Ateneo de Zamboanga University

College of Nursing

CASE OF Pulmonary Tuberculosis

A 48-year-old male accompanied by his wife brought to the Emergency Room of Brent Hospital
and Colleges Incorporated. The wife verbalized that the patient has been coughing with blood
streaked for more than two (2) weeks already. The wife verbalized also that he has on and off
fever.
Initial assessment by the nurse showed that the patient is febrile with difficulty of breathing,
sweating and lethargic. The patient weighs 52 kgs- malnourished
The vital signs are as follow:
 Temperature - 38.9C
 Apical pulse – 101 beats/minute
 Respiration – 28 breaths/minute
 Oxygen saturation – 94%
The doctor ordered the following for the patient:
 routine laboratory works
 oxygen by nasal cannula at 2 liters/min
 chest x-ray
 Paracetamol 500mg 1 tab evey 4 hour PRN for fever
 Tranexamic Acid 10mg/kg IVT every 6 hours PRN for hemoptysis
 Myrin P Forte 3 tablets OD 1 hour before breakfast
Stocks on hand:
 Paracetamol 500 mg/tab
 Tranexamic Acid 100mg/ml
 Myrin P Forte tab
Laboratory Results:

Results Normal Values

RBC 5.1x10/L 4.0 – 5.2
Hgb 15.5g/dl 115 – 155g/dl
Hct 40% 35 - 40%
Platelets 240,000 150000 - 400000
WBC 20 x 10/L 4.5 – 14.5 x 10/L

Lung X – ray Film:

Normal chest x-ray chest x-ray with

Tuberculosis
 Plan of Activities

Date: August 2-4, 2021

Area: Eeab Hospital

Ward: ER

Shift: 7am-3pm

GENERAL OBJECTIVES:

Acquisition and application of knowledge, skills, and attitude through the utilization of nursing process in
the care of patients with infectious and inflammatory diseases with emphasis on health promotion,
prevention, and maintenance of health.

Learning Objectives:

At the end of the 24 hours of Related Learning Experience, I will be able to:

1) To establish rapport with the Clinical Instructor, Duty mates, Staff professionally
2) To be oriented with the policies and protocols of current hospital
3) Acquire knowledge about the process of activities required in this hospital
4) Utilize/demonstrate the skills needed for Physical Assessment of patients properly
5) Assess the given patient’s health condition with Gordon’s Assessment
6) Determine the possible complication on a patient with Pulmonary tuberculosis
7) Identify the signs and symptoms of the presented medical condition
8) Determine the medical equipment/ nursing kit needed for physical assessment

Time Activities Specific Objectives

Day 1

6:30 am – 6. 45 am - Arrival at the waiting - To meet with other group

area members

6:45am – 7:00 am - Arrival at hospital - To start endorsement

7:00 am – 7:15 am - Checking of uniform and - To check readiness of group

attendance members

7:15 am – 7:30 am - Sub-grouping the - To know their specific area of

members and delegation responsibility
of areas of
responsibilities

7:30 am – 7:45 am - Courtesy call to the Head - To pay respect to the health care
Nurse, Staff Nurses, and providers and inform them
other health personnel about our presence

- Orientation regarding - To get acquainted with assigned

7:45 am – 8:00 am hospital setting institution

- Nurses go for rounds - To check for the patient

8:00 am – 8:15 am
- Introduction with - To get the patient acquainted
8:15am – 8:30 am patient, inform about with the nurse and is willing to
physical assessment and coordinate
Gordon’s assessment and
get vital signs of patient

- Ask questions with - To know what and when to

8:30 am – 9:00 am patient regarding provide medication to patient
medications taken and
current state and provide
morning care

- Break time. Remind the - To be well prepared for the next

group to stay inside operation
9:00 am – 9:15am
hospital premises.

- Assemble equipment for - To note down information of

physical assessment and assessment for the next
9:15 am – 11:00 am start assessment with endorsement
patient
- To inform doctor during their
11:00 am – 12:00 pm - Ask questions with rounds of any sign of
patient while utilizing abnormality from patient
Gordon’s assessment
pattern

- Lunch - To be prepared for next

operation
12:00 pm – 12:30 pm - To assemble the group and make
- Checking of attendance
sure its complete
- Check and document - To see if there is an anomaly to
12:30 pm – 1:15 pm patient’s vital signs their vital signs
1:15 pm – 1:30 pm
- Assist nurse on duty in
administering medication - To know the process of dosage
to patient administration in hospital setting
1:30 pm – 2:00 pm
- Complete chartings

2:00 pm – 2:30 pm - Discuss activities

throughout the day
 2:30pm – 2: 59 pm - dismissal
3:00 pm
Physical Assessment + Gordon’s Assessment
1) Gordon’s 11 functional health pattern
Functional Health Pattern Pattern describes
Health perception/ Health View of the patient about the
management disease and how to deal with
patients who carried the disease.
Nutritional- Metabolic The ability of patients to consume
food has decreased due to the
lack of appetite.
Elimination Patients with pulmonary TB is
rare, impaired bowel and bladder
elimination.
Activity-Exercise Usually, the patient experienced a
decrease in activity associated
with body weakness experienced.
Cognitive- Perceptual Memory pulmonary TB patients
mostly found not impaired.
Sleep- Rest Rest and sleep are often disturbed
due to cough experienced at
night.
Self-Perception/ Self-Concept Feelings receive from patient with
the situation, most patients are
not impaired self-concept.
Role-Relationship Changes in the pattern of relations
role in responsibilities or changes
Examples
The patient has been coughing
with blood streaked for more
than two (2) weeks already.
The wife verbalized also that
he has on and off fever. Initial
assessment by the nurse
showed that the patient is
febrile with difficulty of
breathing, sweating and
lethargic.
The lack of appetite in patient
is due to patient’s consistent
occurrence of coughing with
blood streaked and fever.
Unaffected
Due to initial assessment of
showing that patient has
difficulty of breathing, activity
is decreased.
Unaffected
Evidence is seen by patient
being lethargic and the on and
off fever may cause hindrance
to patient’s sleeping schedule
Unaffected
Patient is not strong enough to
come to the hospital on his
 in physical capacity to perform the own thus, role is replaced by
role. wife to perform and bring
patient to hospital.

Sexuality-Reproductive The patient's ability to perform in The patient is lacking in energy

accordance with the gender roles. due to limited rest and
The patient does not do sexual increasing fever therefore
because of the weakness of the unable to perform sexual
body. reproduction.

Coping/Stress tolerance Defense mechanism used by The patient is brough to the

patient is to seek help from Emergency room to seek help
others. in coping with their own
weakness of the body.

Value- Belief The religion of the patient and Unaffected

patient compliance in performing
religious teachings usually not
impaired in patient’s system
values and beliefs.