INTRODUCTION

As a part of my clinical postings in Medical Surgical Nursing, I was posted to the intensive
care unit of Dhanwantri Hospital, jodhpur. There were about 8 patients; among them I selected
Mr. Prakash as my patient who was suffering tuberculosis for my study.

BIOGRAPHICAL INFORMATION
Name : Mr. Prakash
Age : 53 years
Sex : Male
I.P. No : 231
Address :ghantagharjodhpur.
Religion : Hindu
Education : Graduation
Marital status : Married
Income : 20000 per month
Occupation : Driver
Ward : male medical ward; Bed 8
Date of admission & time : Diagnosis : Tuberculosis
Surgery : Nil

CHIEF COMPLAINTS
Mr. Prakashadmittedto dhanwantri hospital, jodhpur with the complaints of fever, severe
cough since 2 weeks.

PRESENT ILLNESS
Mr. Prakashcomplaints of fever, severe cough since 2 weeks and admitted to
dhanwantrihospital. It was diagnosed as tuberculosis. Symptoms decreases after taking
medications prescribed by doctor.
PAST HEALTH HISTORY
 Mr. Prakashhad no significant past medical history. He wasn’t undergone any surgeries in
the past.

PERSONAL HISTORY
Mr. Prakashbelongs to a middle class family. He is married. He takes mixed diet 3 times
a day. He has a bad habit of alcoholism. He has difficulty in sleeping. He has good relationship
with neighbors and relatives.

FAMILY HISTORY
There are 5 members in his family including his wife, two sons and a daughter. All the
other family members are healthy. There are no communicable diseases in his family.
KEY

Male
Female
Patient

SOCIO-ECONOMIC HISTORY
Mr. Prakash is the breadwinner in his family. They earns from business. Monthly income is
around 20000/-. His living standard is moderate. They belong to a middle class family.
ENVIRONMENTAL HISTORY
Mr. Prakashis residing in their own roofed semi pucca house. Their house is well ventilated.
Their house is electrified and gets water from near borewell.
NUTRITIONAL HISTORY
Mr. Prakashis a non vegetarian. He does not have any allergy to food items. He likes non
vegetarian diet. He takes food 3 times a day.

ELIMINATION HISTORY
Mr. Prakash’sbowel and bladder functions were normal.
 PHYSICAL EXAMINATION
GENERAL OBSERVATION
Posture : Normal
:No lordosis or kyphosis
Personal appearance : Not well groomed.
Emotional status : anxious
Co-operativeness : Co-operative

VITAL SIGNS

VITAL SIGNS PATIENT’S VALUE NORMAL VALUE

Temperature 98.8 degree F 98.6 degree F
Pulse 78/minute 60-80/ minute
Respiration 24/minute 18-24/ minute
Blood pressure 120/80 mm Hg 120/80mmHg

HEIGHT & WEIGHT

Height : 166 cm
Weight : 66 kg
SKIN
Color : Brown, no cyanosis or jaundice
Edema : No edema
Moisture/turgor : warm
HEAD
Shape : Normal cephalic, no lesions, normal distribution
Scalp : clean
Movement : normal range of motion possible.
EYES
Eyebrows : symmetric
Eyelids : No edema
Eye lashes : No infection
Conjunctiva : Normal
Sclera : White and clear, no yellowish discolouration
Visual acuity : Normal
PERRLA : Pupils round symmetrical, reactive to light.
Eye movements : Normal
EARS
External ear : No discharges and infections. Cerumen present
Appearance : Auricles are normal and symmetrical
Hearing : Normal hearing.
NOSE
Nostrils : No deviated nasal septum and running nose.
Appearance : No nasal flaring.
Sense of smell : Normal
MOUTH AND THROAT
Infections : No glossitis, no stomatitis
Lips : Symmetric, dry and no lesions
Tongue : Dry, pink, no coatings
Teeth : Dental caries absent
Gum : No gingivitis
Buccal mucosa : No lesions
Palate : Intact, symmetrical
Sense of taste : Normal
NECK
Appearance : No deformity, tenderness or swelling.
Trachea : No deviation, and tenderness
Lymph nodes : Not palpable
Thyroid gland : Symmetric. Not enlarged
: No distended neck veins.
CHEST AND RESPIRATORY SYSTEM
INSPECTION
Symmetry : Symmetrical
Expansion : Normal
Equality of movement: Normal
Type of respiration : Normal
Rate : 24/ minute
Rhythum : Regular

PALPATION
Vocal tactile fremitus : Normal
: No local swelling.
PERCUSSION
Resonance
AUSCULTASTION
Bronchial : Normal
Bronchovescular : Normal
Vescular : Normal
Friction rub : Nothing significant

CARDIOVASCULAR SYSTEM
INSPECTION
Chest countour : Normal
Neck : No jugular vein distention
PERCUSSION
Normal
AUSCULTATION
Heart rate :Apical heart rate is 78/ minute.
ABDOMEN
INSPECTION
Movement : Normal
AUSCULTATION
Normal sounds
PERCUSSION
No signs of fluid accumulation
PALPATION
No enlargement of organs

BACK
Spinal curvature : No deformity
Symmetry : Symmetrical
Movement : Normal ROM
GENETALIA AND GROIN
Nothing significant
UPPER AND LOWER EXTREMITIES
Normal ROM possible
NERVOUS SYSTEM
Higher functions : Normal
Speech : Fluent and clear
Sensory and motor function : Normal
Cranial nerves and reflexes : Normal

INVESTIGATIONS

INVESTIGATIONS PATIENT’S VALUE NORMAL VALUE

Hb 12 gm% 12-16gm%12-16gm%
WBC 9600cmm 4000-11000cmm

Urine analysis
Sugar Nil Nil
Albumin Nil Nil

Tuberculosis (TB)
Introduction
Tuberculosis (TB) is a contagious infection that usually attacks your lungs. It can also spread to other
parts of your body, like your brain and spine. A type of bacteria called Mycobacterium tuberculosis
causes it.

This bacteria is thought to be over 3 million years old. Knowledge of the disease dates back to ancient
Greece and Rome. Tuberculosis, formerly called consumption, was the top cause of death in the U.S. at
the beginning of the 20th century.

While it's largely controlled in the U.S. now, it still kills more than a million people worldwide every
year.

People with HIV/AIDS and others with weakened immune systems are at higher risk of getting
tuberculosis because their bodies have a harder time fighting the bacteria.
Tuberculosis Types
A TB infection doesn’t always mean you’ll get sick. There are several stages and forms of the
disease:

 Primary TB. This is the first stage of a tuberculosis infection. Your immune system may
be able to fight off the germs. But sometimes it doesn't destroy all of them, and they keep
multiplying. You may not have any TB symptoms at this stage, or you might have a few
flu-like symptoms.
 Latent TB. You have the germs in your body, but your immune system keeps them from
spreading. You don’t have any symptoms, and you’re not contagious. But the infection is
still alive and can one day become active. If you’re at high risk for reactivation, your
doctor will give you medications to prevent active TB. This usually happens if you
have HIV, you had an infection in the past 2 years, your chest X-ray is unusual, or your
immune system is weakened.
 Active TB. The germs multiply and make you sick. You can spread the disease to others.
Some 90% of active cases in adults come from a latent TB infection.
 Active TB outside the lungs. A tuberculosis infection that spreads from your lungs to
other parts of the body is known as extrapulmonary tuberculosis. Your symptoms will
depend on which part of your body the infection affects.

A latent or active TB infection can also be drug-resistant, meaning certain

medications don’t work against the bacteria.
 Review anatomy & physiology

When a person gets active TB disease, it means TB bacteria are multiplying and attacking the
lung(s) or other parts of the body, such as the lymph nodes, bones, kidney, brain, spine and even
the skin. From the lungs, TB bacteria move through the blood or lymphatic system to different
parts of the body.

Anatomy

Anatomically, the lung has an apex, three borders, and three surfaces. The
apex lies above the first rib.
The three borders include the anterior, posterior, and inferior borders. The
anterior border of the lung corresponds to the pleural reflection, and it creates
a cardiac notch in the left lung. The cardiac notch is a concavity in the lung
that formes to accommodate the heart. The inferior border is thin and
separates the base of the lung from the costal surface. The posterior border is
thick and extends from the C7 to the T10 vertebra, which is also from the
apex of the lung to the inferior border.
The three surfaces of the lung include the costal, medial, and diaphragmatic
surfaces. The costal surface is covered by the costal pleura and is along the
sternum and ribs. It also joins the medial surface at the anterior and posterior
borders and diaphragmatic surfaces at the inferior border. The medial surface
is divided anteriorly and posteriorly. Anteriorly it is related to the sternum,
and posteriorly it is related to the vertebra. The diaphragmatic surface (base)
is concave and rests on the dome of the diaphragm; the right dome is also
higher than the left dome because of the liver.
The right and left lung anatomy are similar but asymmetrical. The right lung
consists of three lobes: the right upper lobe (RUL), the right middle lobe
(RML), and the right lower lobe (RLL). The left lung consists of two lobes:
the left upper lobe (LUL) and the left lower lobe (LLL). The right lobe is
divided by an oblique and horizontal fissure, where the horizontal fissure
divides the upper and middle lobe, and the oblique fissure divides the middle
and lower lobes. In the left lobe, there is only an oblique fissure that separates
the upper and lower lobe.
The lobes further divide into segments that are associated with specific
segmental bronchi. Segmental bronchi are the third-order branches off the
second-order branches (lobar bronchi) that come off the main bronchus.
The right lung consists of ten segments. There are three segments in the RUL
(apical, anterior, and posterior), two in the RML (medial and lateral), and five
in the RLL (superior, medial, anterior, lateral, and posterior). The oblique
fissure separates the RUL from the RML, and the horizontal fissure separates
the RLL from the RML and RUL.
There are eight to nine segments on the left, depending on the division of the
lobe. In general, there are four segments in the left upper lobe (anterior,
apicoposterior, inferior, and superior lingula) and four or five in the left lower
lobe (lateral, anteromedial, superior, and posterior).
The hilum (root) is a depressed surface at the center of the medial surface of
the lung and lies anteriorly to fifth through seventh thoracic vertebrae. It is
the point at which various structures enter and exit the lung. The hilum is
surrounded by pleura, which extends inferiorly and forms a pulmonary
ligament. The hilum contains mostly bronchi and pulmonary vasculature,
along with the phrenic nerve, lymphatics, nodes, and bronchial vessels. Both
left and right hilum contain a pulmonary artery, pulmonary veins (superior
and inferior), and bronchial arteries. Also, in the left hilum, there is one
bronchus, the principal bronchus, and in the right hilum, there are two
bronchi, the eparterial and hyparterial bronchi. From anterior to posterior, the
order in the hilum is the vein, artery, and bronchus.
Structure and Function

The function of the lung is to get oxygen from the air to the blood, performed
by the alveoli. The alveoli are a single cell membrane that allows for gas
exchange to the pulmonary vasculature. There are a couple of muscles that
help with inspiration and expiration, such as the diaphragm and intercostal
muscles. Sternocleidomastoid and scalene muscles are used for accessory
respiration when the patient is in respiratory distress or failure. The muscles
help create a negative pressure within the thorax, where the pressure of the
lung is less than the atmospheric pressure, to help with inspiration and filling
of the lungs. Also, the muscles help with creating a positive pressure within
the thorax, where the pressure of the lung is greater than the atmospheric
pressure, to help with expiration and emptying of the lung.
Blood Supply and Lymphatics
The main distinction is between the pulmonary artery and bronchial arteries.
The pulmonary artery takes deoxygenated blood from the heart to be
oxygenated by the lung parenchyma. However, the bronchial arteries provide
oxygen for survival to the lung parenchyma.
The main pulmonary artery emerges from the right ventricle and bifurcates
into the left main and right main pulmonary arteries. The pulmonary artery
branches usually trail and expand along the branches of the bronchial tree and
eventually become capillaries around the alveoli. The pulmonary veins
receive oxygenated blood from the alveoli capillaries and deoxygenated
blood from the bronchial arteries and visceral pleura. Four pulmonary veins
come together at the right atrium.
Bronchial circulation is part of the systemic circulation. The left bronchial
artery arises as two (superior and inferior) from the thoracic aorta. The right
brachial artery usually comes from one of the following three: the right
posterior intercostal artery, with the left superior bronchial artery off the aorta
or directly from the aorta. The bronchial veins collect the deoxygenated
blood and empty it into the azygos vein.
The superficial and deep lymphatic plexuses drain the lung. The lymph flow
from lung parenchyma first drains into the intraparenchymal nodes and then
to the peribronchial nodes. Subsequently, the lymphatics will drain to the
tracheobronchial, paratracheal lymph nodes, the bronchomediastinal trunk,
and then into the thoracic duct.
Nerves
The phrenic nerve comes from C3,4,5 cervical nerve roots. It innervates the
fibrous pericardium, portions of the visceral pleura, and the diaphragm.
The lung receives innervation from two main sources: the pulmonary plexus
(a combination of parasympathetic and sympathetic innervation) and the
phrenic nerve. The pulmonary plexus is at the root of the lung and consists of
efferent and afferent autonomic nerve fibers. It consists of branches of the
vagus nerve (parasympathetic) and sympathetic fibers—the plexus branches
around the pulmonary vasculature and bronchi. The parasympathetic
innervation causes constriction of the bronchi, dilation of the pulmonary
vessels, and increase gland secretion. The sympathetic innervation causes
dilation of the bronchi and constriction of the pulmonary vessels.
Physiologic Variants
Accessory fissures may occur; these may be superficial or deep at the hilum.
They may cause odd patterns on X-ray during specific pathologies.
Other variations that may occur can include agenesis (absence of a lung),
aplasia, or accessory lobes (can cause imaging variations).

Disease Condition
Tuberculosis (TB) is a serious illness that mainly affects the lungs. The
germs that cause tuberculosis are a type of bacteria.

Tuberculosis can spread when a person with the illness coughs, sneezes
or sings. This can put tiny droplets with the germs into the air. Another
person can then breathe in the droplets, and the germs enter the lungs.

Tuberculosis spreads easily where people gather in crowds or where

people live in crowded conditions. People with HIV/AIDS and other
people with weakened immune systems have a higher risk of catching
tuberculosis than people with typical immune systems.
Drugs called antibiotics can treat tuberculosis. But some forms of the
bacteria no longer respond well to treatments.

Classification

When tuberculosis (TB) germs survive and multiply in the

lungs, it is called a TB infection. A TB infection may be in one
of three stages. Symptoms are different in each stage.

Primary TB infection. The first stage is called the primary

infection. Immune system cells find and capture the germs. The
immune system may completely destroy the germs. But some
captured germs may still survive and multiply.

Most people don't have symptoms during a primary infection.

Some people may get flu-like symptoms, such as:

 Low fever.

 Tiredness.

 Cough.

Latent TB infection. Primary infection is usually followed by

the stage called latent TB infection. Immune system cells build a
wall around lung tissue with TB germs. The germs can't do any
more harm if the immune system keeps them under control. But
the germs survive. There are no symptoms during latent TB
infection.

Active TB disease. Active TB disease happens when the

immune system can't control an infection. Germs cause disease
throughout the lungs or other parts of the body. Active TB
disease may happen right after primary infection. But it usually
happens after months or years of latent TB infection.

Symptoms of active TB disease in the lungs usually begin

gradually and worsen over a few weeks. They may include:

 Cough.

 Coughing up blood or mucus.

 Chest pain.

 Pain with breathing or coughing.

 Fever.

 Chills.

 Night sweats.

 Weight loss.
  Not wanting to eat.

 Tiredness.

 Not feeling well in general.

Active TB disease outside the lungs. TB infection can spread

from the lungs to other parts of the body. This is called
extrapulmonary tuberculosis. Symptoms vary depending on
what part of the body is infected. Common symptoms may
include:

 Fever.

 Chills.

 Night sweats.

 Weight loss.

 Not wanting to eat.

 Tiredness.

 Not feeling well in general.

 Pain near the site of infection.

Active TB disease in the voice box is outside the lungs, but it
has symptoms more like disease in the lungs.

Common sites of active TB disease outside the lungs include:

 Kidneys.

 Liver.

 Fluid surrounding the brain and spinal cord.

 Heart muscles.

 Genitals.

 Lymph nodes.

 Bones and joints.

 Skin.

 Walls of blood vessels.

 Voice box, also called larynx.

Active TB disease in children. Symptoms of active TB disease

in children vary. Typically, symptoms by age may include the
following:

Teenagers. Symptoms are similar to adult symptoms.

1- to 12-year-olds. Younger children may have a fever that
won't go away and weight loss.

Infants.The baby doesn't grow or gain weight as expected. Also,

a baby may have symptoms from swelling in the fluid around
the brain or spinal cord, including:

 Being sluggish or not active.

 Unusually fussy.

 Vomiting.

 Poor feeding.

 Bulging soft spot on the head.

 Poor reflexes.

Etiology

Tuberculosis is caused by a bacterium called

Mycobacterium tuberculosis.

People with active TB disease in the lungs or voice box can

spread the disease. They release tiny droplets that carry the
bacteria through the air. This can happen when they're
speaking, singing, laughing, coughing or sneezing. A
person can get an infection after inhaling the droplets.

The disease is more likely to spread when people spend a

lot of time together in an indoor space. So the disease
spreads easily in places where people live or work together
for long periods. Also, the disease spreads more easily in
crowded gatherings.

A person with a latent TB infection cannot pass the disease

to other people. A person taking drugs to treat active TB
disease usually can't pass the disease after 2 to 3 weeks of
treatment.

Drug-resistant TB

Some forms of the TB bacteria have become drug resistant.

This means that drugs that once cured the disease no longer
work.

This happens, in part, because of naturally occurring

genetic changes in bacteria. A random genetic change in a
bacterium might give it some quality that makes it more
likely to survive the attack of an antibiotic. If it does
survive, then it can multiply.

When antibiotic drugs aren't used correctly — or drugs fail

to kill all the bacteria for another reason — the conditions
are ideal for more-resistant versions of the bacteria to get
established and multiply. If these bacteria are passed on to
other people, a new drug-resistant strain can grow over
time.

Problems that can lead to such drug-resistant strains of

bacteria include the following:

People didn't follow directions for taking the drugs or

stopped taking the drugs.

They weren't prescribed the right treatment plan.

Drugs were not available.

The drugs were of poor quality.

The body didn't absorb the drugs as expected.

Risk factors
Anyone can get tuberculosis, but certain factors increase
the risk of getting an infection. Other factors increase the
risk of an infection becoming active TB disease.

The Centers for Disease Control and Prevention

recommends a TB test for people who have an increased
risk of TB infection or active TB disease. Talk to your
health care provider if you have one or more of the
following risk factors.

Risk of TB infection

Certain living or working conditions make it easier for the

disease to pass from one person to another. These
conditions increase the risk of getting a TB infection:

Living with someone with active TB disease.

Living or traveling in a country where TB is common,

including several countries in Latin America, Africa, Asia
and the Pacific Islands.
Living or working in places where people live close
together, such as prisons, nursing homes and shelters for
homeless people.

Living in a community identified as being at high risk of

tuberculosis.

Working in health care and treating people with a high risk

of TB.

Risk of active TB disease

A weakened immune system increases the risk of a TB

infection becoming active TB disease. Conditions or
treatments that weaken the immune system include:

 HIV/AIDS.

 Diabetes.

 Severe kidney disease.

 Cancers of the head, neck and blood.

 Malnutrition or low body weight.

 Cancer treatment, such as chemotherapy.

 Drugs to prevent rejection of transplanted organs.

 Long-term use of prescription steroids.

 Use of unlawful injected drugs.

 Misuse of alcohol.

 Smoking and using other tobacco products.

 Age and active TB disease

 The risk of a TB infection becoming active TB disease

changes with age.

 Under 5 years of age. Until children reach age 5, they

have high risk of a TB infection becoming active TB
disease. The risk is greater for children under age 2.
Tuberculosis in this age group often leads to serious
disease in the fluid surrounding the brain and spinal
column, called meningitis.

 Age 15 to 25. People in this age group have an

increased risk of developing more-severe active TB
disease in the lungs.
  Age 65 and older. The immune system weakens
during older age. Older adults have a greater risk of
active TB disease. Also, the disease may be more
difficult to treat.

REFERENCES
 Lewis, Hetkemper, Dirksen. “Medical Surgical Nursing- Assessment and management of
clinical problems”; 6th edition; Mosby publication, New Delhi. Page No:601-607.
 Brunner and Suddarth’s “Textbook of Medical-surgical Nursing”; 1 1th edition; Vol.1;
Lippincot Williams and Willkins publishers, New Delhi. Page No:546-548.