PULMONARY D E L A C R U Z , J E S F E L

TUBERCULOSIS
•Tuberculosis is a common and often deadly infectious disease caused by mycobacteria, in humans mainly
Mycobacterium tuberculosis. Tuberculosis usually attacks the lungs but can also affect the central nervous system,
the lymphatic system, the circulatory system, the genitourinary system, the gastrointestinal system, bones, joints, and
even the skin.

•Tuberculosis is spread through the air, when people who have the disease cough, sneeze, or spit. Most infections in
human beings will result in asymptomatic, latent infection, and about one in ten latent infections will eventually
progress to active disease, which, if left untreated, kills more than half of its victims. The classic symptoms of
tuberculosis are a chronic cough with blood-tinged sputum, fever, night sweats, and weight loss. Infection of other
organs causes a wide range of symptoms.

INTRODUCTION
 NURSING THEORY
FLORENCE NIGHTINGALE
“ENVIRONMENTAL THEORY”

•Florence Nightingale viewed the manipulation of the physical

environment as a major component of nursing care. When one or
more aspects of the environment are out of balance, the client
must use increased energy to counter the environmental stress.
These stresses drain the client of energy needed for healing.
A. Nursing Health History
I. Demographic

Name: Mr. ADL

Age: 24 years old
Religion: Roman Catholic
Civil Status: Single
Occupation: Car washer
Nationality: Filipino
Admitting Diagnosis: Pulmonary Tuberculosis, Pneumohyrothorax Right

II. Admission Data

A 22-year-old male patient was admitted to the emergency room last August 21, 2020, accompanied by relatives
with a chief complaint of difficulty of breathing.
III. History of Present Illness

Last two months, the family observed Mr. ADL is losing weight and has a decrease of appetite but instead of eating
foods he is more on vices, then his condition became worse according to family’s observation.

A month prior to admission, the patient’s condition became more at its worst and his cough became productive with
intermittent spots of blood in the sputum upon coughing. He also started to have night sweat, became sluggish and
spent lots of time sleeping. He was advised by the family to have a check-up and visit the nearest hospital or clinic,
but he refused everything that his family suggested, according to his sister.

Based on the statement of his mother, two days prior to admission, Mr. ADL experienced body weakness, fatigue,
and on the day of admission last August 21, 2020, in Rizal Provincial Hospital, he suddenly was complaining of
difficulty of breathing, one hour after he ate his lunch.
IV. Past Medical History

Referring to the statements made by his sister, Mr. ADL was diagnosed with Pulmonary Tuberculosis
last 2014, 6 years ago. He entered a rehabilitation program sponsored by the local government in Cavite
that will provide the beneficiates with 100% coverage on the six months duration in curing the disease.
The six months duration in curing the disease became successful, he was cured by the medication given by
the sponsored but due to vices like smoking and active drinking of liquor, the disease from the past became
active again.

By 2015, the patient had finger clubbing and through the course of my interview, it was confirmed
that at early age, my patient was suspected of heart problem; “Mahina daw po ang puso niya. Lahat din
naman kami, normal na sa amin ang mababa ang dugo mga 90/70”, as verbalized by the patient’s sister.
V. Familial History

Last 2012, 8 years ago, his father died from heart attack. Two of his uncles died from respiratory
diseases, one is from Tuberculosis, and another is from lung cancer.

 
VI. Personal and Social History
Mr. ADL is a car washer. He is working since 2016 during weekdays. The location is near to their
house, and he earns 150 pesos per day. He shares some of his earnings to his mother as one of their
resources of foods. He plays basketball and he has a good voice, according to his sister.
VII. Review of Systems

The data gathered are all coming from the mother as it was the patient subjective complaint.

SYSTEM  
General Generalized body weakness
Skin Dry
Nose Runny nose, with discharges
Throat & Mouth Dry mouth
Respiratory Difficulty of breathing, dyspnea upon exertion.
Cough
CVS Dyspnea upon exertion and chest pain
GIT Constipated at times, defecates every other day.
Extremities Joint pain
Neurologic Weakness
Endocrine Excessive night sweating
Psychiatric Depression, Ignores interview
Gordon’s Review of Systems

I. SELF PERCEPTION- SELF CONCEPT PATTERN

In my observation, the patient looks shy. He just minds his own self maybe because he is still in pain due to
chest tube thoracostomy attached on his right chest.

II. ROLE- RELATIONSHIP PATTERN

Mr. ADL is close to his mother. He lives with his mother since he was born. All the good values that he has, was
educated by his mother, but during his adolescence stage he became abusive in his body. He became active with many
kinds of vices that are influenced by his friends.
III. SEXUALITY and REPRODUCTIVE PATTERN

According to the mother, she does not have an idea about sexual activity of Mr. ADL; she only knew that Mr.
ADL is single and no girlfriend as of now.
 

IV. VALUE BELIEF AND PATTERN

Mr. ADL is a Roman Catholic, sometimes he visit the church, one ride of jeep from their house, twice a
month.

V. HEALTH PERCEPTION

Patient regularly goes to barangay health center to have his checkup. He doesn’t have any life insurance and
health card. Patient wants to regain his strength so that he can back to work.
A. Physical Assessment
a. General appearance:

Patient appeared weak looking but was somehow coherent in high fowlers position due to CTT attached to his right
chest. Mr. ADL ignores my kind interview, but he is willing to cooperate when it comes in taking vital signs, physical
assessment and giving medication. The patient’s skin was dry, especially on the lower extremities. IVF of D5NM 1L + 1 amp
of Moriavit at 50cc level was attached to his right hand.

Measurement

  FIDINGS NORMAL VALUES ANALYSIS/

  INTERPRETATION
(Ht, wt) Height: 5’5” BMI: 18.5—24.9 BMI below normal as a result of
  Weight: 101 lbs malnutrition
  BMI: 16.3
Vital Signs Temp: 36.0 C Temp: 37 C With some abnormal findings in the
PR: 90 bpm PR: 60-100 bpm respiratory rate.
RR: 29 bpm RR: 16-20 bpm Increase RR; difficulty of
BP: 100/70 mmHg BP: 120/80 mmHg breathing.
 Diagnostic Procedures

a. Chest X-ray August 21, 2020

Impression: Pulmonary Tuberculosis (PTB)
Right sided Pneumohydrothorax

b. RT Hemithorax August 22, 2020

Ultrasound done on the right hemithorax, there is a significant fluid in the right lower hemithorax.
Minimal fluid is seen with loculations noted of about 36cc. Echoes noted within probably due to air.
Impression: Minimal loculate hydrothorax, right

c. Radiological Report August 23, 2020

Impression: Pulmonary Tuberculosis, Left
Pneumohydrothorax, Right
C. Anatomy and Physiology

UPPER RESPIRATORY TRACT

The upper respiratory tract conducts air from outside the body to the lower
respiratory tract and helps protect the body from irritating substances. The upper
respiratory tract consists of the following structures:
The nasal cavity, mouth, pharynx, epiglottis, larynx, and upper trachea;
the esophagus leads to the digestive tract.

LOWER RESPIRATORY TRACT

The lower respiratory tract begins with the trachea, which is just below the
larynx. The trachea, or windpipe, is a hollow, flexible, but sturdy air tube that
contains C-shaped cartilage in its walls. The inner portion of the trachea is
called the lumen.
Each structure of the lower respiratory tract, beginning with the trachea,
divides into smaller branches. This branching pattern occurs multiple times,
creating multiple branches.
Pathophysiology Precipitating Factors: 

Etiology: Occupation (health care workers)

Predisposing Factors:
Mycobacterium Repeated close contact with infected persons.
 Immune compromised status
tuberculosis Economically- disadvantaged or homeless/ poor housing
Severely malnourished
Living in overcrowded areas
Age: young and old
Exposure or inhalation of infected droplet nuclei from infected clients by Alcohol abuse/ dependent
Nationality: Filipino
coughing, sneezing, talking, laughing and singing
Poor hygiene
 
Lack of access to health care
Tubercle bacilli invasion in the apices of the lungs or near the pleura of the lower
lobes Low socio-economic status

 
Bronchopneumonia develops in the lung tissue and tubercle bacilli are ingested
  - Pallor - chest pain
by wandering macrophages
- tachypnea -dizziness
Many of the bacilli survived before hypersensitivity and immunity develops
- Weakness – fatigue - tachycardia

Surviving bacilli is carried into bronchopulmonary lymph nodes via the lymphatic hypoxia
system and may even spread throughout the body
↓oxygen
Inflammatory response occurs, TB specific lymphocyte produces T-lytic enzyme carrying
which lyses bacteria and alveolar tissue capacity dyspnea
 
Material (bacteria & macrophage) become necrotic Areas of the lungs are inadequately
- productive cough ventilated
 
- phlegm Production of cavities filled with cheese-like mass of tubercle bacilli, dead WBCs, necrotic lung tissue  
Partial occlusion which interferes w/
- crackles
the diffusion of O2 & CO2
PRIMARY INFECTION
 
CHAPTER II –PLANNING

a. List of Prioritized Nursing Diagnosis

CUES NURSING PROBLEM RANK JUSTIFICATION

Subjective Cues: Ineffective airway clearance 1  Airway must be given the first attention as
- Patient verbalized, “Matagal na akong related to retained secretions in based on the rule of ABC which is
inuubo. Wala namang plema. Nahihirapan the respiratory tract secondary Airway, Breathing and Circulation.
akong huminga”. to bacterial infection as
  evidenced by crackles upon
Objective Cues: auscultation.
- Presence of adventitious breath sound
(Crackles) upon auscultation.
-The patient is coughing without phlegm.
- Oriented
- BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm,
T-37.5 C
- Difficulty vocalizing
- Has hallow eyes.
- Bluish nail beds.
 
Subjective cues: Hyperthermia related to 2  Lack of action in this health care
-The husband of the client verbalized, “Naku hindi infection as evidenced by problem may cause dehydration
na nawala ang lagnat ng asawa ko, pabalik-balik increased WBC which may later cause a bigger threat
na lang” to the health of the client.
 
Objective cues:
-Flushed skin; warm to touch
-Increase body temperature higher than normal
range
-Increased respiration
-The patient is sweating
-T: 37.5˚C

Subjective cues: Imbalanced Nutrition: Less 3  This condition needs to be

- The patient is only eating 4 spoons of rice with than Body Requirements addressed immediately for the client
viand. related to inability to ingest to be able to gain enough strength in
- The relative verbalized “Hindi siya nakakakain food because of prolonged performing her usual activities.
ng maayus dahil sa kanyang ubo”. cough as evidenced by
decreased BMI.
Objective cues:
- The patient weight is 31.5 kilograms.
- Poor muscle tone.
- Appears weak.
- Minimal subcutaneous fat.
 
 ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
           
Subjective Cues: Ineffective airway Short-term Goal: - Obtain vital signs of the patient. - Health status is regulated through homeostatic Goal met. Within
- Patient verbalized, clearance related After 1 hour of nursing   mechanisms. A change in V/S might indicate 4 hours of nursing
“Matagal na akong to retained intervention, patient will   health change. intervention, the
inuubo. Wala namang secretions in the be able to mobilize her - Auscultate the lungs to note any   patient was able
plema. Nahihirapan respiratory tract secretions through the lung sounds. -Crackles are intermittent sounds that occur to maintain patent
akong huminga”. secondary to interventions done by the   when air moves through airway that contain airway through
  bacterial infection nurse.   fluids. the mobilization
Objective Cues: as evidenced by   - Perform Chest physiotherapy.   of secretions as
- Presence of crackles upon     -Tapping the chest can loosen the secretions. evidenced by
adventitious breath auscultation. Long-term Goal: - Suction secretion as needed. productive cough.
sound (Crackles) upon Within 4 hours of nursing   -Suction removes secretions using a strong  
auscultation. intervention, the patient   pressure.
-The patient is will be able to maintain - Increase the amount of oral fluid  
coughing without patent airway through the intake as ordered by the doctor. -Current data indicates that fluid restriction may
phlegm. mobilization of secretions   reduce blood volume and decrease cerebral
- Oriented as evidenced by productive   circulation. The lack of volume causes the blood
- BP- 90/70 mmHg, cough.   to be thick and sluggish and may decrease the
CR: 84 bpm, RR: 36   mobilization of nutrition and toxins out of the
cpm, T-31.5 C - Administer bronchodilators as circulation.  
- Difficulty vocalizing ordered.
- Has hallow eyes.   - They act on the respiratory tract; it opens
- Bluish nail beds. - Elevate the head of the bed. narrowed airways.
 
- For maximal lung expansion that will improve
oxygen delivery.

b. Nursing Care Plan

Chapter III - IMPLEMENTATION
A. Medical Management

1. Drug Study
 Generic Name: RIFAMPICIN 2 Tablets before lunch and 1 tablet before dinner
Brand Name: MYRIN-P FORTE
Classification Action Indication Adverse Effect Nursing
Consideration
Antituberculosis Inhibits RNA synthesis, Initial phase treatment and Disorder of the blood and Explain to the
decreases tubercle bacilli retreatment of all forms of TB in lymphatic system, immune patient to expect an
replication category I and II patients caused system, metabolism and orange color of
by susceptible strains of nutrition, CNS, eye, GI, urine.
mycobacterium. skin and tissues, renal,  
fever, dryness of mouth. Monitor I & O.

Generic Name: IPRATROPIUM BROMIDE q4 hours

Brand Name: COMBIVENT, DOUNEB
Classification Action
Anti-cholinergic An anti-cholinergic that
bronchodilator blocks the action of
acetylcholine at
parasympathetic sites in
bronchial smooth muscles.
Indication Adverse Effect Nursing
Consideration
Maintenance treatment of Hypotension, insomnia, Monitor vital signs
bronchospasm due to COPD, metallic or unpleasant Monitor intake and
bronchitis, emphysema, asthma. taste, palpitations, urine output
reaction.  
Generic Name: AMINO ACID 20ml/ Ampule TIV q8 hrs
Brand Name: MORIAVIT

Classification Action Indication Adverse Effect Nursing

Intervention
Calorics (Nutritional Provides a substrate for Total Parenteral Nutrition CNS: Fever Monitor body
Drug) protein synthesis or GI: Flushing temperature every 4
increases conservation of GU: Osmotic dieresis hours.
existing body protein. Metabolic: electrolytes  
  imbalance, weight gain
Musculoskeletal:
Osteoporosis
2. Treatment

Treatment /
Classification Indication Contraindication Nursing Responsibilities
Infusion
*Hypovolemia *Do not connect flexible plastic
containers of intravenous solutions in
*Heat-related series, i.e., do not piggyback
emergencies connections. Such use could result in air
Plain NSS Isotonic *CHF
*Freshwater drowning embolism due to residual air being
drawn from one container before
*Diabetic administration of the fluid from a
ketoacidosis(DKA) secondary container is completed.
3. Diet
Sample Menu Plan
1am Meal Serving
5am    
9am DAT  
1pm  
6pm  

D. Surgical Management

Mr. ADL has a fluid (hydrothorax) in his right lung, but when chest tube thoracostomy was performed
last August 22, 2020, there was no fluid extracted, the fluid was noted in the right lung.
CHAPTER IV – EVALUATION
Discharge Planning Instruction

M- Medications

Medications should be taken as ordered and prescribed by the physician to avoid complications and help manage the
condition of the patient. The intensive phase is for 2 months, and the maintenance phase is for 4 months. Medicines are readily
available at the health center.
 
E- Exercise

 Instruct the patient to have a time for deep breathing exercise everyday for several times at home to helps achieved maximal
lung expansion and for relaxation.
 Immediately stop any activities that might causes undue fatigue, increased shortness of breath or chest pain.

T- Treatment

 Remind the importance of taking the medication in the right time and dose.
 Sleep in a room with good ventilation.
 Limit your activity to avoid fatigue. Frequent rest is advice.
H- Health Teachings

 Advise to take the medication on time and with the right dosage.
 Semi-fowlers position is advice most of the time for breathing relaxation.
 Avoid close contact with others until the doctor finds it okay.
 Advise the client to turn head when coughing. Cover mouth when coughing then throw used tissues in the plastic bag.
 Keep hands clean. Maintain proper hygiene.
 Advise the relatives to clean the environment regularly since it is one of the factor that contribute to the speared of
bacteria.
O- Out- patient follow- up

Most of the treatment to cure Pulmonary Tuberculosis can be given at home but must be taken as explained by the health care
worker. The family has the responsibility to check the status of the patient and the progress of it.

D- Diet

 Diet as tolerated is advice by the attending physician, to sustain his nutritional needs.
 High protein diet for tissue repair - meat and green leafy vegetables.
 
S- Spiritual practice
Mr. ADL’s religion is Catholic, encourage the patient pray daily, go to church regularly and increase his faith with God
Almighty.
 NTENSIVE PHASE CONTINUATION PHASE
Regimen Drugs Interval and Dose Drugs Interval and Dose Range of Total Comments
(minimum duration) (minimum duration) Doses

1 INH 7 days/week for 56 doses INH 7 days/week for 126 182 to 130 This is the preferred regimen for patients with
RIF (8 weeks) RIF doses (18 weeks) newly diagnosed pulmonary TB.
PZA or or
EMB 5 days/week for 40 doses 5 days/week for 90
(8 weeks) doses (18 weeks)

2 INH 7 days/week for 56 doses INH 3 times weekly for 54 110 to 94 Preferred alternative regimen in situations in
RIF (8 weeks) RIF doses (18 weeks) which more frequent DOT during continuation
PZA or phase is difficult to achieve.
EMB 5 days/week for 40 doses
(8 weeks)

3 INH 3 times weekly for 24 INH 3 times weekly for 54 78 Use regimen with caution in patients with HIV
RIF doses (8 weeks) RIF doses (18 weeks) and/or cavitary disease. Missed doses can lead
PZA to treatment failure, relapse, and acquired drug
EMB resistance.

4 INH 7 days/week for 14 doses INH Twice weekly for 36 62 Do not use twice-weekly regimens in HIV-
RIF then twice weekly for 12 RIF doses (18 weeks) infected patients or patients with smear positive
PZA doses and/or cavitary disease. If doses are missed then
EMB therapy is equivalent to once weekly, which is
inferior.

Reference: https://www.cdc.gov/tb/topic/treatment/tbdisease.htm?fbclid=IwAR0FrJqOIUQztNf_xXMyg6kVSyFpKoPV7_E0eo5-TIvSeoRKaRCo0XLNiBU