due to the disease process.
(Fundamentals of Nursing)
Abnormal, the condition is related to the decreased size
of the right lung and poor inspiratory effort due to pain.
(http://www.nurse411.com/Heart_Lung_Sounds.asp)
A. AORTIC and Auscultation No pulsations No pulsations felt Normal
PULMONIC AREAS

B. TRICUSPID AREA Auscultation No pulsations; no lift or No pulsations of lifts Normal

heave

C. APICAL AREA Auscultation Pulsations visible in 50% of Has full pulsation Normal
adults and palpable in most
PMI in fifth LICS at or
medial to MCL

D. EPIGASTRIC AREA Auscultation Aortic pulsations Has pulsation Normal

E. CARDIOVASCULAR Auscultation S1: Usually heard at all Has full and rapid pulsation. Normal
AREAS AUSCULTATION sites 84 bpm/minute.

Usually louder at the apical Sounds on the aortic and

area pulmonic areas; has a lub Normal
sound on the apex and dub
S2: Usually heard at all sounds on the tricuspid area.
sites
Blood pressure is 90/70 mm
Usually louder at the base Hg. Normal
of heart

Systole: silent interval;

slightly shorter duration
than diastole at normal
heart rate (60 to 90
beats/min)

Diastole: silent interval;

slightly longer duration
than systole at normal heart

XII. CAROTID ARTERIES
1. Carotid artery palpation
XIV. AXILLAE
1. Axillary, subclavicular, and
supraclavicular lymph nodes
XV. ABDOMEN
1. Skin integrity
2. Abdominal contour
rates
S3: in children and young
adults
S4: in many older adults
Palpation Symmetric pulse volumes; Has weak pulsation. Abnormal, decreased amount of blood volume passing
full pulsations, thrusting Symmetrical pulse. the artery. (Black, Medical Surgical Nursing7th edition,
quality; quality remains page 1574).
same when the client
breathes, turns head, and
changes from sitting to
supine position; elastic
arterial wall
Inspection No tenderness, masses, or Have no masses and nodules. Abnormal, The appocrine glands located in the axillae
nodules Presence of a foul smelling produces sweat. The secretion of these glands is
odor. odorless, but when decomposed or acted upon by
bacteria in the skin, it takes on a musky, unpleasant
odor. (Kozier et.al, Fundamentals of Nursing 7th ed.
Page 699)
Inspection Unblemished skin; uniform Uniform color and has no Normal
color blemishes
Inspection Flat, rounded(convex), or Has a concave abdomen. Normal
scaphoid(concave)
3. Enlargement of liver or Inspection No evidence of No enlargement of the spleen Normal
spleen enlargement of liver or and liver seen
spleen

4.Symmetry of contour Inspection Symmetric contour Has a symmetrical abdominal Normal

contour

5. Abdominal movements Inspection Symmetric movements Abdominal movements noted Normal

associated with respirations, caused by respiration; when inhaling.
peristalsis or aortic pulsations visible peristalsis in very
lean people; aortic
pulsations in thin persons at
epigastric area

6. Vascular pattern Inspection No visible vascular pattern Has no blood vessels visible Normal

XVI.
MUSCULOSKELETAL
SYSTEM

A. MUSCLES

1. Muscle size and comparison Inspection Proportionate to the body; Proportionate to the body; Normal
on the other side even in both sides even in both sides

2. Fasciculation and tremors in Inspection No fasciculation and Has no fasciculation and Normal
the muscles tremors tremors

3. Muscle tonicity Palpation Even and firm muscle tone Weak muscle tone Abnormal, possibly related to the amount of food that
patient is eating due to loss of appetite.
(http://en.wikipedia.org/wiki/Muscle_weakness)

4. Muscle strength Palpation Has equal muscular Weak muscle strength Abnormal, possibly related to the amount of food that
patient is eating due to loss of appetite.
strength on both sides (http://en.wikipedia.org/wiki/Muscle_weakness)
C. JOINTS

1. Joint swelling Inspection No swelling, no warmth, no No swelling, no warmth, no Normal

redness, no pain, no redness, no pain, no crepitus
crepitus

EXTREMETIES Inspection, Palpation No swelling, no warmth, no No edema, no pain when Abnormal, patient is febrile with temperature of 38.1
due to disease process.
redness, no pain. moved. Warmth to touch.
(Fundamentals of Nursing)

Neurologic Assessment:

Category Normal Findings Actual Findings Analysis and interpretation

Mental Status

Level of Consciousness Alert Alert Normal

Orientation Oriented Oriented to person, time and Normal

place.
Language test Coherent Coherent Normal

Recall Able to remember Able to state what happened to Normal

her in the past.

Cranial Nerves

CN 1 Able to smell and Able to identify the scent of the Normal

Olfactory recognize stimuli alcohol

CN 11 20x20 vision, able to read, Pupil size is 3 mm, able to read, Abnormal, it is a refractive defect of the eye in which collimated
Optic 3-5 mm [pupil size] myopia or nearsightedness. light produces image focus in front of the retina when
accommodation is relaxed. It is caused by an eyeball that is longer
than normal, which may be a familial trait. Transient mayopia
occurs due to influenza, steroids, sever dehydration and large
intake of antacids. (Black, Medical Surgical Nursing7th edition, page 1963).
Normal
(+) Extraoccular Pupils react to light. There is
CN III, IV, VI Movement (EOM); constriction and consensual
Occulomotor Lateral Upward and accommodation. Able to move
Trochlear downward; pupils reactive the eyes in any direction in
Abducens to light. unison.

Normal
Able to feel and clearly Able to feel my finger on her face
CN V identify stimulus, with while covering her eyes.
Trigeminal bilateral facial sensation.
 With active corneal reflex.

(+) Corneal reflex , (+) Facial symmetry Normal

Facial asymmetry
CN VII
Facial

Able to hear clearly, can Can hear clearly and can walk. Normal
CN VIII maintain balance
Vestibulocochlear

Present gag reflex, able to

(+) gag reflex, uvula at the
CN IX, X center, soft palate rises
Glossopharyngeal
Vagus
Able to shrug shoulders
against resistance and able
CN XI to turn the head side and
Accessory (Spinal) against resistance.
swallow and able to idebtify the Normal
taste of the food.
Can shrug shoulders against
resistance and can turn the head Normal
fro right to right.

Able to move tongue from

side to side
Able to protrude the tongue and
move it side to side. Normal

CN XII
Hypoglossal
Muscle Strength MNT Grading System:
Left Arm (+5) Active motion against
full resistance
Right Arm (+5) Active motion against
full resistance
Left Leg (+5) Active motion against
full resistance
Right Leg (+5) Active motion against
full resistance
G. Patterns of Functioning
The researchers utilized the Gordon’s typology in assessing the pattern of functioning of our patient in her life. How does she manages and
takes care of herself based on Eleven Patterns.
Prior to Hospitalization
+4 active motion against some Abnormal, possibly related to the amount of food that patient is
resistance. eating. Possible exhaustion experienced by the patient when she
coughs. (http://en.wikipedia.org/wiki/Muscle_weakness)
Abnormal
+4 active motion against some
resistance.
Abnormal
+4 active motion against some
resistance. Abnormal
+4 active motion against some
resistance.
Functional Health Pattern
Norms and Standards
Health perception- Health Management
 The patient doesn’t have complete immunization because according to her it is
not available during those days and having immunization during those years
are expensive and they cannot afford it.
 She was never been hospitalized.
 No known allergies to any foods and drugs. She can eat fish, oyster and others.
 Does not experience any accidents.
 When she had a disease, she used herbal medicines like guava leaves, oregano,
lagundi, etc.
 For her, being healthy is important. A person is healthy when she is strong, she
can do what she wants and does not experience any diseases.
 She does not have any regular medical and dental check-ups.
 When she is experiencing something wrong in her body, she does not tell it
promptly because according to her it is tolerable.
 She does not have a regular exercise, instead she cleans the house and washes
the clothes of her family.
 The patient is malnourished.
 She takes a bath once a day and brushes her teeth once a day.
 She does use lotion, shampoo and soap.
 She washes her hands regularly but not always using soap.
 When she feels discomfort in her body she also goes to the manghihilot
because it is available on their area and it is more approachable.
 She often forgot to cover her mouth and nose when someone sneezes and
coughs in front of her.
 A person has a disease when she eats little amount of food, when she is weak.
 Health for her is important for proper functioning.
 Whenever she is sick, she get’s money from her children especially to the
eldest, which is working abroad.
 She wears slippers while inside their house. She feels that her hygienic
practices are adequate, and she feels clean and neat.
 The patient is non-smoker and she does not drink any alcoholic beverages.
 She denies the use any illicit drugs.
Measure for personal cleanliness and grooming, called personal hygiene, promote
physical and psychological well-being. Various studies have confirmed that improved
personal hygiene practices reduce illness rates. (Larson, 2002; Larson and Aiello,
2001).
Personal hygiene practices vary widely among people. The time of the day one
bathes and how often one shampoo or changes the bed linens, and sleeping garments are
relatively unimportant. What is important is that personal care be carried out
conveniently and frequently enough to promote personal hygiene.
Illness, hospitalization and institutionalization generally require modifications in
hygiene practices. In these situations, the nurse helps the patient to continue some
hygiene practices, and can teach the patient and family members, when necessary,
regarding hygiene. Nurses assist the patient with basic hygiene must respect individual
patient preferences, providing only the care that patients cannot or should not provide
for themselves.
(Fundamentals of Nursing 5th edition by Taylor, page 1005).
Malnutrition is the lack of sufficient nutrients to maintain healthy bodily functions
and is typically associated with extreme poverty in economically developing countries.
Most commonly, malnourished people either do not have enough calories in their diet,
or are eating a diet that lacks protein, vitamins, or trace minerals. Medical problems
arising from malnutrition are commonly referred to as deficiency diseases. Deficiency
in micronutrients such as Vitamin A reduces the capacity of the body to resist diseases.
Deficiency in iron, iodine and vitamin A is widely prevalent and represent a major
public health challenge. An array of afflictions ranging from stunted growth, reduced
intelligence and various cognitive abilities, reduced sociability, reduced leadership and
assertiveness, reduced activity and energy, reduced muscle growth and strength, and
poorer health overall are directly implicated to nutrient deficiencies.
(http://en.wikipedia.org/wiki/Malnourishment)
The main purpose of washing hands is to cleanse the hands of pathogens (including
bacteria or viruses) and chemicals which can cause personal harm or disease,
particularly diarrhea and pneumonia. To maintain good hygiene, hands should always
be washed after using the toilet, changing a diaper, tending to someone who is sick, or
handling raw meat, fish, or poultry, or any other situation leading to potential
contamination. Hands should also be washed before eating, handling or cooking food.
Conventionally, the use of soap and warm running water and the washing of all surfaces
thoroughly, including under fingernails is seen as necessary. Alcohol rub sanitizers kill
bacteria, multi-drug resistant bacteria (MRSA and VRE), tuberculosis, and viruses
(including HIV, herpes, RSV, rhinovirus, vaccinia, influenza, and hepatitis) and fungus.
(http://en.wikipedia.org/wiki/Hand_washing)
Herbalists treat many conditions such as asthma, eczema, premenstrual syndrome,

Nutritional Metabolic Pattern
 She loves to eat pork, fish and vegetables.
 She is not choosy when it comes to any cook and kind of food.
 She eats 3x a day
 She consumes less food serving size due to loss of appetite brought by disease
process.
 She does not eat any junk foods.
 She drinks 5 glasses of water a day.
 For her, the amount of food she consumes is adequate.
 She takes food supplement but it is not frequent.
 During snack time, she usually eats banana because it is affordable and readily
available in their place.
 When her cough started, she is not eating the appropriate amount of food.
 According to her husband, she usually eats 4 spoons of rice with viand only. It
is due to her cough and loss of appetite.
 During her hospitalization, she is on diet as tolerated with aspiration
precaution.
 She eats food given by the hospital.
 She is taking vitamin B6 and other medications.
Elimination
 She defecates twice a week and sometimes she feels pain and difficulty.
 According to her the characteristic of her stool is hard, dry and colored dark
brown.
 She feels pain at her abdomen on the hypogastric and umbilical area.
 She urinates 7x a day and does not feel any pain and difficulty.
rheumatoid arthritis, migraine, menopausal symptoms, chronic fatigue, and irritable
bowel syndrome, among others. Herbal preparations are best taken under the guidance
of a trained professional. Be sure to consult with your doctor or an herbalist before self-
treating. Some common herbs and their uses are discussed below. Please see our
monographs on individual herbs for detailed descriptions of uses as well as risks, side
effects, and potential interactions. (http://www.umm.edu/altmed/articles/herbal-medicine-
000351.htm)
Nutrition is a basic human need that changes throughout the life cycle and along the
wellness-illness continuum.
(Fundamentals of Nursing 5th edition by Taylor, page 1135)
An adequate food intake consists of balance essentials nutrients: water,
carbohydrates, fats, proteins, vitamins and minerals. Habits about eating are affected by
many factors like financial and health conditions. (Kozier et.al, Fundamentals of
Nursing 7th ed. Page 1171,1175)
The middle aged adult should continue to eat a healthy diet, following the
recommended portions of the 5 food groups, with special attention to protein, calcium
and limiting consumption to cholesterol. Two to three liters of fluid should be included
in the diet. Pre menopausal women need to ingest sufficient calcium and vitamin d to
prevent osteoporosis. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1180,1181)
An adult individual needs to balance energy intake with his or her level of physical
activity to avoid storing excess body fat. Dietary practices and food choices are related
to wellness and affect health, fitness, weight management, and the prevention of
chronic diseases such as osteoporosis, cardiovascular diseases, cancer, and diabetes.
For adults (ages eighteen to forty-five or fifty), weight management is a key factor
in achieving health and wellness. In order to remain healthy, adults must be aware of
changes in their energy needs, based on their level of physical activity, and balance
their energy intake accordingly. (http://www.faqs.org/nutrition/A-Ap/Adult-
Nutrition.html)
Inadequate nutrition is associated with marked weight loss, generalized muscle
weakness, altered functional ability, increased susceptibility to infection, impaired
pulmonary function and prolonged length of hospitalization. (Kozier et.al,
Fundamentals of Nursing 7th ed. Page 1190).
Elimination can be affected by a person’s developmental stage, daily patterns, the
amount and quality of fluid or food intake, the level of activity, lifestyle, emotional
states, pathologic processes, medication, and procedures such as diagnostic test and
surgery. Most people have individual pattern of elimination including frequency, timing
considerations, position and place. For most people defecation is a private affair
experienced easily only in the comfort of one’s own bathroom. Defecation may be
  Previously her defecation pattern is daily, but when her condition exacerbated,
it is also affected.
Activity and Exercise
 She does not have any work, she is a plain house wife, who is in-charge of her
children.
 Her usual activity is cleaning the house, cooking and washing the clothes of
her children.
 She loves to listen to radio programs usually in the afternoon.
 She likes to converse with her friends and neighborhood.
 When she cleans, it is usually for 1 hour because she gets easily tired.
 Her youngest child helps her in the household chores.
 When after all the chores are done she will rest and watch television.
 She does not involve her self in any vigorous activities.
 However, she is aware that her activity is not enough, and she recognizes the
importance of having regular exercise.
difficult in shared hospital room with only a curtain for privacy.
(Fundamentals of Nursing 5th edition by Taylor, page 1341)
The frequency of defecation is highly individualized, varying from several times
per day to two to three times per week. Sufficient bulk in the diet is necessary to
provide fecal volume. Bland diets and low-fiber diets are lacking in the bulk and
therefore create insufficient residue of waste products to stimulate the reflex for
defecation. Low-residue foods such as rice, eggs and lean meats move more slowly
through the intestinal tract. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1228).
Activity stimulates peristalsis, thus facilitating the movement of chime along the
colon. (Fundamentals of Nursing 5th edition by Taylor, page 1229).
A person’s urinary habits depend on social culture, personal habits and physical
abilities. Urine collects in the bladder contains between 250 to 450 ml of urine. (Kozier
et.al, Fundamentals of Nursing 7th ed. Page 1256).
The excretory function of the kidney diminishes with age but usually not
significant below normal levels unless disease intervenes. With age, the number of
functioning nephrons decreases to some degree, impairing the kidneys filtering abilities.
The amount of flood intake affects the urinary frequency of an individual. Foods high in
sodium or fluids high in sodium ca cause fluid retention because water are retained to
maintain the normal concentration of the electrolyte. (Kozier et.al, Fundamentals of
Nursing 7th ed. Page 1258-1259).
The human body was designed for motion, and regular exercise is necessary for its
healthy functioning. Individuals who choose inactive lifestyles or who are forced into
inactivity by illness or injury placed themselves at high risk for serious health problems.
(Fundamentals of Nursing 5th edition by Taylor, page 1116)
Vigorous physical activity is not always needed to achieve positive result.
(Fundamentals of Nursing 5th edition by Taylor, page 1117)
Lack of exercise, inactivity, or immobility related to illness, or injury place a person
at high risk for serious health problems. Immobility can affect the major body systems.
Like the benefits, a person receives from exercise, complications resulting from
immobility differ occurrence and severity based on the patients age and overall health
status. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1118).
The wonderful tool of exercise can help teens become fit and healthy. Performing
some form of physical activity daily will significantly boost your “basal metabolic
rate”—the number of calories your body burns in order to keep you alive. By having a
high metabolism, you burn calories 24 hours a day—even while you sleep! You can
literally turn your body into a fat-burning machine!
This has many benefits: With a strong metabolism comes a strong immune system.
When you burn fat, the toxins are released into the bloodstream, and are quickly carried
out of the body through sweat. This inoculates you against the probability of developing

Cognitive-perceptual
 The patient is an elementary graduate.
 She stops studying because of financial problem
 She can read and write properly.
 She is aware to different people or happening around her.
 She can talk properly.
 During the interview her voice is weak.
 According to her she is sensitive to the feelings of the people around her.
 There are no any blockages of communication noted.
 She is not always reading any books like pocket books.
 She can express her feelings appropriately.
 She does not have any difficulty when it comes to communication.
Sleep and Rest
 The patient regularly sleeps at 8:00pm. The patient sleeps a total of 5 hrs.
every night.
 She is experiencing intermittent sleep disturbance because according to her she
feels difficulty of breathing and cough.
 She usually sits because according to her she can breath more easily.
cancerous and diseased cells. Therefore, hard exercise—that makes you sweat—is very
good for you.
Exercise also helps to regulate the amount of insulin released into the bloodstream.
Insulin is commonly referred to as “the fat-making hormone.” Its job is to metabolize
blood sugar into energy. But too much insulin in the bloodstream keeps your body from
burning stored fat. Years of an overworked pancreas—the organ that produces insulin—
can lead to “onset (type 2) diabetes.” However, if you use—burn—more calories than
you consume, you significantly reduce the chances of developing this disease.
Exercise can also help control other problems, such as: Sleep apnea, moodiness,
stress, decreased energy, cardiovascular disease, high cholesterol and others. There are
too many benefits to list here. But be assured that this tool can help you become a fit,
stronger, disease-free, and overall healthier person. The main goal of aerobic exercise is
to keep the heart elevated for an extended period of time for the purpose of
strengthening the heart and lungs. The most common aerobic exercise is walking.
Running is the quickest way to lose weight, because it burns many calories. It also tones
your calves and thighs. However, to avoid extreme muscle aches or injuries, do not
begin a running routine until you have performed two to three months of aerobic
walking. (http://www.thercg.org/youth/articles/0201-tioe.html)
Cognition is greatly affected by education. Those who study and develop their skills
have better cognitive performances because they have been provided with different
information and chances to develop their self. Perception is affected by the sensory
diseases. Presence of any sensory abnormalities affects or halters perception that would
affect proper communication. (Black, Medical Surgical Nursing7th edition, page 1880).
Cognition involves a person’s intelligence, perceptual ability and ability to process
information. It represents a progression of mental abilities from illogical to logical
thinking, from simple to complex problem solving and from concrete to abstract ideas.
(Kozier et.al, Fundamentals of Nursing 7th ed. Page 359).
For no known reason, 8 hours of sleep a night has been the accepted standard for
adults despite obvious variations seen in the general population. It is important however
that a person follows a pattern of rest that maintains well-being. Many factors affect a
person’s ability to rest. Illnesses and various life situations that causes physiological
stress tends to disturb sleep. Sleep quality is also influenced by certain drugs Some
decreases REM sleep (barbiturates ,amphetamines and antidepressants) and some are
  She takes a nap in the morning from 8 am to 11 am.
 She feels that her sleep and rest is inadequate.
 She sleeps together with her husband.
 They have a separate room from their children.
 Sleeping is important to her.
Self-perception
 According to her there is something wrong in her health and body.
 As a mother, she sometimes feels sad because she cannot do the previous
things like going with her husband in the farm.
 According to her husband she is a good mother and a good wife.
 Her strength is her family, when there are any circumstances that involving
any family member she is concerned and make some moves.
 She is simple.
seen to
cause sleep problems (steroids, caffeine and asthma medications)
(Kozier et.al, Fundamentals of Nursing 7th ed. Page 1169-117).
The National Sleep Foundation in the United States maintains that eight to nine
hours of sleep for adult humans is optimal and that sufficient sleep benefits alertness,
memory and problem solving, and overall health, as well as reducing the risk of
accidents.[8] A widely publicized 2003 study[9] performed at the University of
Pennsylvania School of Medicine demonstrated that cognitive performance declines
with fewer than eight hours of sleep.
It has also been shown that sleep deprivation affects the immune system and
metabolism. In a study by Zager et al in 2007,[21] rats were deprived of sleep for 24
hours. When compared with a control group, the sleep-deprived rats' blood tests
indicated a 20% decrease in white blood cell count, a significant change in the immune
system.
Scientists have shown numerous ways in which sleep is related to memory. In a study
conducted by Turner, Drummond, Salamat, and Brown[28] working memory was shown
to be affected by sleep deprivation. Working memory is important because it keeps
information active for further processing and supports higher-level cognitive functions
such as decision making, reasoning, and episodic memory. Turner et al. allowed 18
women and 22 men to sleep only 26 minutes per night over a 4-day period. Subjects
were given initial cognitive tests while well rested and then tested again twice a day
during the 4 days of sleep deprivation. On the final test the average working memory
span of the sleep deprived group had dropped by 38% in comparison to the control
group. (http://en.wikipedia.org/wiki/Sleep)
Self concept is one’s mental image of oneself. A positive self concept is essential to
a person’s mental and physical health. Individuals with a positive self concept are better
able to develop and maintain interpersonal relationship and resist psychological and
physical illness.
Self concept involves all of these self perceptions, that is, appearance, values and
beliefs that influences behaviors and that are referred to when using the words I or me.
Body image is ho the person perceives the size, appearance and functioning of the body.
If a person’s body image closely resembles one’s ideal body, the individual is more
likely to think positively about the physical and non-physical concept of self.
Self concept is also affected by role-strains. People undergoing role-strains are
frustrated because they feel or made to feel inadequate or unsuited to a role.
Illness and trauma can also affect the self-concept. People responds to different
stressors such as illness and alterations in function related to aging in a variety of ways:
acceptance, denial, withdrawal and depression are common. (Kozier et.al,
Fundamentals of Nursing 7th ed. Pages 957-962).
Role-relationship
 She was the fourth child in her family.
 She is married and they have 6 children.
 She is performing the trypical responsibilities of a plain house wife.
 Her children have a good relationship to her.
 She is being cared by her children who are very supportive to her.
 Her husband is a good husband he is a provider who does everything for the
family to have food.
 She has a harmonious relationship with her brothers and sisters. Whenever
there are any problems, they are helping each other.
 She can form a healthy relationship with others.
 She is the person who chooses her friends.
 She is a very quite person.
 She does not have any enemies.
Sexuality-reproductive
 She is engage in sexual activity to her husband only.
 Presently she is still active in her sex life.
 She still have regular menstruation.
 She is aware that she will have cessation of her menstruation.
 She dresses appropriately, based on her gender.
 She is also able to express her feminine attitudes.
Relationship to another person is a developed manner in which there is the sharing
of self, showing care and putting trust. A healthy relationship affects an individual’s
emotional development, it will facilitate the channeling of the ideas, feeling of joy an
others.
An interpersonal relationship is a relatively long-term association between two or
more people. This association may be based on emotions like love and liking, regular
business interactions, or some other type of social commitment. Interpersonal
relationships take place in a great variety of contexts, such as family, friends, marriage,
acquaintances, work, clubs, neighborhoods, and churches. They may be regulated by
law, custom, or mutual agreement, and are the basis of social groups and society as a
whole. A relationship is normally viewed as a connection between two individuals, such
as a romantic or intimate relationship, or a parent-child relationship.
All relationships involve some level of interdependence. People in a relationship
tend to influence each other, share their thoughts and feelings, and engage in activities
together. Because of this interdependence, anything that changes or impacts one
member of the relationship will have some level of impact on the other member.
Psychologists have suggested that all humans have a basic, motivational drive to form
and maintain caring interpersonal relationships.
According to attachment theory, relationships can be viewed in terms of attachment
styles that develop during early childhood. These patterns are believed to influence
interactions throughout adulthood by shaping the roles people adopt in relationships.
(http://en.wikipedia.org/wiki/Intimate_relationship)
Sexuality is defined not only by a person’s genetalia but also by attitudes and
feelings. It can also be defined as learned behaviors in how a person reacts to his or her
own sexuality and by how one behaves in relationships with others.
(Fundamentals of Nursing 5th edition by Taylor, page 931)
Sexuality is a crucial part of a person’s identity. Sex is central to who we are, to our
emotional well-being and to the quality of our lives. The world health organization
defined sexual health as the integration of the somatic, emotional, intellectual and social
aspect of sexual beings in ways that are positively enriching and that enhances
personality, communication and love. (Kozier et.al, Fundamentals of Nursing 7th ed.
Pages 973).
During the middle adulthood both men and women experience decreased hormone
production causing the climacteric, usually called menopausal in women. These events
often affect the individuals self-concept, body image and sexual identity.
Women through the menopausal period experiences hot flushes, vasomotor
instability, sleep disturbances, vaginal dryness, genital tract atrophy, mood changes and
skin, hair changes. The incidence of osteoporosis and cardiovascular lipid changes also
increases. The climacteric in the males is no as dramatic in the females; changes are
more gradual.
 Sexual response love and play involve people’s emotional, psychologic, physical and
spiritual make up, which plays a significant role in the satisfaction. Sexual desires
fluctuates within each person and varies from person to person. If people suppresses or
block out conscous sexual desires, they may not experience any physiological respose.
(Kozier et.al, Fundamentals of Nursing 7th ed. Pages 975,980).
Coping-stress Coping mechanisms which are behaviors used to decrease stress and anxiety. Many
 Whenever she has problem, she asks guidance from our Lord coping behaviors are learned, based on one’s family past experiences, and socio-cultural
 She watches television as her stress management. influences and expectations.
 She always listen to radio programs when she feels lonely. (Fundamentals of Nursing 5th edition by Taylor, page 855)
 When she gets mad, she just keep quiet.
 When she experiences coughing and difficulty of breathing she just relaxes and
breathes deeply.
 Her husband or children taps her back when she coughs.
Value-belief Spiritual well-being is the condition that exists when the universal spiritual needs for
 She is a Roman Catholic meaning and purpose, love and belonging, and forgiveness are met. O’ Briens
 She attends mass occasionally. conceptual model of spiritual well-being in illness identified three empirical referents of
 She always ask the guidance of our Lord spiritual well-being: personal faith, religious practice and spiritual contentment.
 Whenever there are Christian events, like Holy week, she participates in the Spiritual beliefs are of special importance to nurses because of the many ways they can
activities like fasting. influence a patient’s level of health and self-care behaviors. (Kozier et.al,
 She believes in ghosts, and elementals. Fundamentals of Nursing 7th ed. Pages 975,979).
 She seldom reads the bible. Spiritual well-being is manifested by a generally feeling of being alive, purposeful
 Does not always pray the rosary. and fulfilled. People nurture or enhance their spirituality in many ways. Some focus on
development of the inner self or world; others focus on the expression of their spiritual
 She respects and obeys her husband.
energy with others or outer world. Relating to one’s inner self or soul may be achieved
 For her education is very important to her children, so she and her husband is
through conducting an inner dialogue with a higher power or with one’s self through
doing all the efforts to send their children to school.
prayer or medications. The expression of a person’s spiritual energy to others is
manifested in loving relationship with and service to others, joy and laughter and
participation in religious services and associated fellow gatherings and activities and by
expression of compassion, empathy, forgiveness and hope. (Kozier et.al, Fundamentals
of Nursing 7th ed. Pages 996).

H. Activities of Daily Living

ASPECT PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION INTERPRETATION and ANALYSIS

1. Nutrition Patient loves to eat meat, fish and vegetables. The patient is on diet as tolerated with The patient can eat any food she wants as long as
She eats anything that is being served to her. aspiration precaution. She eats dry, thickened it is dry, thickened, and frothy. It should be in a
 She does not eat junk foods. She is not taking
food supplements like vitamins frequently.
She eats 4 spoons of rice with viand because
according to her it is due to her cough and loss
of appetite. She eats thrice a day.
2. Elimination Patient voids 7 times a day, and defecate twice
a week. She doesn’t experience any pain and
difficulty in terms of urination. Previously her
defecation pattern is daily, but when her
condition exacerbated, it is also affected.
3. Exercise Cleaning their house is the only activity she
considered as her exercise. She does not have
routine exercise. However, she is aware that
her activity is not enough, and she recognizes
the importance of having regular exercise. She
loves to listen to radio programs usually in the
afternoon.
When after all the chores are done she will rest
and watch television.
4. Hygiene Patient takes a bath every day, brushes her
teeth once a day. She wears slippers while
inside their house. She feels that her hygienic
practices are adequate, and she feels clean and
neat. There is body odor noted.
5. Substance Use Patient is a non-smoker and denies use of illicit
drugs. She does not drink alcohol.
6. Sleep and Rest Sleeping is important to her. She is
experiencing intermittent sleep disturbance
food on a small frequent feeding. She is
advised to chew food properly.
The patient does not defecate or urinated
during the conduct of the interview.
Deep breathing and coughing exercises are
advised and performed. The patient has
decreasing function as the disease progresses.
The patient is advised to use disposable mask;
isolate/dispose used tissues properly; frequent
hand washing; cover mouth and nose when
sneezing and coughing.
The patient doesn’t use any prohibited
substances like alcohol, cigarettes and illicit
drugs.
Patient stated she can sleep at:
Day shift:
 9am-10am
small frequent feeding, as to avoid aspiration.
The patient does not defecate for more than a
week due to decreased gastric motility related to
decrease physical activity. For most people
defecation is a private affair experienced easily
only in the comfort of one’s own bathroom.
Defecation may be difficult in shared hospital
room with only a curtain for privacy.
(Fundamentals of Nursing 5th edition by Taylor,
page 975 & 979)
The patient performs deep breathing exercise as
instructed by the nurse.
Avoid transmission of microorganisms among
patients and hospital worker.
(Fundamentals of Nursing)
The patient does not use any addictive
substances. Illicit drugs are strictly prohibited in
the hospital premises, even cigarette smoking and
alcohol drinking.
Many factors affect a person’s ability to rest,
illness and various life situations that causes
physiological stress tends to disturb sleep quality
 because according to her she feels difficulty of  3pm-5pm is also influence by certain drugs that are seen to
breathing and cough. She takes a nap during Night shift: cause sleep problems such as:
breaktime, from 12 noon to 1 pm. She sleeps  9pm-11:30pm  Steroids
together with her husband. The patient  1am-5am  Caffeine
regularly sleeps at 8:00pm and wakes up at  Asthma medications
Patient verbalized that she had adequate sleep
1:00 am. She feels that her sleep and rest is
and rest during confinement than at home. (kozier et. Al, Fundamentals of Nursing 7TH
inadequate because of her conditions. edition page 1169)
7. Sexual Activity She dresses appropriately, based on her gender. Not applicable Not applicable
She still has regular menstruation. She is
engage in sexual activity to her husband only.
Presently she is still active in her sex life

I. Patients Concept about Health, Illness and Hospitalization

HEALTH ILLNESS HOSPITALIZATION

The patient believes that being healthy is being strong,
does not experience any sickness and energetic.
- Health is defined as a state of complete physical, mental
and social well-being and not merely the absence of
disease or infirmity. WHO definition
For the patient, an individual is weak and eats little
amount of food.
-Is a disease, sickness or the condition of being in a poor
health, either physically or mentally. (Blackwell’s Nursing
Dictionary)
The patient looks at hospitalization as the last recourse
when one has an illness. For the patient, it is the place
where an individual is being treated from severe cases.
- Placement of an individual in a hospital for observation,
diagnostic test, or treatment for some diseases.
(Blackwell’s Nursing Dictionary)

J. Laboratory and Diagnostic Examination

 Blood examinations

DATE PROCEDURE NORMS RESULT INTERPRETATION and ANALYSIS

Dec. 13, 2013 Hemoglobin 120-160g/L 110 g/L LOW
Due to malnutrition; anemia
Hematocrit 0.38-0.40 g/L 0.33 g/L LOW
Due to malnutrition, slight dehydration
RBC count 4.2-5.4x 1012 per liter 4.8 x 10 NORMAL
WBC 5-10x109/L 15.2 x 10 HIGH
 Leukocytosis indicates infection
Neutrophils 81.3% 84.1% HIGH
Acute bacterial infection
Lymphocytes 10.2% 8.6 % LOW
Low lymphocyte concentration associated with increase
rate of infection
Basophils 0.1% 0.1 % NORMAL
Monocytes 7.5% 6.3 % LOW
Depleted in overwhelming bacterial infection
Eosinophils 0.9% 0.9 % NORMAL
Platelets 150-450x109/L 234 x 10 NORMAL
Fasting Blood Sugar 70-110 mg/dl 96 mg/dl NORMAL
Creatinine 44.2-106.08 umol/L 98.8 umol/L Normal
Na 135-145mmol/L 136mmol/L NORMAL
K 3.6-5.5mmol/L 4.1mmol/L NORMAL

 Sputum AFB

SPUTUM COLLECTION Dec. 20,2013

1st collection POSITIVE

2nd collection POSITIVE

Positive for Mycobacterium tuberculosis in the active stage of the disease.

 Urinalysis

Specimen free catch

Color yellow
Appearance cloudy
Specific gravity 1.038
pH 7.0
protein negative
glucose negative
ketones negative
bilirubin 1+
blood negative
 bacteria few

 Electro Cardiogram – normal findings

 Chest X-ray

The patient had undergone chest x-ray upon admission. The film shows presence of infiltrates or clouds. The right is smaller than the
left lung, particularly the lower lobe of the right lung.

K. Impression/Diagnosis

Dr. Gonzales, the patient’s attending physician, who diagnosed the disease as Pulmonary tuberculosis. This diagnosis is supported by the
pathognomonic signs that manifested by the patient. These include intermittent fever in the afternoon, difficulty of breathing, coughing, weight loss and
chest pain. This diagnosis is supported by the following diagnostic exam such as sputum AFB and chest x-ray.

L. Course in the Ward

The patient was accompanied by her husband and her children. While waiting for the doctor, she was placed in a wheel chair.

DATE MEDICAL PROCEDURES/ORDERS NURSING ASSESSMENT and FUNCTION

September 19, 2013 - History taking Upon admission:

- Physical assessment -GCS E4 V5 M6
- Neurological Assessment - Vital signs BP- 90/60 mmHg, CR: 84 bpm, RR: 36 cpm, T-38.1 C
- Chest-x-ray - IV insertion done at the right arm, infusing well.
- IVF of PNSS 1 liter to run for 12 hours. -Due meds given
- Medications - X-ray result obtained.
 Acetylcysteine dissolved in ½ glassof water TID - History taking
 B complex 2 ampules TIV stat - Physical assessment done
 Cefuroxime 500 mg/Cap - Neurologic assessment done
 Theophylline 1 cap TID -crackles noted upon auscultation.
 Salbutamol + ipratropium neb, 1 neb every 6 hours 2:40 AM
- Diet as Tolerated with aspiration precaution. -Received from ER to Medicine ward.
- Placed in pulmonary ward
- Patient was oriented.
- Kept rested
-Advised relatives to use mask and hand washing regularly.
- On DAT with aspiration precaution
 M. Ecologic Model

Hypothesis
The patient developed PTB thru the inhalation of mycobacterium tuberculosis due to being exposed to an environment, specifically in their community,
where in some people around her have Pulmonary Tuberculosis. Not always covering her nose and doing proper hand washing are the practices that have
predisposes the patient to develop the disease. She had come in close contact with people who had PTB.

Agent
 Tuberculosis is a common and deadly infectious disease caused by mycobacterium mainly Mycobacterium tuberculosis.
 Mycobacterium tuberculosis. A rod-shaped organism.
 The disease is directly transmitted through inhalation of organisms directly into the lungs.

Host
 46 yrs old
 Female
 Filipino, Roman Catholic
 Highest educational attainment: Elementary graduate.
 Living together with her family in Navotas city
 Have incomplete vaccination.
 Practices hand washing but improper without soap.
 Takes a bath once a day and brushes teeth once.
 Does not always cover her nose and mouth in situations needed to.
 Does not have a regular medical check up.
 Exposed to a person who is carrier of M. Tuberculosis.

Environment
The patient resides in a crowded community where in cases with Tuberculosis is present. The present environment where she resides is not polluted. TB
is an airborne infection. People who are most commonly infected are those who have repeated close contact with an infected person.
 The researchers used the epidemiologic web causation model, in which this model focuses to the complex multi factorial causes of a disease.

Financial
insufficiency. Does not always cover her
nose and mouth when
exposed to a person who
coughs or sneezes.
Does not regularly take
Does not have a vitamins and minerals
regular medical
check up.

HOST
Educational
Inadequate of Infected of Tuberculosis
attainment. Weakened
knowledge about Meningitis. Lack of
health immune system
immunizations
management. .

Degenerat
ion of
healthy
cells..
 Airborne transmission
Does not
practice proper
Taking a bath once a day hand washing.
and brushing teeth only
Exposure to a carrier of M.
once.
tuberculosis.

Mayco Bacterium
Tuberculosis
Analysis
PTB is caused by mycobacterium tuberculosis. This bacterium enters the host thru the nose and mouth. It first affects the alveoli of the lungs then this
bacterium spreads thru the bloodstream. This bacterium migrates to other parts of the body.
Hand washing has been the most effective means of preventing transfer. It is the true prevention. Not covering the nose and mouth when someone
sneezes or coughs causes the bacteria in their sputum to travel through the air. The so called airborne transmission will now take place affecting the individual.
Living in an unhealthy place predisposes the individual to develop certain diseases especially those within the respiratory system. (Brunner and
Suddarth’s Textbook of Medical- Surgical Nursing 11th ed by Smeltzer et al p. 643)

Conclusion and recommendation

The researchers therefore conclude that PTB can be prevented if we always clean the environment, practicing proper hand washing, personal hygiene
and use of personal protective equipments are the things that are very important. Personal
discipline is a crucial factor. As nurses, they are focused on promoting wellness through
health education especially to that of the poor.

III, CLINICAL DISCUSSION OF THE DISEASE

A. Anatomy and Physiology

Respiration is the process by which living organisms take in oxygen and release carbon
dioxide. The human respiratory system, working in conjunction with the circulatory system,
supplies oxygen to the body's cells, removing carbon dioxide in the process. The exchange of
these gases occurs across cell membranes both in the lungs (external respiration) and in the
body tissues (internal respiration). Breathing, or pulmonary ventilation, describes the process
of inhaling and exhaling air. The human respiratory system consists of the respiratory tract
and the lungs.
Respiratory tract

The respiratory tract cleans, warms, and moistens air during its trip to the lungs. The tract can be divided into an upper and a lower part. The upper part
consists of the nose, nasal cavity, pharynx (throat), and larynx (voice box). The lower part consists of the trachea (windpipe), bronchi, and bronchial tree.
The nose has openings to the outside that allow air to enter. Hairs inside the nose trap dirt and keep it out of the respiratory tract. The external nose leads to a
large cavity within the skull, the nasal cavity. This cavity is lined with mucous membrane and fine hairs called cilia. Mucus moistens the incoming air and traps
dust. The cilia move pieces of the mucus with its trapped particles to the throat, where it is spit out or swallowed. Stomach acids destroy bacteria in swallowed
mucus. Blood vessels in the nose and nasal cavity release heat and warm the entering air.
Air leaves the nasal cavity and enters the pharynx. From there it passes into the larynx, which is supported by a framework of cartilage (tough, white connective
tissue). The larynx is covered by the epiglottis, a flap of elastic cartilage that moves up and down like a trap door. The epiglottis stays open during breathing, but
closes during swallowing. This valve mechanism keeps solid particles (food) and liquids out of the trachea. If something other than air enters the trachea, it is
expelled through automatic coughing.

Alveoli: Tiny air-filled sacs in the lungs where the exchange of oxygen and carbon dioxide occurs between the lungs and the bloodstream.

Bronchi: Two main branches of the trachea leading into the lungs.

Bronchial tree: Branching, air-conducting subdivisions of the bronchi in the lungs.

Diaphragm: Dome-shaped sheet of muscle located below the lungs separating the thoracic and abdominal cavities that contracts and expands to force air in and
out of the lungs.

Epiglottis: Flap of elastic cartilage covering the larynx that allows air to pass through the trachea while keeping solid particles and liquids out.

Pleura: Membranous sac that envelops each lung and lines the thoracic cavity.

Air enters the trachea in the neck. Mucous membrane lines the trachea and C-shaped cartilage rings reinforce its walls. Elastic fibers in the trachea walls allow
the airways to expand and contract during breathing, while the cartilage rings prevent them from collapsing. The trachea divides behind the sternum (breastbone)
to form a left and right branch, called bronchi (pronounced BRONG-key), each entering a lung.

The lungs

The lungs are two cone-shaped organs located in the chest or thoracic cavity. The heart separates them. The right lung is somewhat larger than the left.
A sac, called the pleura, surrounds and protects the lungs. One layer of the pleura attaches to the wall of the thoracic cavity and the other layer encloses the lungs.
A fluid between the two membrane layers reduces friction and allows smooth movement of the lungs during breathing.
The lungs are divided into lobes, each one of which receives its own bronchial branch. Inside the lungs, the bronchi subdivide repeatedly into smaller airways.
Eventually they form tiny branches called terminal bronchioles. Terminal bronchioles have a diameter of about 0.02 inch (0.5 millimeter). This branching
network within the lungs is called the bronchial tree.
The terminal bronchioles enter cup-shaped air sacs called alveoli (pronounced al-VEE-o-leye). The average person has a total of about 700 million gas-filled
alveoli in the lungs. These provide an enormous surface area for gas exchange. A network of capillaries (tiny blood vessels) surrounds each alveoli. As blood
passes through these vessels and air fills the alveoli, the exchange of gases takes place: oxygen passes from the alveoli into the capillaries while carbon dioxide
passes from the capillaries into the alveoli.
This process—external respiration—causes the blood to leave the lungs laden with oxygen and cleared of carbon dioxide. When this blood reaches the cells of
the body, internal respiration takes place. The oxygen diffuses or passes into the tissue fluid, and then into the cells. At the same time, carbon dioxide in the cells
diffuses into the tissue fluid and then into the capillaries. The carbon dioxide-filled blood then returns to the lungs for another cycle.
Breathing

Breathing exchanges gases between the outside air

and the alveoli of the lungs. Lung expansion is brought about
by two important muscles, the diaphragm (pronounced DIE-a-
fram) and the intercostal muscles. The diaphragm is a dome-
shaped sheet of muscle located below the lungs that separates
the thoracic and abdominal cavities. The intercostal muscles
are located between the ribs.
Nerves from the brain send impulses to the
diaphragm and intercostal muscles, stimulating them to
contract or relax. When the diaphragm contracts, it moves
down. The dome is flattened, and the size of the chest cavity is
increased. When the intercostal muscles contract, the ribs
move up and outward, which also increases the size of the
chest cavity. By contracting, the diaphragm and intercostal
muscles reduce the pressure inside the lungs relative to the
pressure of the outside air. As a consequence, air rushes into
the lungs during inhalation. During exhalation, the reverse
occurs. The diaphragm relaxes and its dome curves up into the
chest cavity, while the intercostal muscles relax and bring the
ribs down and inward. The diminished size of the chest cavity
increases the pressure in the lungs, thereby forcing air out.
A healthy adult breathes in and out about 12 times
per minute, but this rate changes with exercise and other
factors. Total lung capacity is about 12.5 pints (6 liters). Under
normal circumstances, humans inhale and exhale about one
pint (475 milliliters) of air in each cycle. Only about three-
quarters of this air reaches the alveoli. The rest of the air
remains in the respiratory tract. Regardless of the volume of
air breathed in and out, the lungs always retain about 2.5 pints
(1200 milliliters) of air. This residual air keeps the alveoli and
bronchioles partially filled at all times.
B. Drug Study
 GENERIC / ACTION CLASSIFICATIO INDICATION CONTRAINDICATION SIDE EFFECTS NURSING
BRAND NAME N INTERVENTION

Theophylline -The main mechanism - Mild stimulant - For chronic - Hypersensitivity -Stomach stomach - Monitor patients’ heart
of action of -Bronchodilator obstructive diseases of - Pregnant. -pain rate.
theophylline is that of the airway. -Diarrhea - Assess for CNS effects.
adenosine receptor -COPD -Headache - Teach the patient to avoid
antagonism. - Restlessness smoking.
- Insomnia - Educate the importance
- Theophylline is a non- - Irritability of taking the right amount
specific adenosine in the right time of
antagonist, medications.
antagonizing A1, A2, - Assess for any
and A3 receptors hypersensitivity.
almost equally, which
explains many of its
cardiac effects and
some of its anti-
asthmatic effects.

Salbutamol - A short-acting β2- - Bronchodialtor -Relief and prevention -Contraindicated with -Dizziness, - Assess for any
adrenergic receptor of bronchospasm in hypersensitivity to albuterol. drowsiness, fatigue, hypersensitivity to
agonist used for the patients with -Use cautiously with headache. albuterol.
relief of bronchospasm reversible obstructive diabetes mellitus (large IV - vomiting, change in - Be cautious when driving.
in conditions such as airway disease doses can aggravate taste -Eat food is a small
asthma and chronic diabetes and ketoacidosis). frequent way.
obstructive pulmonary -Inhalation: Treatment - Maintain beta- adrenergic
disease. of acute attacks of blocker on stand by.
bronchospasm

-Prevention of
exercise-induced
bronchospasm.

Vitamin B - Support and increase - Water soluble - Encourage patient to take

the rate of metabolism. Vitamin the vitamin regularly.
- Maintain healthy skin - Encourage them to go to
and muscle tone the doctor before drinking
- Enhance immune and any vitamins.
nervous system
 function.
- Promote cell growth
and division including
that of the red blood
cells that help prevent
anemia.

Cefuroxime - Inhibits bacterial cell - Antibacterial - Treatment of - Hypersensitivity to - GI bleeding - Observe for signs and
wall synthesis by infections caused by cefuroxime and other - Headache symptoms of anaphylaxis
binding to one or more staphylococci and cephalosphorine. - Nausea during first dose; with
of the penicillin-binding other microorganisms - Dizziness prolonged therapy, monitor
proteins (PBPs) which like klebsiella. - Vomiting renal, hepatic, and
in turn inhibits the final - Treatment of - Increased BUN and hematologic function.
transpeptidation step of susceptible infections Creatinine - Educate the importance
peptidoglycan synthesis of the lower of taking the right amount
in bacterial cell walls, respiratory tract in the right time of
thus inhibiting cell wall medications.
biosynthesis. - Assess for any
-Bacteria eventually hypersensitivity.
lyse due to ongoing
activity of cell wall
autolytic enzymes
(autolysins and murein
hydrolases) while cell
wall assembly is
arrested.
Acetylcysteine -Is any agent which Mucolytic -Acute & chronic -Contraindicated with -Urticaria, -Should be taken with food
dissolves thick mucus respiratory tract asthmatic patients and bronchospasm, -The sachet should be
usually used to help affections w/ abundant patients with history of nausea, vomiting. dissolve into a glass of cold
relieve respiratory mucus secretions. peptic ulceration. -Aerosol treatment: or warm water, and drink
difficulties. -Used in the treatment Rhinitis, stomatitis. immediately.
(hydrolyzing of wet cough. -Do not dissolve other
glycosaminoglycans: medicines together with
tending to break acetylcysteine, since both
down/lower the acetylcysteine and the
viscosity of mucin- other drug effect could be
containing body influenced or cancelled.
secretions/components). - Assess for any allergies.
Isoniazid The most effective Antitubercular drug Tuberculosis caused Severe hypersensitivity to Peripheral - store in dark, tightly
tuberculostatic agent. by human, bovine, and isoniazid or in clients with neuropathy, nausea & closed containers
Probably interferes with BCG strains of previous isoniazid vomiting, heartburn, - administer with
lipid and nucleic acid Mycobacterium associated hepatic injury or dizziness, optic pyridoxine, 10-50 mg/day,
metabolism of growing tuberculosis side effects. Active liver neuritis, hepatitis in malnourished,
bacteria, resulting in disease. alcoholic, or diabetic
alteration of the clients to prevent
bacterial wall. Is symptoms of peripheral
tuberculostatic. neuropathy.
-
Rifampin Suppresses RNA Antitubercular drug All types of Hypersensitivity; not Diarrhea, nausea & When used for
synthesis by binding to tuberculosis. Must be recommended for vomiting, headache, tuberculosis, continue
the beta subunit of used in conjunction intermittent therapy. drowsiness, anorexia, therapy for 6-9 months.
DNA-dependent RNA with at least one other sore mouth/tongue,
polymerase. This tuberculostatic drug, flushing
prevents attachment of but is the drug of
the enzyme to DNA choice for retreatment.
and blockade of RNA
transcription. Both
bacteriostatic and
bactericidal; most
active against rapidly
replicating organisms.

IV Fluid

Treatment / Infusion Classification Indication Contraindication Nursing Responsibilities

Plain NSS Isotonic *Hypovolemia *CHF *Do not connect flexible plastic containers of intravenous
solutions in series, i.e., do not piggyback connections.
*Heat-related emergencies Such use could result in air embolism due to residual air
being drawn from one container before administration of
*Freshwater drowning the fluid from a secondary container is completed.

*Diabetic ketoacidosis(DKA) *Pressurizing intravenous solutions contained in flexible

 plastic containers to increase flow rates can result in air
embolism if the residual air in the container is not fully
evacuated prior to administration.

*Use of a vented intravenous administration set with the

vent in the open position could result in air embolism.
Vented intravenous administration sets with the vent in
the open position should not be used with flexible plastic
contain.

IV NURSING PROCESS

A. Long Term Objective

After two month of intensive treatment the patient will not experience the signs and symptoms of PTB. The complications brought about by
PTB will be prevented through proper participation to the different medical and nursing interventions.

B. Problem List

CUES NURSING PROBLEM RANK JUSTIFICATION

Subjective Cues: Difficulty of breathing 1  Airway must be given the first attention as based on the rule of
- Patient verbalized, “Matagal na akong ABC which is Airway, Breathing and Circulation. In addition,
inuubo.Nahihirapan na akong huminga”. difficulty of breathing can cause anxiety to the client that is
why, immediate attention must be done. Addressing the
Objective Cues: problem to proper health care provider will give patent airway
- Presence of adventitious breath sound to the client. Oxygenation is a vital need for every cell, if there
(Crackles) upon auscultation. are any problems related to it can easily affect the functioning
-The patient is coughing with phlegm. of the individual.
- Oriented  Retained secretions can cause blockage of airway which will
- GCS E4V5M6 further cause difficulty of breathing (Fundamentals of Nursing
- BP- 90/60 mmHg, CR: 84 bpm, RR: 36 cpm, 7th ed by Kozier et al. p. 1299)
T-38.1 C
- Difficulty vocalizing
- Has hallow eyes.
- Bluish nail beds.
-use of axillary muscles when breathing
Subjective:
-The husband of the client verbalized, “Naku
hindi na nawala ang lagnat ng asawa ko,
pabalik-balik na lang”
Objective:
-Flushed skin; warm to touch
-Increase body temperature higher than normal
range
-Increased respiration RR= 36cpm
-The patient is sweating
-T: 38.1˚C
Subjective:
- The patient is only eating 4 spoons of rice with
viand.
- The relative verbalized “Hindi siya nakakakain
ng maayus dahil sa kanyang ubo”.
Objective:
- The patient weight is 31.5 kilograms.
- Poor muscle tone.
- Appears weak.
- Minimal subcutaneous fat.
- can eat half serving of hospital food only
Subjective:
- The husband verbalizes that her wife is easily
getting tired. Her maximum work is one hour
only, and then she would go to rest.
- Her usual activities is cleaning the house,
cooking and washing the clothes. Their children
help her wife.
Hyperthermia related to
infection as evidenced by
increased WBC
Imbalanced Nutrition: Less than
Body Requirements related to
loss of appetite secondary to
deceased process.
Activity intolerance related to
inadequate oxygen supply as
evidenced by easy fatigability.
2  This demands immediate treatment/care and subsequent
medical attention, as they can result in delirium and
convulsions. This is an actual problem that needs to addressed.
 Lack of action in this health care problem may cause
dehydration which may later cause a bigger threat to the health
of the client.
3  This condition needs to be addressed immediately for the client
to be able to gain enough strength in performing her usual
activities.
 The body obtains energy in the form of calories from
carbohydrates, protein and fat. The body uses energy for
voluntary activities such as walking and in involuntary
activities such as breathing. (Fundamentals of Nursing 7th ed by
Kozier et al.)
4  This nursing diagnosis is not life threatening and doesn’t need
immediate attention, however, it can affect the body’s normal
functioning
 Individuals who have inactive lifestyles or who are faced with
inactivity because of illness or injury are at risk for many
problems that can affect major body systems. Clients
experience a significant decrease in the muscular strength and
agility whenever they do not maintain a moderate amount of
physical activity. (Fundamentals of Nursing 7th ed by Kozier et
al. p. 1068).
 Subjective: Sleep Deprivation related to 5  This condition doesn’t need immediate attention but needs to
- The patient regularly sleeps at 8:00pm and prolonged physical discomfort be addressed for sleep is a basic human need.
wakes up at 1:00 pm. (dyspnea) as evidenced by  A lack of rest for long periods can cause illness or worsening
- She usually sits because according to her she inability to concentrate of existing illness. (Fundamentals of Nursing, 6th ed by Potter
can breath more easily. and Perry p. 1206)
- She takes a nap in the morning from 8 am to 11
am.
- She is experiencing intermittent sleep
disturbance because according to her she feels
difficulty of breathing and cough.

C. Nursing Care Plan

ASSESSMENT NURSING BACKGROUND GOAL and NURSING RATIONALE EVALUATION

DIAGNOSIS KNOWLDEGE OBJECTIVES INTERVENTION

Subjective Cues: Ineffective breathing Intermediate Cause: Short term Goal: A. After 15-30
- Patient verbalized, pattern related to - Retained secretions Objectives: Objective 1: mins of nursing
“Matagal na akong difficulty of breathing in the respiratory Independent-Facilitative: - Health status is regulated interventions
inuubo. Nahihirapan as evidenced by tract. Within 15-30 mins 1. Obtain vital signs of the through homeostatic the patient was
akong huminga”. increased RR and of nursing patient. mechanisms. A change in able to
presence of crackles Intermediate Cause: intervention the V/S might indicate health experience
Objective Cues: on both lung fields. - Inflammatory patient will be able change. (Taylor et.al, FON relief from
- Presence of response to experience 5th ed. Page 523) difficulty of
adventitious breath effective breathing breathing as
sound (Crackles) upon Root Cause: pattern as evidenced 2. Observe for respiratory rate -Nasal flaring and use of evidenced by
auscultation. - Bacterial infection by RR within and rhythm; presence of nasal accessory muscles indicates RR 26cpm.
- presence of of the respiratory normal range. flaring; and use of accessory increased effort is required Goal partially
productive cough system. muscles when breathing like for breathing. met.
- nasal flaring Long term goal: the diaphragm and coastal B. After 4-8 hours
- RR = 36cpm Health Implication: muscles. of nursing
- use of accessory This condition can Within 4-8 hours of 3. Perform the Blanch Test. intervention
muscles in breathing cause Acute nursing intervention - Blanch test reflects the patient was able
- bluish nail beds Respiratory Distress the patient will be adequacy of o2 circulation to maintain
Syndrome (ARDS) able to maintain in the periphery. normal
which results from normal breathing breathing
the combination of pattern as evidenced 4. Auscultate the lungs to note -Crackles are intermittent pattern as
infection and by RR in normal any lung sounds. sounds that occur when air evidenced by
inflammatory range, absence of moves through airway that RR ranging
response. The lungs nasal flaring and use contain fluids. (Taylor et.al, from 18-20
become quickly filled of accessory muscle. FON 5th ed. Page 1386) cpm, absence of
with fluid and nasal flaring
become very stiff. Objective 2: -Tapping the chest can and use of
This stiffness, Independent- Facilitative: loosen the secretions. accessory
combined with 1. Perform Chest (Taylor et.al, FON 5th ed. muscles in
difficulties extracting physiotherapy. Page 1251) breathing. Goal
oxygen due to the successfully
alveolar fluid creates -Suction removes secretions met.
a need for ventilation. Dependent-Facilitative: through the use of a strong
Septic shock is one 1. Suction secretion as needed. pressure.
potential
complication.
2. Increase the amount of oral - Current data indicates that
(Black, Medical fluid intake as ordered by the fluid restriction may
Surgical Nursing 7th doctor. actually reduce blood
ed. Page 1896) volume and decrease
cerebral circulation. The
lack of volume causes the
blood to be thick and
sluggish and may decrease
the mobilization of nutrition
and toxins out of the
circulation. Patient should
be maintained in a
euvolemic state rather than a
fluid-restricted state. (Black,
MSN 7th ed. Page 2201)
- They act on the respiratory
Dependent-Supplemental: tract, it opens narrowed
1. Administer bronchodilators airways.
as ordered. (Black, MSN 7th ed. Page
1652)
- For maximal lung
Objective 3: expansion that will improve
Independent-Facilitative: oxygen delivery.
1. Elevate the head of the bed. -Position changes allow free
movement of the diaphragm
2. Position the head in the and expansion of the chest
midline of the body. wall. (Taylor et.al, FON 5th
 ed. Page 1396)

Asessment Nursing Diagnosis Background Goal And Objectives Nursing Interventions Rationale Evaluation
Knowledge
 EFFECTIVENESS

Subjective: Hyperthermia Etiology After 30- 40 minutes of

related to nursing interventions,
-The husband of the inflammatory Immediate the client will be able to 1. After 5 minute of
client verbalized, response as Cause: lessen temperature from nursing intervention, the
“Naku hindi na evidenced by warm 38 C to less than 37.7 C family of the client able
nawala ang lagnat to touch skin and Inflammatory to assess for the
ng asawa ko, temperature of 38.1 response of the causative/ contributing
pabalik-balik na C body against factor/s that may alter
lang” microorganisms. 1. After 5 minute of the condition of the
nursing intervention, patient.
the family of the client INDEPENDENT
Objective:
-Flushed skin; warm will be able to assess 2. After 15 minutes of
Intermediate  Identify underlying cause  To know for the right
to touch for the causative/ nursing intervention the
Cause: (in our case it is due to treatment to be given.
-Increase body contributing factor/s family of the client able
inflammatory response cause
temperature higher and be able to to evaluate effects of
Infection of M. by the disease process)
than normal range participate in one hyperthermia and able to
Tuberculosis intervention. participate in some of the
-Increased
respiration , RR= 36 intervention that they
Root Cause:
cpm may render to reduce
-The patient is Weakened body’s temperature of
sweating 2. After 15 minutes of the patient.
immune system. nursing interventions,
-T: 38.1˚C
the family of the client
will be able to evaluate INDEPENDENT
effects of hyperthermia
and be able to  Monitor patient’s vital signs.  Temperature of 102˚F-
Health participate in at least 3 Give particular attention to the 106˚F (38.9˚C- 41.1˚C)
Implication: out of 4 interventions. temperature. suggests acute infectious
disease process. Fever 3. After 15 minutes of
Fevers of 104 F pattern may aid in nursing intervention the
(40 C) or higher diagnosis; eg 24 hour period family of the client able
demand suggest septic episode, to attain wellness after
immediate home septic endocarditis or some of the dependent
treatment and Tuberculosis (TB). Chills and independent nursing
subsequent often precede temperature intervention that
medical attention, spikes.
Efficiency:
as they can result [Nursing Care Plans Edition
in delirium and 6, page 667. Copyright 2002 After 40 minutes of
convulsions, by Marilyn E. Doenges, RN,

 Assess for presence of
posturing or seizures.
 Monitor/ record all sources
of fluid loss such as urine.
 Note presence/ absence of
sweating as body attempts to
increase heat loss by
evaporation, conduction and
diffusion.
DEPENDENT
 Administer antipyretics as
orederd; paracetamol 500
mg/tab 1 tab q4 prn T>37.8 C
3. After 15 minutes of
nursing interventions,
the family of the client
BSN, MA, CS] nursing intervention the
patient’s temperature
 To note for further care to decreased from 38.1˚C to
be given. 37.4˚C.
 Oliguria and/or renal
failure may be occurring Appropriateness:
due to hypotension,
dehydration. [NANDA] -All of the following
intervention helps in
decreasing patient’s
 Evaporation is decreased body temperature,
by environmental factors of maintaining it in normal
high humidity and high range and monitoring in
ambient temperature as well progress of the
as body factors producing condition.
loss of ability to sweat or
sweat gland dysfunction.
Acceptability:
[NANDA]
The family and the
patient has willfully
 Used to reduce fever by its
accepted and be able to
central action on the
participate in the
hypothalamus; fever should
interventions done to the
be controlled in patients
patient.
who are neutropenic or
asplenis. However, fever
may be beneficial in
limiting growth of
organisms and enhancing
autodestruction of infected
cells.
[Nursing Care Plans Edition
6, page 667. Copyright 2002
by Marilyn E. Doenges, RN,
BSN, MA, CS]
will be able to assist
with measures to reduce
body temperature and  May help reduce fever.
participate in at least 3 Note: use of ice water/
out of 4 interventions. INDEPENDENT alcohol may cause chills,
actually elevating
 Provide tepid sponge baths; temperature. In addition,
avoid use of alcohol. alcohol is very drying to
skin.
[Nursing Care Plans Edition
6, page 667. Copyright 2002
by Marilyn E. Doenges, RN,
BSN, MA, CS]

 To support circulating
volume and tissue perfusion.
[NANDA]
DEPENDENT

 Administer replacement  To meet increased

fluids and electrolytes. metabolic demands.
[NANDA]

4. After 2 minutes of
nursing intervention,
the family of the client  Provide high-calorie diet,
will be able to promote tube feedings or parenteral
wellness and give 2 out nutrition.
of 2 interventions.
 To prevent dehydration.
[NANDA]

INDEPENDENT

 Discuss importance of
adequate fluid intake.  Indicates need for prompt
intervention.
  Review signs and symptoms
of hyperthermia (eg. Flushed
skin, increased body
temperature, increased
respiratory/heart rate).

D. Discharge Planning
Medications Continue Taking the Anti-TB drugs. The intensive phase is for 2 months and the maintenance phase is for 4 months. Medicines are readily
available at TB- DOTS since the patient was enrolled for the TB-DOTS program.

Exercise/Economic Factor Practice deep breathing exercise and coughing exercises. Resume previous activities. Prevent extraneous work. Have a regular physical
exercise like brisk walking for 30 minutes daily. For financial insufficiency, there are government drug stores available. The patient may
continue her work in the factory.

Treatment Follow faithfully the regimen for tuberculosis, especially the medications. Have a regular sputum test and chest x-ray , as ordered by the
doctor to monitor progress of the decease.

Health Teaching The client should practice hand washing regularly. Always cover the mouth and the nose when exposed to person who coughs or sneezes.
She should not spit anywhere, instead spit in a single container to prevent transfer of M. Tuberculosis.

Out-patient Follow-up Always have a regular check up at your nearest health center, at least once a week to monitor the progress of the treatment. The client
should report immediately to the physician if there is difficulty of breathing, there is productive cough more than 5 days and there is chest
pain and experiencing fatigue.

Diet The diet should be high caloric. Always drink a lot of water. Also eat fruits and vegetables. Don’t skip meals. If there are any food
supplements available, consult it with the doctor. Eat vitamin c rich food to strengthen immune systems.

Spiritual/Sexual Activities Always pray for the guidance of the Lord. Spiritual health affects the wellness of an individual greatly. Strengthen relationship with Lord
by showing love and respect to the people around you. May continue/resume sexual activity.