primary koch's infection 2

I. INTRODUCTION

The joke is that you are not a Filipino if you do not have a TB. It might sound

amusing but it gives you a glimpse of how prevalent this disease is. In the late 1990’s,

the Philippines was fourth in the world for the number of cases of tuberculosis, and had

the highest number of cases per head in South East Asia. Today, there has been some

improvement but a lot still need to be done. Among the 22 countries in the world

accounting for 80 percent of TB worldwide, the Philippine is now ranked no. 9. Almost 75

of Filipinos die everyday because of TB. Almost everyone gets vaccinated with BCG as

a child, and yet, this does not ensure that you will develop TB later. Is the Direct

Observe Treatment Strategy (DOTS) working? To a certain extent yes, and only if those

with symptoms consult immediately. The problem is that most Filipinos ignore their

symptoms, continue to roam around and spread the infection, and consult only when

there is blood coming out when they cough. Also, over the years, no one has developed

a better vaccine and a better class of drugs against this infection. Meanwhile, the multi

drug resistance capability of the organism due to mutation continues to progress.

Primary Koch’s infection or primary tuberculosis is defined as infection of an

individual lacking previous contact with or immune responsiveness to tubercle bacilli. In

primary lung infection, a single lesion (known as Ghon’s focus) is usually found

immediately subjacent to the pleura in the lower part of the upper lobes or upper part of

the lower lobes of one lung, rarely elsewhere. These localizations reflect the areas

receiving the greatest volume flow of inspired air.

Although tuberculosis is now both treatable and to some degree preventable,

still, it is one of the bacterial infection affecting worldwide. Its true incidence cannot be

precisely determined because (1) only a fraction of persons with M. Tuberculosis

manifest clinical disease at anyone time; (2) all infected persons remain indefinitely at

risk of developing active disease; and (3) case reporting, even in developed countries, is

always incomplete.

According to the World Health Organization, the Philippines rank fourth in the

world for the number of cases of tuberculosis and have the highest number of cases per

head in Southeast Asia. The Philippines is among the 22-burdened countries in the

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world according to WHO. TB is the 6th leading cause of illness and the 6th leading cause

of deaths among Filipinos. Most TB patients belong to the economically productive age

(15-54 years old) according to the 2nd National Prevalence Survey in 1997).

In 1996, WHO introduced the Directly Observed Treatment Short Course (DOTS)

to ensure completion of treatment. The DOTS strategy depends on five elements for its

success: Microscope, Medicine, Monitoring, Directly Observed Treatment, and Political

Commitment. If any of these elements are missing, our ability to consistently cure TB

patients slips through our fingers.

MORTALITY

Ten Leading Causes of Mortality by Sex

Number, Rate/100,000 Population & Percentage

Philippines, 2003

Cause Male FemaleBoth Sexes

Number Rate Percent*

1. Heart Diseases 38,677 29,019 67,696 83.5 17.1

2. Vascular System Diseases 29,054 22,814 51,868 64.0 13.1

3. Malignant Neoplasm 20,634 18,664 39,298 48.5 9.9

4. Accidents 27,720 6,246 33,966 41.9 8.6

5. Pneumonia 15,831 16,224 32,055 39.5 8.1

6. Tuberculosis, all forms 18,367 8,404 26,771 33.0 6.8

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7. Symptoms, signs and abnormal

clinical, laboratory findings, NEC10,740 10,623 21,363 26.3 5.4

8.Chronic lower respiratory diseases 12,998 5,907 18,905 23.3 4.8

9. Diabetes Mellitus 6,823 7,373 14,196 17.5 3.6

10. Certain conditions originating in the

perinatal period 8,397 5,725 14,122 17.4 3.6

Source: The2003 Philippine Health Statistics

*percent share from total deaths, all causes, Philippines

Last Update: January 11, 2007

MORBIDITY

TEN LEADING CAUSES OF MORBIDITY

No. & Rate/100,000 Population

PHILIPPINES, 2003

CAUSEMALE FEMALE BOTH SEXES

Rate** Rate** Number Rate*

1. Acute Lower RTI and Pneumonia 770.9 748.2 674,386 861.2

2. Diarrheas 695.0 655.0 615,692 786.2

3. Bronchitis/Bronchiolitis 639.6 677.0 604,107 771.4

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4. Influenza 455.4 503.1 431,216 550.6

5. Hypertension 325.4 420.7 325,390415.5

6. TB Respiratory 126.4 84.0 92,079 117.9

7. Heart Diseases 28.8 29.2 30,398 38.8

8. Malaria 41.1 30.4 28,549 36.5

9. Chickenpox 30.3 30.4 26,137 33.4

10. Measles 30.2 30.4 25,535 32.6

Source: 2003 FHSIS Annual Report

** rate/100,000 of sex-specific pop.

* Total population of regions with reports only

Last Update: January 11, 2007

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CURRENT TREND: A More Reliable Test For Latent TB

Two new interferon-gamma blood test assays to detect latent tuberculosis

infection (LTBI) showed customers were exposed to a supermarket employee in Holland

who had smear-positive tuberculosis, while traditional tuberculin skin tests (TST) did not,

according to a large contact study.

Ailko Bossink, M.D., Ph.D., of the Department of Pulmonology at

Diakonessenhuis Utrecht in The Netherlands, and eight associates recruited 785

supermarket customers who had not received BCG vaccine against tuberculosis, the

immunizing agent prepared from Calmette-Guéren bacillus. TST results are not accurate

in those vaccinated with BCG.

All individuals in the study cohort were recruited from over 20,000 customers who

had shopped at the supermarket for more than 10 months. Many had numerous contacts

with the infected employee, who had been contagious since February 2004. The large-

scale contact investigation began in January 2005.

For the study, researchers selected 469 customers randomly on the day that

their TST was administered and 316 with a TST result of more than 0 mm.

TSTs are based on a skin reaction to injection, scratching or puncturing the skin with a

purified protein derivative of tuberculosis bacterium. Swelling and redness indicate a

positive result.

"Among the 785 study participants, TST results were associated with age,

whereas positive interferon-gamma blood test assay results were significantly

associated with cumulative shopping time," said Dr. Bossink. "TST results were not

associated with any measure of exposure to the index case in the supermarket."

The researchers noted that positive TST responses largely reflected delayed

type hypersensitivity due to remote infection with M. tuberculosis acquired before the

source case at the supermarket became infectious.Among the 759 shoppers who had

valid results from both interferon-gamma blood assay, slightly over 80 percent (608)

were concordant negative with both blood tests, while 72 were concordant positive and

79 were discordant. Overall agreement between the two tests was 89.6 percent.

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"Notably, positive interferon-gamma blood assays were observed in a significant

proportion of recently exposed contacts with a negative TST result," he added. "The

clinical significance of this finding merits further study if the blood tests are to replace the

TST and be used for therapeutic decisions."

"The key question is whether the two new IGRAs are better than the TST in

predicting the development of TB disease, and thus identifying persons who will benefit

most from latent TB infection (LTBI) therapy. There is abundant evidence, from

numerous large-scale cohorts and randomized trials, regarding the prognosis of

untreated persons with positive TST results; this remains the greatest advantage of the

TST."

"What is urgently needed is similar longitudinal studies of cohorts who have been

tested with IGRA (ideally both IGRAs) and the TST," they continued. "However, in

almost all low-incidence, high-income countries, it would be ethically impossible not to

treat persons with evidence of LTBI. Moreover, in high-incidence countries, where

treatment of LTBI is not the current standard of care, it would seem unethical to test for a

condition without plans to offer appropriate treatment."

"However, this should not be a problem. Almost everyone would agree that

individuals with concordant positive TST and IGRA are likely to have LTBI and they will

never inform the question as to which test predicts active TB better. Thus, such patients

can and should be managed appropriately. However, individuals with discordant results

(TST+/IGRA- or vice versa) will be informative regarding the risk of development of

active disease without treatment. In addition, because the clinical interpretation, and

therefore management is unclear for persons with such discordant results, equipoise

exists. Therefore, close observation without treatment is reasonable and ethical."

Reference: ScienceDaily (Mar. 15, 2007) — Second issue for March 2007 of the

American Journal of Respiratory and Critical Care Medicine, published by the American

Thoracic Society. Adapted from materials provided by American Thoracic Society.

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http://www.thoracic.org/

Summary:

These new interferon gamma blood test assays used to detect latent tuberculosis

infection are still under studies and it has not yet been approved except for one, known

as Quantiferon-TB Gold. Although the interferon-gamma blood tests are now considered

more specific and show a better correlation with exposure than tuberculin skin testing, it

has not been demonstrated whether they provide a valid basis for therapeutic decisions

regarding treatment. If studies conclude the efficacy and efficiency of these interferon

gamma blood tests, we would be able to avoid false-negative results given by tuberculin

skin testing thus making it easier for health care workers to do case finding measures

and tracing of those who are exposed to the disease. But problems may also arise with

these new discoveries in terms of its availability and affordability especially here in our

country. We just hope that these new tests would be able to detect latent tuberculosis

without completely phasing out the traditional tuberculin skin testing in order for patients

to have an option in which test would be more convenient for them since these new test

would surely be expensive.

Reason for choosing study

I decided to choose this case, because I wanted to acquire more knowledge

about Koch’s Infection and to use the knowledge I 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 the disease. I also wanted to focus

on preventive measures. This can cause Tuberculosis Meningitis, a very rare and fatal

disease and I would not want that to happen, so I will focus more on information

campaign as part of primary prevention of health, presently our country has so many

cases in Koch’s Infection. This study will help the nursing profession by providing

information about the proper management and care for patient. It will also educate the

people and vulnerable individuals to seek medical care in order to prevent TBM. It will

increase awareness about the importance of having a healthy life style and clean

environment

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OBJECTIVES

1. NURSE-CENTERED

After the completion of the study, the nurse researcher shall be able to:

Perform a comprehensive assessment of the patient

Enumerate the signs and symptoms of Koch’s Infection

Identify and list diagnostic procedures that would help in the diagnosis of Koch’s

Infection

Identify nursing problems utilizing the subjective and objective cues based on the

patient’s response

Perform appropriate therapeutic interventions for each of the formulated nursing

diagnosis

Have a background of the disease condition

Known the current trends about the disease

Know the incidence, prevalence and mortality rate of the disease

Identify factors present to the patient that predisposed him to the said disease

Explain briefly the anatomy and physiology of the disease

Gain proper knowledge and understanding about the existing disease condition,

it’s pathophysiology, sociology and etiology involved in its acquisition and

progression

Identify the difference modifiable and non-modifiable factors for the occurrence of

the disease

Identify the different early clinical manifestations of the disease condition

Analyze the different laboratory and diagnostic procedures, their indications to

the disease and identify the nursing interventions before, during and after the

performance of the said procedures

Identify the different signs and symptoms manifested by the client who have had

Koch’s Infection and explain how these signs and symptoms occur

Identify the common complications of Koch’s Infection and the appropriate

preventive measures

Explain the different treatments or medical modalities and their importance, and

different nursing interventions during the performance of the said procedure

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Identify common medications used as a treatment for the diseases, their

mechanism of action, adverse affects and nursing interventions before, during

and after the administration of the medications, appropriate nursing diagnoses

and their corresponding effects for the disease conditions

Render appropriate nursing interventions to prevent complications of the disease.

2. CLIENT-CENTERED

Have a background of the disease condition ( Koch’s Infection )

Know the reasons why such diagnostic procedures and treatments are

performed

Know the progress of the disease

Cooperate in the necessary medical and nursing interventions

Know the reasons why the patient experiences the signs and symptoms of the

diseases

Know preventive measures in response to the disease so as to prevent

deterioration of the patient’s condition

Participate willingly in the care of his conditions such as adhering to health

teachings provided

Have the necessary awareness for the condition’s familial tendency and thus

perform appropriate activities that may prevent eventual progress of the disease

(for the client’s significant others).

II. NURSING ASSESSMENT

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A. PERSONAL HISTORY

1. Demographic data

Baby M is 1 year old at the time of assessment, male Filipino, who was born on

November 31, 2008 via Normal Spontaneous Home delivery in district hospital of

Pampanga. He’s the only child of Papa PJ and Mama KC and devout members of the

Roman Catholic. They’ve been married for three years now. Papa PJ is a tricycle driver

and Mama KC is a plain housewife. Papa PJ loves to play “Tong-its” and bets to

cockfights when he has extra money. They prefer to sit and watch TV during the night.

Baby M was admitted at the hospital in Pampanga last December 19, 2009; with a chief

complain of difficulty in breathing and an impression and admitting diagnosis of T/C

Pneumonia. He was discharged last December 26, 2009 with a final diagnosis of Koch’s

Infection.

2. Socio-Economic & Cultural Factors

Papa PJ finished grade VI at a public school in Pampanga, being a tricycle

driver, he earns P250/day. Papa PJ provides the needs of Baby M. Baby M’s

grandparents on his father side also give financial support for their needs. Mama KC is

the one who does the shopping and cooking. Baby M usually eats “lugaw” for his

breakfast. For lunch and dinner, he prefers eating rice with soup broth. In between

meals, Baby M is being milk fed. He was just breast fed for about two months. On usual

day he has crackers, biscuits for his snack. Baby M prefers crackers, biscuits, fruits like

apple and orange and for his main meals; he prefers rice with soup broth. Baby M is still

on milk feeding, he also drinks fruit juices. Since Baby M is just 1 year old, mother and

other SO’s take care of him and assist him in his activities of daily living like eating,

bathing, dressing and grooming. He passes stool twice a day and around 4 diaper

changes a day. Usually he sleeps at 9 pm and wakes up at 6 am in the morning. He

usually sleeps 8-9 hours their source of water came from water district and pitcher

pump. They believe in herbolaryo and manghihilot, used herbal medicines such as

Lagundi for cough and colds.

3. Environmental Factors

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Baby M with his parents and grandparents on his father side live in a two-storey

house made of concrete and wood. There are about 12 steps to reach the upper portion

of the house. He and his mother usually spend their time in their bedroom located at the

second floor. Mother sees to it that the door in their bedroom is always close for safety.

They have pail flush toilet located at the back of their house. Their drainage is open and

flowing, unsanitary because of the presence of debris. Use plastic bag for garbage

disposal and throw their garbage in their compost pit located at their backyard, use

mosquito net when they sleep, use physical force t kill rodents.

B. GROWTH AND DEVELOPMENT

STAGE

Infancy and childhood

DEVELOPMENTAL CRISIS

Trust vs. Mistrust

1 year

Motor

: Walks with one hand held

: Stands alone and with support

: Grasps bottle in one hand

Language

: Uses “mama” with specific meaning

: Has vocabulary of two words besides mama and dada

Cognitive

: Obeys simple requests such as “kiss mama”

Personal social adaptive

: Points with index finger

: Releases toy into your hand

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: Holds cup to drink

: Gives affection

C. FAMILIAL-HEALTH ILLNESS HISTORY

Based on the diagram, parents of Mama KC are both healthy. They do not

manifest any disease condition. Father of Papa PJ has history of PTB, asthma and is a

smoker. Mother of Papa PJ is said to be healthy. Baby M currently has Primary Koch’s

infection.

LEGEND:

- healthy

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Lolo Diego54 y/o

Lolo Popoy57 y/o

Lola Babes45 y/o

Mama KC20 y/o

Lola Basha53 y/o

Papa PJ22 y/o

Baby M1 y/o

- w/ asthma, history of PTB, Smoker

- w/ asthma, smoker

- w/ Primary Koch’s infection

D. HISTORY OF PAST ILLNESS

Baby M had received vaccinations for BCG, Hepatitis B, DPT, OPV, and Measles.

Vaccines for Varicella, Anti-flu, and Hepatitis A are not yet given. The most common

illnesses Baby M had experienced were colds, cough, and fever. During these

conditions, parents resorted to over the counter medications sometimes they used

herbal medicines such as Lagundi for cough and colds. Baby M’s first hospitalization

was when he was 3 months old because of convulsion due to high fever. SO cannot

remember what medications were given during Baby M’s first hospitalization. Present

hospitalization is Baby M’s second. Baby M has no allergy to any medications or food.

Current medications were Salbutamol nebule given in a pediatrician’s clinic.

E. HISTORY OF PRESENT ILLNESS

Two days prior to admission, Baby M experienced cough and colds. One day

prior to admission, Baby M with SO consulted a pediatrician due to persistent cough and

colds. Nebulization with Salbutamol 1 nebule was provided in the pediatrician’s clinic.

But there was no relief of cough and colds, so few hours prior to admission, Baby M with

SO consulted again the pediatrician. Nebulization with Salbutamol 2 nebules was given

30 minutes apart. Baby M experienced difficulty of breathing and therefore was brought

to the emergency room of a public secondary hospital. Upon assessment, Baby M had

(+) Crackles on bilateral lung fields and attending physician ordered for the admission of

Baby M.

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F. PHYSICAL EXAMINATION

Upon Admission (December 19, 2009)

(Lifted from the chart)

Vital Signs: T= 36.2, CR= 132 bpm, RR= 30 bpm

Weight: 9 kg

General Appearance:

HEENT: pale palpebral conjunctiva, anicteric sclerae, moist buccal mucosa

Chest: symmetrical chest expansion, (-) retraction, with effort respiration and use of

accessory muscles when breathing

Cardio: adynamic precordium, tachycardia, (-) murmur

Abdominal: flat, soft, non-tender, no organomegally

Chief complaint: DOB

Nurse-Patient Interaction

Sunday, December 20, 2009

VITAL SIGNS:

Temperature -36.6°C, Respiratory Rate- 29 bpm

Heart Rate- 128 bpm

GENERAL SURVEY

The patient is conscious and coherent. The patient lies comfortably on the bed in

a semi-Fowlers position. There was full mobility of the body and movements are

coordinated. He was wearing a blue shirt with white print and pajamas. Patient was

generally clean and well-groomed. Patient’s nails were short and clean. No body odor

was noted. He was able to maintain eye contact and was cooperative to the nurse.

Skin

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The color of the skin is light brown with no lesions; the temperature of the skin is

uniform. Epidermis appears uniformly thin over most of the body with equal distribution

of hair, the skin had a poor skin turgor with none tenderness.

Hair

The hair is evenly distributed to the body. Scalp hair is also evenly distributed and there

were no patches of hair loss noted. Hair color was black .There were no lice, sores and

dandruff noted.

Nails

The nail surfaces were convex and show no abnormalities. The nails showed pale nail

beds and have a capillary refill time of 2 seconds.

Head

Skull and Face

The skull was normocephalic and there were no tenderness, nodules or masses noted

upon palpation. Has symmetric facial features, no abnormalities noted such as

periorbital edema.

Eyes

The hair in eyebrows are distributed evenly and eyebrows are symmetrically aligned,

and have no scaling or lesions; the skin of the eyelids was intact without redness,

swelling, discharge or lesion and eyelashes were equally distributed along the lid

margins and curve outward. No protrusion or sunken appearance. The conjunctiva was

smooth and moist. Visual Acuity, Extra Ocular movement and Visual field are not

applicable due to his age.

Ears

The ears are equal in size with no swelling or thickening; skin color of the auricles is

consistent with the patient’s facial skin color. The skin is intact with no lumps or lesions;

there was no pain claimed by the patient when the pinna was palpated. Both pinnas

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recoiled immediately when tested for elasticity. The patient was able to hear whispered

words to both ears.

Nose

The nose is in the midline, and in proportion to other facial features; No deformity,

asymmetry, inflammation, or skin lesions noted. There was no swelling, discharge or

bleeding noted upon inspection.

Mouth

The lips are pinkish in color. No cracking or lesions noted. Gums are pinkish in color,

teeth are white and 8 teeth were intact. No swelling or bleeding was noted. The tongue

is pink and even. Located at the midline, no ulceration found, symmetrical and moves

freely there were no inflammed tonsils noted.

Neck

The head is positioned at the midline, the accessory muscles are symmetrical and the

head was held erect and still.The trachea is in the midline position, no inflammation of

cervical lymph nodes and thyroid glands. There was no pain and limitation during the

active motion. There was no bruit upon auscultation.

Breast

The skin is smooth and even in color. No redness, bulging, edema, dimpling, or

discoloration was noted on the area of both breasts and the axillary areas. The nipples

are symmetrical, everted, and brown in color. No ulceration, bleeding or discharge and

there are no palpable nodes noted in the entire region of the breasts and the axilla.

Chest

The chest is symmetrical, no lesions found, no shallow breathing, no sign of deformities,

no presence of mass, no sign of abnormalities, no resonant sound. Positive rales or

crackles upon auscultation.

Heart

Patient has adynamic precordium and normal rate and regular rhythm of the heart. No

bruit and murmurs heard upon auscultation.

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Abdomen

The skin is unblemished and uniform in color; there are no rashes or striaes noted. Flat

abdomen and is symmetric in contour; Umbilicus is at the midline, inverted, with no sign

of discoloration, inflammation or herniation. Bowel sound are normal which range from 5

to 10, high pitched and gurgling. Tympany over the stomach and gas-filled bowels.

Dullness is heard over liver and spleen.

Examination of extremities

Upper Extremities

Symmetrical in shape with no signs of deformities.

Lower Extremities

Symmetrical in shape with no presence of edema, lesions, and tenderness, can walk

with one hand held.


Monday, December 21, 2009

VITAL SIGNS:


Heart Rate- 125 bpm

GENERAL SURVEY

The patient is conscious and coherent. He was able to smile and respond

actively. The patient lies comfortably on the bed in a supine position. There was full

mobility of the body and movements are coordinated. He was wearing a blue shirt with

white print and pajamas. Patient was generally clean and well-groomed. Nails were short

and clean. With a slight odor of sweat was noted. He was able to maintain eye contact

and was cooperative to the nurse.

Skin

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Hair

The growth of hair is straight evenly distributed. Hair color was black .There were no

sores and dandruff and no infestations of lice noted.

Nails

The nail surfaces were convex and show no abnormalities. The nails are short and dirty

with no clubbing upon assessment and have a capillary refill time of 2-3 seconds.

Head

Skull and Face



periorbital edema.

Eyes

Eyebrows and eyelashes are equally distributed, eyebrows are black, the skin of the

eyelids was intact without redness, swelling, discharge or lesion and eyelashes were

equally distributed along the lid margins and curve outward. No protrusion or sunken

appearance. The conjunctiva was smooth and moist. Visual Acuity, Extra Ocular

movement and Visual field are not applicable due to his age.

Ears

The ears are equal in size with no swelling or thickening.The auricles are symmetrical

and have the same color as facial skin. Presence of minimal cerumen noted at the

external ear canal. Parallel to the inner canthus of the eye upon inspection. Pinna recoils

after it is folded

Nose

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With symmetric nares, has no discharge and uniform in color. He breathes through both

nares. Nasal septum intact and at the midline. No tenderness and lesions noted upon

inspection and palpation. No nasal discharge.

Mouth




freely there were no inflamed tonsils noted.

Neck

Neck is straight, head centered. He is able to move it without difficulty or discomfort. No

masses or lumps noted.

Breast





Chest




Heart



Abdomen

Patient’s skin in the abdomen is uniform in color. There are no lesions and tenderness

noted when palpated. With audible bowel sounds.

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Upper Extremities


Lower Extremities


with one hand held.


Tuesday, December 22, 2009

VITAL SIGNS:


Heart Rate- 124 bpm

GENERAL SURVEY



mobility of the body and movements are coordinated. He was wearing a red shirt with

black print and shorts. Patient was generally clean and well-groomed. Nails were short

and clean. No body odor was noted. He was able to maintain eye contact and was

cooperative to the nurse.

Skin

The color of the skin is light brown with no lesions, the temperature of the skin is



Hair

20



dandruff noted.

Nails



Head

Skull and Face



periorbital edema.

Eyes







Ears





words to both ears.

Nose

21




Mouth





Neck


head was held erect and still. The trachea is in the midline position, no inflammation of



Breast





Chest




Heart



Abdomen

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of discoloration, inflammation or herniation. Bowel sounds are normal which range from

5 to 10, high pitched and gurgling. Tympany over the stomach and gas-filled bowels.



Upper Extremities


Lower Extremities


with one hand held.


Wednesday, December 23, 2009

VITAL SIGNS:


Heart Rate- 120 bpm

GENERAL SURVEY

The patient is asleep .Upon awake, was unable to smile but responsive to stimuli

and cry actively. The patient carries by his mother. There was full mobility of the body

and movements are coordinated. He was wearing a pink shirt and shorts. Patient was

generally clean and well-groomed. Nails were short and clean. No body odor was noted.

He was able to maintain eye contact.

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Skin



of hair. Skin turgor is good, when pinched it springs back to its previous state.

Hair



dandruff noted.

Nails



Head

Skull and Face



periorbital edema.

Eyes







Ears




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words to both ears.

Nose




Mouth





Neck


head was held erect and still.The trachea is in the midline position, no inflammation of



Breast





Chest




25

Heart



Abdomen



of discoloration, inflammation or herniation. Bowel sounds are normal which range from

5 to 10, high pitched and gurgling. Tympany over the stomach and gas-filled bowels.



Upper Extremities


Lower Extremities


with one hand held.


Thursday, December 24, 2009

VITAL SIGNS:


Heart Rate- 120 bpm

GENERAL SURVEY



mobility of the body and movements are coordinated. He was wearing a purple shirt and

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pajamas. Patient was generally clean and well-groomed. Nails were short and clean. No

body odor was noted. He was able to maintain eye contact and was cooperative to the

nurse.

Skin




Hair



dandruff noted.

Nails



Head

Skull and Face



periorbital edema.

Eyes







27

Ears





words to both ears.

Nose




Mouth





Neck





Breast





Chest




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Heart



Abdomen



of discoloration, There were no tenderness over the abdomen in all quadrants; relaxed

abdomen with smooth and constant tension upon light palpation. and no tenderness was

noted upon deep palpation.


Upper Extremities

Symmetrical in shape with no signs of deformities. The skin color in hands is uniform in

color, no redness or discolorations noted.

Lower Extremities


with one hand held. The skin color in feet is uniform in color, no redness or

discolorations noted.


Friday, December 25, 2009

VITAL SIGNS:


Heart Rate- 120 bpm

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GENERAL SURVEY


actively. The patient carries by his father. There was full mobility of the body and

movements are coordinated. He was wearing a purple shirt and pajamas. Patient was

generally clean and well-groomed. Nails were short and clean. No body odor was noted.

He was able to maintain eye contact and was cooperative to the nurse.

Skin

The color of the skin is light brown with no lesions, the temperature of the skin is



Hair



dandruff noted.

Nails



Head



periorbital edema.

Eyes





30



Ears





words to both ears.

Nose




Mouth





Neck





Breast





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Chest




Heart



Abdomen



of discoloration, There were no tenderness over the abdomen in all quadrants; relaxed

abdomen with smooth and constant tension upon light palpation. and no tenderness was

noted upon deep palpation.


Upper Extremities

Symmetrical in shape with no signs of deformities. The skin color in hands is uniform in

color, no redness or discolorations noted.

Lower Extremities


with one hand held. The skin color in feet is uniform in color, no redness or

discolorations noted.

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DIAGNOSTIC AND LABORATORY PROCEDURES

a. Complete Blood Count

Diagnostic Procedure

Indication(s) or Purpose(s)Date OrderedDate Results

receivedResults

Normal Values

Analysis and Interpretation of results

HemoglobinThis is indicated to the patient to

determine the presence of body fluid

deficit due to elevated Hgb level.

To monitor the iron status and oxygen

carrying capacity of the blood

Date ordered:

12/19/09

Date results

received:

12/19/09

130 g/L 110-150 g/L

The hemoglobin level is normal.

This means that the client has

normal oxygen carrying capacity

of the blood.

33

HematocritThis is indicated to determine the

patient’s hydration status and

presence of anemia.

Date ordered:

12/19/09

Date results

received:

12/19/09

.39 g/L .29-.44g/L The Hematocrit level of the

patient is normal. This means

the patient has normal

hydration status.

WBCThis is indicated to determine

presence of infection and inflammation

and indicated to show the extent of

depression of humoral antibody

formation.

Date ordered:

12/19/09

Date results

received:

12/19/09

9.0g/L 5-109 /L The WBC of the patient is

within normal value which

means that there is no

presence of infection and

inflammation.

34

NeutrophilsThis is indicated to determine

presence of viral infection.

Date ordered:

12/19/09

Date results

received:

12/19/09

.61 .45-.60 The value of neutrophils is

within normal which indicates

that there was no presence of

viral infection.

Lymphocytes This is indicated to determine presence of infection.

Date ordered:12/19/09

Date results received:12/19/09

.53 .20-40% The lymphocytes level of the patient is high which means that there is a presence of infection or immunodeficiency.

Nursing Responsibilities:

35

Before:

Obtain a history of the patient’s complaints, including a list of known allergens.

Obtain a history of the patient’s gastrointestinal, hematopoietic, immune, and respiratory systems, as well as results of previously performed tests

and procedures.

Obtain a list of medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals. The requesting health care practitioner

and laboratory should be advised if the patient regularly uses these products so that their effects can be taken into consideration when reviewing

results.

Explain the procedure to the patient and its purpose.

Tell the patient that this test requires a blood sample. Explain who will perform the venipuncture and when.

Explain to the patient that patient may experience slight discomfort from the needle puncture and the tourniquet.

Tell the patient that no special diet or fasting is required.

Notify the physician and/or the laboratory of drugs the patient is currently taking that may affect test results; it may be necessary to restrict them.

Inform the patient that specimen collection takes approximately 5 to 10 minutes.

During:

Adhere to standard precaution.

Direct the patient to breathe normally and to avoid unnecessary movement.

If the patient is receiving IV infusion obtain the blood from the opposite arm.

Instructed the patient to avoid opening and closing the hand after a tourniquet is applied.

Perform a venipuncture, and collect the specimen in a 5-mL lavender-top (EDTA) tube. The specimen should be analyzed within 6 hours when

stored at room temperature or within 24 hours if stored at refrigerated temperature. If it is anticipated the specimen will not be analyzed within.

36

4 to 6 hours, two blood smears should be made immediately after the venipuncture and submitted with the blood sample. Smears made from

specimens older than 6 hours will contain an unacceptable number of misleading artifactual abnormalities of the RBCs, such as echinocytes and

spherocytes as well as necrobiotic WBCs.

Label the specimen, and promptly transport it to the laboratory.

After:

Apply pressure to the venipuncture site until bleeding stops.

If large hematoma develops at the venipuncture site, monitor pulses distal to the site.

b. Chest X-ray

37

Diagnostic Procedure

Indication(s) or Purpose(s)

Date OrderedDate Results

receivedResults Normal Values

Analysis and Interpretation of results

Chest X-ray

Chest X-ray is a

procedure used to

evaluate organs and

structures within the

chest for symptoms

of disease.

Date ordered:

12/19/09

Date Results

Received:

12/20/09

There are hazy and patchy infiltrations in

both lung fields. Nodular densities in the

retrocardiac space. The heart is normal in

size by configuration, diaphragms,

costopenic angles and the visualized

bones are intact.

Normal lung

fields, cardiac

size, mediastinal

structures,

thoracic spine,

ribs, and

diaphragm

Impression:

Bronchopneumonia, Primary

Koch’s Infection

Nursing Responsibilities:

Before:

Inform the patient about the purpose of the procedure, various positions to assume, and the need to hold his or her breath. For related tests, refer to

the cardiovascular and respiratory system tables.

Inform the patient that the procedure takes 5 to 10 minutes.

There are no food or fluid restrictions.

Inform the patient that no pain is associated with the study.

During:

Instruct the patient to remove clothing and metallic objects from the waist up.

38

Give the patient a gown and robe to wear.

Remove any wires connected to electrodes, if allowed.

Place patient in a standing, sitting, or recumbent position in front of the x-ray film holder.

For portable examinations, elevate the head of the bed to the high Fowler’s position.

Have the patient place hands on hips, extend neck, and position shoulders forward.

Position the chest with the left side against the film holder for a lateral view.

Instruct the patient to inhale deeply, to hold his or her breath while the x-ray is taken, and then exhale after the film is taken.

After:

Inform the patient of the possible need for additional chest x-rays to evaluate progression of the disease process or to determine the need for a

change in therapy.

Determine if the patient or family members have any further questions or concerns.

A physician sends a written report to the ordering health care provider, who discusses the results with the patient.

Evaluate test results in relation to the patient’s symptoms and other tests performed. Related diagnostic tests include computed tomography and

magnetic resonance imaging of the chest as well as a lung scan.

39

III. ANATOMY ANDPHYSIOLOGY

The respiratory system is situated in the thorax, and is responsible for gaseous

exchange between the circulatory

system and the outside world. Air is

taken in via the upper airways (the

nasal cavity, pharynx and larynx)

through the lower airways (trachea,

primary bronchi and bronchial tree)

and into the small bronchioles and

alveoli within the lung tissue.

The lungs are divided into lobes; The left lung is composed of the upper lobe,

the lower lobe and the lingula (a small remnant next to the apex of the heart), the right

lung is composed of the upper, the middle and the lower lobes.

Mechanics of Breathing

To take a breath in, the external intercostal muscles contract, moving the ribcage

up and out. The diaphragm moves down at the same time, creating negative pressure

within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and

so expand outwards as well. This creates negative pressure within the lungs, and so air

rushes in through the upper and lower airways.

Expiration is mainly due to the natural elasticity of the lungs, which tend to

collapse if they are not held against the thoracic wall. This is the mechanism behind lung

collapse if there is air in the pleural space (pneumothorax).

40

Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form very narrow

terminal bronchioles, which terminate in the alveoli. There are many millions of alveloi in

each lung, and these are the areas responsible for

gaseous exchange, presenting a massive surface

area for exchange to occur over.

Each alveolus is very closely associated with a

network of capillaries containing deoxygenated

blood from the pulmonary artery. The capillary and

alveolar walls are very thin, allowing rapid

exchange of gases by passive diffusion along

concentration gradients.

CO2 moves into the alveolus as the concentration is

much lower in the alveolus than in the blood, and

O2 moves out of the alveolus as the continuous flow

of blood through the capillaries prevents saturation

of the blood with O2 and allows maximal transfer

across the membrane.

41

IV. THE PATIENT AND HIS ILLNESS

PATHOPHYSIOLOGY OF PULMONARY TUBERCULOSIS

BOOK CENTERED

Modifiable Risk Factors Non-Modifiable Risk Factors

Tissue reaction will result on accumulation of exudates in the

alveoli of the lungs. Weight lossAnorexia FatigueChest pain

Non-productive

cough

Leading to narrowing of lumen of the bronchioles alveoliNarrowing passage of

airways

Bacilli can also be transported via the lymph system and blood stream.

Bacteria are transmitted through the airways to the alveoli. (droplet infection)

- Contact with active TB pt.- Lifestyle (smoking)- Immunocompromised status

(HIV infection)- Substance abuse - Malnutrition- Living in a crowded place

B BInhalation of Mycobacterium

- Age

- Sex

- Family History

- Environment

Mycobacterium bacilli travel and lodges to the lungs.

Bacterial deposits start to multiply.

Infection

Tissue reaction will result on accumulation of exudates in the alveoli of the lungs.

Weight loss

Anorexia Fatigue

Chest pain Non-productive cough

Body’s immune system responds initiating inflammatory reaction.

Phagocytes engulf many of the bacteria Fever occurs late in the afternoon

(Because this Bacteria is opportunistic)

Leading to narrowing of lumen of the bronchioles alveoli

Narrowing passage of airwaysCOMPLICATIONS

1. LUNG DAMAGE, 2.BILIARY TB, 3.MENINGEAL TB

42

V. PATHOPHYSIOLOGY OF PULMONARY TUBERCULOSIS (client centered)

Modifiable Risk Factors Non-Modifiable Risk Factors

CracklesRales

Bacteria are transmitted through the airways to the alveoli. (Droplet infection)

- Contact with undiagnosed TB pt.- Living in a crowded place

B B BInhalation of Mycobacterium Bacilli

- Age

- Environment

Mycobacterium bacilli travel and lodges to the lungs.

Bacterial deposits start to multiply.

Infection

Tissue reaction will result on accumulation of exudates in the alveoli of the lungs.

Difficulty of breathing Non-productive cough

Body’s immune system responds initiating inflammatory reaction.

Phagocytes engulf many of the bacteria

Leading to narrowing of lumen of the bronchioles alveoli

Narrowing passage of airwaysSigns and Symptoms

43

SYNTHESIS OF THE DISEASE

Koch’s Infection is an infectious disease caused by slow- growing bacteria that

resembles a fungus, Myobacterium tuberculosis, which is usually spread from person to

person by droplet nuclei through the air. The lung is the usual infection site but the

disease can occur elsewhere in the body.

Typically, the bacteria from lesion (tubercle) in the alveoli. The lesion may heal, leaving

scar tissue; may continue as an active granuloma, heal, then reactivate or may progress

to necrosis, liquefaction, sloughing, and cavitation of lung tissue. The initial lesion may

disseminate bacteria directly to adjacent tissue, through the blood stream, the lymphatic

system, or the bronchi.

Most people who become infected do not develop clinical illness because the body’s

immune system brings the infection under control. However, the incidence of

tuberculosis (especially drug resistant varieties) is rising. Alcoholics, the homeless and

patients infected with the human immunodeficiency virus (HIV) are especially at risk.

Complications of tuberculosis include pneumonia, pleural effusion, and extrapulmonary

disease. The Predisposing Factors are malnutrition, overcrowding, alcoholism, ingestion

of infected cattle, virulence, and over fatigue.

The sign and Symptoms are productive cough-yellowish in color, low fever, night sweats,

dyspnea, anorexia, generated body malaise, weight loss, chest back pain and

hemoptysis

TB results from infection by any of the TB complex mycobacteria, including

Mycobacterium tuberculosis, M bovis, M africanum, M microti, and M canetti.

TB can be divided into primary, progressive-primary, and postprimary forms on the basis

of the natural history of the disease. Postprimary TB results from either reactivation of a

latent primary infection or, less commonly, from the repeat infection of a previously

sensitized host. The term “postprimary” is preferred to “reactivation” when referring to

the clinical diagnosis because firmly distinguishing recurrence from an antecedent

infection is impossible in most cases.

Approximately 10% of all infected patients are likely to develop reactivation, and the risk

is highest within the first 2 years or during periods of immunosuppression.

The major determinants of the type and extent of TB disease are the patient’s age and

immune status, the virulence of the organism, and the mycobacterial load. Postprimary

44

TB is typically a disease of adolescence and adulthood that results from reactivation of

an initially contained infection by a TB complex mycobacterium. Pulmonary reactivation

usually occurs in the apical and posterior segments of the upper lobes or in the superior

segments of the lower lobes.This distribution may be related to the higher oxygen

tension or the reduced perfusion and lymphatic clearance in these lung segments.

Sources:

Medscape

News Author: Laurie Barclay, MD

CME Author: Désirée Lie, MD, M

CME Released: 01/10/2005; Valid for credit through 01/10/2006

45

V. THE PATIENT AND HIS CARE

A. Medical Management

a. IVF, Nebulization, Oxygen Therapy

Medical

Management/

Treatment

Date ordered,

performed,

changed/ d/c

General Description Indications or PurposesClient’s response to the

treatment

IVF

D5.3NaCL Date ordered:

12-19-09

Date performed:

12-19-09 to 12-26-09

Date changed/dc:

12-26-09

5% Dextrose, 0.3 Sodium

Chloride is an isotonic solution

-maintenance of fluid in clients

who cannot drink or eat

-replacement fluids when large

amounts are lost

-administration of IV medications

- It reduces the edema, stabilizes

blood pressure and regulates

urine output

The patient exhibited

improved hydration status

as evidenced by good skin

turgor.

The patient received

parenteral medications.

46

Nursing Responsibilities

Pre-Procedure

Verify the doctor’s order.

Identify the patient.

Verify the patient’s name by asking his S.O.Assess the client previous experience with IV therapy and arm placement

preference

Determine if client is to undergo any planned surgeries or procedures

Assess the type and duration of IV therapy as ordered by the physician or license

Assess the laboratory data and client history of allergies

Asses client’s medical history for chronic illnesses

Explain the procedure to the patient/SO and explain the purpose of the procedure.

Medical

Management/

Treatment

Date ordered,

performed, changed/

d/c

General DescriptionIndications or

Purposes

Client’s response to

the treatment

Nebulization Date ordered: 12-19-

09

Date performed: 12-19-

09

to 12-25-09

Date changed/dc: 12-

25-09

Delivers most medications

administered through inhaled

route.

To administer

Salbutamol, necessary

to loosen patients

secretions.

The patient improved

breathing pattern &

airway exchange as

evidenced by absence

of cyanosis.

47

Nursing Responsibilities

Before:

a. Check doctor’s order

b. Prepare the equipment

c.Explain the procedure to the client

d. Place medication into the nebulization kit and turn machine on.

During:

a. Instruct the patient to breathe in the vapor

b. Shake the nebulization equipment from side to side.

c.If necessary, directly place the mouthpiece in the mouth

After:

a. Clean equipment thoroughly

b. Document the procedure.

48

Generic name/Brand

name

Date ordered Route/Dosage/Frequency

of administration

General

action/Classification

Client's response

to the medication

with S/E

Amikacin/Amikin Started: Dec 19,

2009

Date performed: 12-

19-09

to 12-25-09

Date changed/dc:

12-25-09

IV

15 mg

Every 8 hours

Amikacin inhibits protein

synthesis in bacteria by

binding to bacterial rib

Anti-

infective agent.

Aminoglycosides

No report signs of

tinnitus and muscle

weakness to the

patient.

49

NURSING RESPONSIBILITIES:

Prior:

o Check doctor's order.

o Verify the patient.

o Wash hands before handling the medication.

o Assess patient’s vital signs prior to administering the medication.

o Obtain a history of previous use and reactions to amikacin. Persons with a negative history of amikacin sensitivity may

still have an allergic response.

During:

o Administer as indicated (right drug, right dosage, right frequency)

o Give IV dose over 1-2 minutes.

o Clean the IV insertion site for medications with a cotton ball with alcohol.

o Gradually inject the drug into the port.

o Administer cautiously and slowly with aseptic technique.

o Observe patient for signs and symptoms of pruritus, wheezing.

After:

o Monitor patient's vital signs

o Advise patient to report the signs of super infection and allergy

o Wash hands

50

o Observe for client's reaction

o Document

51

Name of

DrugDate Ordered

Route and

Frequency of

Administrati

on

General Action and Mechanism

of Action Indication and

Purposes

Client's response to the

medication with S/E

Ampicillin:

Omnipen

Started: Dec 19,

2009

Date performed:

12-19-09

to 12-21-09

IV route

100mg q 6

hours

General Action: Anti infectives

Mechanism of Action: Bactericidal

action; spectrum is broader than

penicillin

To fight against

infection due to

vaginal bleeding

The patient didn't manifest any

signs and symptoms of

inflammation.

Side Effects: Diarrhea, nausea,

vomiting


Prior:





52

o Obtain a history of previous use and reactions to ampicillin. Persons with a negative history of ampicillin sensitivity

may still have an allergic response.

During:







After:



o Wash hands


o Document

53

Generic name/Brand name

Date ordered/started/discontinued

Route/Dosage/Frequency of administration

General action/ClassificationClients response to the

medication w/ SE

Hydrocortisone

Cortizan

Started: Dec. 21, 2009

Date performed: 12-21-09

to 12-22-09

Changed to Prednisone: Dec.

23, 2009

IV

150 mg

Every 6 hours

Glucocorticoid with Anti-

inflammatory effect because of

its ability to inhibit prostaglandin

synthesis, inhibit migration of

macrophages leukocytes,

fibroblasts at site of

inflammation.

Anti-inflammatory

No repert signs of headche,

increased intarcranial presure

and restlessness.


Prior:




54


o Obtain a history of previous use and reactions to hydrocortisone. Persons with a negative history of hydrocortisone

sensitivity may still have an allergic response.

During:







After:



o Wash hands


o Document

Generic

name/Brand

Date Route/Dosage/Frequency General Clients

response to

55

name ordered/started/discontinued of administration action/Classification the medication

w/ SE

Ipratropium

bromide

Combivent

Started:

Dec. 21, 2009 (10am)

Inhalation

½ nebule

Every 8 hours

Anti-cholinergic

(atrophine-like); relaxes

bronchial smooth

muscle.

Bronchodilator

No report signs

of GI irritation

and nausea.


Prior:





During:

o Assess respiratory rate.

o Ausculcate lung sounds.

56

o Assess pulses.

o Warn patient to avoid accidentally spraying drug into eyes. Temporary blurring of vision may result.

After:



o Wash hands


o Document

Generic name/Brand

name



General Action/Classification

Client’s response to medication

Cefuroxime

Roxicef

Started:

Dec. 21, 2009 (4pm)

Date performed: 12-21-09

to 12-25-09

IV

250 mg

Every 8 hours

Binds to bacterial cell

wall membrane,

causing cell death.

Bactericidal action

against susceptible

bacteria.

Dizziness,

drowsiness,

fatigue,

headache,

vomiting,

change in taste

57

Anti-infective 2nd

generation

Cephalosphorin


Prior:





o Obtain a history of previous use and reactions to cefuroxime. Persons with a negative history of cefuroxime sensitivity

may still have an allergic response.

During:






58


After:



o Wash hands


o Document

Generic name/Brand



General action/Classification

Clients response to the medication

59

name w/ SE

Albute-rol

Salbutamol

Started:

Dec. 19, 2009 (10pm)

Revised:

Dec. 20, 2009 (2pm)

Inhalation

1 nebule + 1 cc NSS

1 nebule

Every 8 hours

Beta 2-adrenergic

bronchodilator.

Anti-asthmatics,

Sympathomimetic.

The patient

improved

breathing pattern

& airway

exchange as

evidenced by

absence of

cyanosis.


Prior:





60

During:





o Observe patient for signs and symptoms of nervousness, tremors, and restlessness.

After:


o Wash hands


o Document

o Advise patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may decrease dry mouth.

Generic name/Brand


Route/Dosage/Frequency of Administration

General action/Classification

Clients response to

61

name the medication w/ SE

Rifampin

Rifampicin

Ordered:

Dec. 22, 2009 (4pm)

Started:

Dec. 23, 2009 (7am)

Revised:

Dec. 23, 2009

Oral

160 mg (Stock dose: 200

mg/5 ml) = 4 ml


mg/5 ml) = 2.75 ml

Once a day, pre-breakfast

Inhibits DNA-

dependent RNA

polymerase, which

impairs RNA synthesis;

bactericidal.

Anti-infective, anti-TB

Red

discoloration of

urine noted.


Prior:


o Verify the patient/SO.


During:


62

o Caution client to avoid sharing of medication.

After:


o Wash hands

Generic name/Brand name Date ordered/started/discontinued

Route/Dosage/Frequency of Administration

General action/Classification Clients response to the medication w/ SE

Isoniazid

Isotamine

Ordered:

Dec. 21, 2009 (4pm)

Started:

Dec. 22, 2009 (7am)

Oral

100 mg = 5 ml

Once a day, pre-breakfast

Inhibits synthesis of mycolic

acids, essential metaboilites

for mycobacteria. The action

may be bactericidal.

Anti-infective, anti-TB

No report signs of rashes.


o Document


Prior:

63




During:



After:


o Wash hands


o Document


Prior:



64


During:

Generic name/Brand name Date

ordered/started/discontinued

Route/Dosage/Frequency of

administration

General

action/Classification

Clients response to the

medication w/ SE

Pyrazinamide

Tebrazid

Ordered:

Dec. 21, 2009 (4pm)

Started:

Dec. 22, 2009 (7am)

Revised:

Dec. 23, 2009

Oral


mg/5 ml) = 2.5 ml

200 mg (stock dose: 250 mg/5

ml) = 4 ml

Bacteriostatic or bactericidal

by unknown mechanisms.

Anti-infective, an-TB

Itching and skin rash noted.



After:


o Wash hands

65


o Document

C .Diet

Type of Diet

Date Ordered

Date Started

Date Changed

General

DescriptionIndication(s)

Specific Foods

Taken

Client’s Response

to Diet

Nothing Per Orem

(NPO)

Date Ordered:

12/19/09

Date Performed:

12/19/09

Date Changed:

12/20/09

No food and fluid

is passed through

the alimentary

canal.

Since the pt has

been admitted

and is to be

subjected to a

series of

observation and

prevent irritating

the body until

definitive

diagnosis is

established.

None The patient strictly

complied with the

prescribed diet.

Soft rice and The patient followed

66

DAT Date ordered::

12/20/09

Date Performed:

12/20/09 -

12/26/09

Any foods and

fluids that are

being tolerated by

the patient.

To provide

nutrients needed

by the body.

chicken Tinola.

Milk

the Diet.

67


Prior:



o Explain the importance of complying with the dietary prescription

o Cite foods that are applicable to the indicated diet.

During:

o Be sure that patient is taking or having foods that he can tolerate.

o Explain the importance of complying with the dietary prescription.

After:

o Assess for patient’s response to the diet.

o Take note for any signs of abdominal pain or as client verbalizes so.

o Document relevant data.

d. Exercise/ Activity

68

Type of Exercise

Date Ordered

Date Started

Date Changed

General DescriptionIndication(s

)Client’s Response

Bed Rest Date Ordered:

12/19/2009

Date Started:

12/19/2009

Date changed:

12-23-09

A medical treatment

which refers to staying in

bed day and night as a

treatment for an illness or

medical condition. Patient

should be restricted from

any stressful activities

and be on bed most of

the time to decrease

oxygen demand and

prevent fatigability.

To decrease

oxygen and

energy

demand

Shakespeare was able to comply with

the prescribed activity and reported

that he had enough rest, gained more

energy, and did not experience

further difficulty of breathing starting

November 4, 2008 with the help of

oxygen therapy.


Prior:


69

o Provide comfort and safety of the client at all times

o State the purpose and indications of the activity.

o Explain to the patient and to his significant others the importance of complying with the order

During:

o Encourage the patient the importance of having adequate amounts of rest.

o Always ensure the comfort of the patient while he complies with the exercise or activity.

o Provide safety measures by removing sharp objects or objects that may hinder range of motion on the bed’s surface

o Provide comfort measures by stretching bed linens and puffing pillows

o Ensure safety by raising the side rails of the bed.

o Monitor and assist the patient as necessary

After:

o Continuous monitoring of the client’s exercise should be observed.

o Nurse should make sure that the patient adheres to the ordered exercise.

o Note tolerance to prescribed activity as well as other significant data.

o Monitor and document patients’ reaction to the treatment given

VIII. NURSING MANAGEMENT

70

ACTUAL NURSING CARE PLAN

Cues Nursing diagnosis

Scientific explanation

Objective Nursing Intervention

Rationale Evaluation

S- “may

konting ubo

siya at

nahihirapan

huminga” as

verbalized by

SO.

O- afebrile,

with on and

off cough and

clear nasal

secretions.

Vital signs:

Pr-128bpm

RR-30cpm

T-36.2c

Ineffective

airway

clearance r/t

retained

secre

tions.

Entry of foreign

substance.

Proliferation/

multiplication of

foreign substance

Compensatory

response

Irritation of

bronchioles

Produce secretion

Accumulation and

After 2-3

hours of

nursing

interventions,

patient will be

able to

maintain

airway

patency.

Established

rapport.

Vital signs

taken and

recorded.

Positioned

head

midline with

flexion

appropriate

for age or

condition.

☺ To gain

trust and

cooperation

from the

patient and

SO.

☺ To have a

baseline data

and monitor

changes in

the patient’s

condition.

☺ To open or

maintain

open airway

in at-rest or

After 2-3

hours of

nursing

interventions,

patient was

able to

maintain

airway

patency as

evidenced by

reduced

secretions.

71

blockage

Bronchoconstrictio

n

Ineffectve airway

clearance

Elevated

head of the

bed/change

position

every 2

hours and

prn.

Kept

environment

allergen/

pollutant

free.

Administere

d

bronchodilat

ors as

ordered.

compromised

individual.

☺ To take

advantage of

gravity

decreasing

pressure on

the

diaphragm

and

enhancing

drainage of/

ventilation to

different lung

segments.

To reduce

irritant effect

on airways.

72

Relaxes

bronchial

smooth

muscles.

Cues Nursing

diagnosis

Scientific

explanation

Objectives Nursing

Intervention

Rationale Evaluation

S> “nahihirapan

syang huminga”

as verbalized by

SO

O>cold clammy

skin

restlessness

RR=50bpm

Impaired

gas

exchange

r/t

ventilation

perfusion

imbalance.

Presence of

bacteria in the lower

respiratory tract

Goes to the alveoli

for proliferation

Immune system will

recognize foreign

After 1-2

hours of

nursing

intervention,

patient will

demonstrate

improved

ventilation

and

Established

rapport

Taken and

recorded vital

signs

☺ To gain

trust and

cooperation

from the

patient and

SO.

☺ To have

After 4 hours

of nursing

intervention,

patient

demonstrated

improved

ventilation and

adequate

oxygenation of

73

substance and

facilitates

inflammatory

response

Macrophages

engulfs the bacteria

Accumulation of

dead cells in the

alveoli

Retention of

secretions and

bronchoconstriction

Leading to

ventilation perfusion

imbalance in the

alveoli and capillary

membrane

Impaired gas

adequate

oxygenation

of tissues.

Elevated head

of bed/position

client

appropriately

Encouraged

frequent

position

changes and

deep

breathing/cough

ing exercises.

Kept

environment

allergen or

pollutant free

Encourage rest

baseline

data and

monitor

changes in

the patient’s

condition.

☺ To

maintain

airway.

☺ To

promote

optimal

chest

expansion.

To

reduce

irritant

effect on

tissues.

74

exchange periods or limit

activities.

airways.

To

prevent

fatigue.

75

Cues Nursing diagnosis Scientific

explanation

Goal Nursing

Intervention

Rationale Expected Outcome

76

S>”la syang ganang

kumain” as

verbalized by the SO

O> Body Weakness

Projectile

vomiting

irritability

loss of appetite

wt: 9.0 kg

DBW=15 kgs

Imbalance nutrition:

less than body

requirements r/t

inability to ingest

adequate nutrients.

Presence of bacteria

in the body

Inflammatory

response occur

Systemic

vasodilation in the

circulation of the

body

Increase peristalsis

Causing pressure in

the intestine

Nausea and vomiting

After 2 months of

nursing intervention,

patient will be able

gain weight from 9.0

kgs to 15 kgs.

Established

rapport

Taken and

recorded vital

signs

Discussed eating

habits including

food preferences

such as giving

colorful food

Noted total daily

intake. As

maintained diary

of calorie intake,

patterns, and

times of eating

☺ To gain trust and

cooperation from the

patient and SO.

☺ To have a

baseline data and

monitor changes in

the patient’s

condition.

☺ To encourage

patient to eat.

☺ To reveal

changes that should

be made in client’s

dietary intake.

After 1 month of


patient was able to

gain weight from 9

kgs to 15 kgs.

77

Loss of appetite

Inability to ingest

adequate nutrients

Imbalance nutrition

Encourage

proper oral

hygiene

Prevent or

minimize

unpleasant odors

Weigh weekly

and document

results

Give

supplemental

vitamins as

ordered

To increase

appetite.

To avoid or

prevent negative

effect on appetite on

eating.

To monitor

effectiveness of

dietary plan.

To induce patient’s

appetite.

78

Cues Nursing diagnosis Scientific

explanation

Objectives Nursing Intervention Rationale

S>” Di naming

alam kung ano

ang gagawin” as

verbalized by SO

O>Inaccurate

follow through of

instructions

Knowledge deficit

regarding condition,

treatment, prevention,

self care, and

discharge needs

related to lack of

exposure to or

misinterpretation of

information as

evidenced by request

for information.

Absence or

deficiency of

cognitive information

about Primary Koch’s

Infection

After 2-3 hours of


pt. will initiate

behavior/ lifestyle

changes to improve

general well-being

and reduced risk of

reactivation of TB

Established

rapport.

Vital signs taken

and recorded.

Determined client’s

most urgent need

from both client’s

and nurse’s

viewpoint.

Stated objectives

clearly in learner’s

terms.

Determined client’s

method of

☺ To gain trust and

cooperation from the

patient and SO.

☺ To have baseline

data and monitor

changes in the

patient’s condition.

☺ To identify starting

point.

☺ To meet learner’s

needs.

☺To facilitate

learning.

79

accessing

information and

include in teaching

plan.

Provided written

information/guideli

nes for client to

refer to as

necessary

☺To Reinforces

learning.

Cues Nursing

diagnosis

Scientific

explanation

Objectives Nursing

Intervention

Rationale Expected

outcome

S>

O> (+) dyspnea

(+)

tachypnea

Irritability

Poor skin

turgor

Impaired

gas

exchange

r/t

ventilation

perfusion

imbalance.

Presence of

bacteria in the

lower respiratory

tract

Goes to the alveoli

for proliferation

Immune system will

recognize foreign

substance and

After 1-2

hours of

nursing

intervention,

patient will

demonstrate

improved

ventilation

and

adequate

oxygenation

Established

rapport

Vital signs taken

and recorded

Elevated head

of bed/position

☺ To gain

trust and

cooperation

from the

patient and

SO.

☺ To monitor

changes in the

patient’s

condition.

Patient

demonstrated

improved

ventilation

and adequate

oxygenation

of tissues.

80

Restlessness

Diaphoresis

Cyanosis

Rr= 45bpm

facilitates

inflammatory

response

Macrophages

engulfs the bacteria

Accumulation of

dead cells in the

alveoli

Retention of

secretions and

bronchoconstriction

Leading to

ventilation

perfusion

imbalance in the

alveoli and capillary

membrane

Impaired gas

of tissues. client

appropriately

Encouraged

frequent position

changes and

deep

breathing/coughi

ng exercises.

Assess for

dyspnea,

tachypnea,

abnormal or

diminished

breath sounds,

increase

respiratory

effect, limited

chest wall

expansion and

fatigue

Note cyanosis/

☺ To maintain

airway

☺ To promote

optimal chest

expansion.

Helps clarify

degree of

difficulty and

changes in

condition

Accumulation

of secretions

or airway

compromise

81

exchange change in skin

color, including

mucus

membranes and

nail beds

Promote bed

rest or limit

activity and

assist with self

care activities as

necessary

Monitor serial

ABG’s or pulse

oximetry

can impair

oxygenation of

vital organs

and tissues

Reducing

Oxygen

consumption

or demand

during periods

of respiratory

compromise

may reduce

severity of

symptoms

Decreased

oxygen

content

(PaO2) or

saturation/

increased

PaCO2

indicate need

82

Provide

supplemental

Oxygen as

appropriate

for intervention

or change in

therapeutic

regimen

Aids in

correcting

hypoxemia

that may occur

secondary to

decreased

ventilation or

diminished

alveolar lung

surface

83

2. Actual SOAPIERs

12/20/09

S1 > “may konting ubo siya at nahihirapan huminga” as verbalized by SO.

S2> “nahihirapan syang huminga” as verbalized by SO

S3> ”la syang ganang kumain” as verbalized by the SO

S4> Di naming alam kung ano ang gagawin” as verbalized by SO

O> Received patient on bed, conscious and coherent with on going IVF of D5 0.3

NaCl 500ml regulated at 56 cc/hr at 250 cc level infusing well on the left hand,

the skin of the eyelids was intact without redness, swelling, discharge or lesion

and eyelashes were equally distributed along the lid margins and curve outward.

No protrusion or sunken appearance. The conjunctiva was smooth and moist.

The chest is symmetrical, no lesions found, no shallow breathing, no sign of

deformities, no presence of mass, no sign of abnormalities, no resonant sound.

Positive rales or crackles upon auscultation. , the skin had a poor skin turgor with

none tenderness, with vital signs taken as follows: Temperature=36.6°C Heart

Rate=128 bpm Respiratory Rate=29 bpm.

A1> Ineffective airway clearance r/t retained secretions.

A2> Impaired gas exchange r/t ventilation perfusion imbalance.

A3> Imbalance nutrition: less than body requirements r/t inability to ingest adequate

nutrients

A4> Knowledge deficit regarding condition, treatment, prevention, self care, and

discharge needs related to lack of exposure to or misinterpretation of information

as evidenced by request for information.

P1> After 2-3 hours of nursing interventions, patient will be able to maintain airway

patency as evidence by reduced secretions.

P2> After 2 hours of nursing interventions the patient will verbalize awareness of

causative factors and initiate necessary interventions.

P3> After 1 month of nursing intervention, patient will be able to gain weight from 9

kgs to 15 kgs.

P4> After 2-3 hours of nursing intervention, patient will be able to initiate lifestyle

changes and participate in treatment regimen to improve general well-being and

reduced risk of reactivation of TB.

84

I1> Established rapport.

Vital signs taken and recorded.

Positioned head midline with flexion appropriate for age or condition.



Elevated head of bed/position client appropriately

Encouraged frequent position changes and deep breathing/coughing exercises.



Discussed eating habits including food preferences such as giving colorful food

Noted total daily intake. As maintained diary of calorie intake, patterns, and

times of eating.

Encourage proper oral hygiene.

Prevent or minimize unpleasant odors.

Weigh weekly and document results.

Give supplemental vitamins as ordered.



Determined client’s most urgent need from both client’s and nurse’s viewpoint.

Stated objectives clearly in learner’s terms.

Determined client’s method of accessing information and include in teaching

plan.

Provided written information/guidelines for client to refer to as necessary.

E1> Goal partially met, the patient maintained airway patency but secretions are still

present.

R1> Reinforce above-mentioned interventions.

E2> Goal met, patient verbalized awareness of causative factors and initiated

necessary interventions.

E3> Goal partially met, the patient was able to eat a little.


E4> Goal met, patient verbalized understanding of causative factors and necessary

interventions.

85

12/21/09

S> 0

O> The patient is asleep .Upon awake, was unable to smile but responsive to stimuli

and cry actively. The patient carries by his mother, with on going IVF of D5 0.3

NaCl 500ml regulated at 56 cc/hr at 400 cc level infusing well on the left hand,

the skin of the eyelids was intact without redness, swelling, discharge or lesion

and eyelashes were equally distributed along the lid margins and curve outward.

No protrusion or sunken appearance. The conjunctiva was smooth and moist.

The chest is symmetrical, no lesions found, no shallow breathing, no sign of


Positive rales or crackles upon auscultation. , the skin had a poor skin turgor with

none tenderness, with vital signs taken as follows: Temperature=36.5°C Heart

Rate=125 bpm Respiratory Rate=27 bpm.


A2> Impaired gas exchange r/t ventilation perfusion imbalance.

A3> Imbalance nutrition: less than body requirements r/t inability to ingest adequate

nutrients

P1> After 2-3 hours of nursing interventions, patient will be able to maintain airway

patency as evidence by reduced secretions.

P2> After 2 hours of nursing interventions the patient will verbalize awareness of

causative factors and initiate necessary interventions.

P3> After 1 month of nursing intervention, patient will be able to gain weight from 9

kgs to 15 kgs.



Elevated head of bed/position client appropriately

Encouraged frequent position changes and deep breathing/coughing exercises.



Discussed eating habits including food preferences such as giving colorful food

Noted total daily intake. As maintained diary of calorie intake, patterns, and

times of eating.

Encourage proper oral hygiene.

Prevent or minimize unpleasant odors.

86

Weigh weekly and document results.

Give supplemental vitamins as ordered

E1> Goal partially met, the patient maintained airway patency but secretions are still

present.


E2> Goal met, patient verbalized awareness of causative factors and initiated

necessary interventions.

E3> Goal met, as evidenced by the patient was able to eat and drink milk regularly.

12/22/09

S1> “medyo hirap pa syang huminga” as verbalized by SO

O> Patient was received on bed, sleeping with an IVF of D5 .3 Nacl 1L at 750cc

level, regulated at 56 gtts/min. monitored and recorded vital signs, fixed bed

linen, changed clothing, kept back dry, assisted in nebulization. Health teachings

were imparted such as proper positioning of thee patient while feeding to prevent

aspiration. Advised significant others of patient to increase patient’s fluid intake.

Positive rales or crackles upon auscultation. Skin turgor is good, when pinched it

springs back to its previous state, with vital signs taken as follows:

Temperature=36.4°C Heart Rate=124 bpm Respiratory Rate=28 bpm.


P1 > After 3 hours of nursing intervention, the S.O will identify ways to maintain

patients patent airway.

I1> established rapport

assessed patients condition

monitored and recorded vs

monitored IVF patency and regulation

instructed S.O to put patient in high back rest

provide adequate rest period

kept back dry

changed position every 2 hours

encouraged S.O to perform frequent hand washing

due meds given

E1 > Goal met as evidence by patient was able to maintain a patent airway.

87

12/23/09

S1> “tamang pagaalaga ba ang ginagawa namin” as verbalized by SO

O1> Patient was received sitting on bed, awake, IV out, afebrile with on and off cough

and clear nasal secretions. Vital signs as follows: temperature: 36.2°, HR: 120

bpm, RR: 24brpm. IVF of D5 .3 Nacl 1L inserted at 6:45pm using vasocan g.24

at right hand and regulated at 56ml/hr, hence IV medications was continued. The

skin of the eyelids was intact without redness, swelling, discharge or lesion and

eyelashes were equally distributed along the lid margins and curve outward. No

protrusion or sunken appearance. The conjunctiva was smooth and moist. The

chest is symmetrical, no lesions found, no shallow breathing, no sign of


Positive rales or crackles upon auscultation

A1> Knowledge deficit regarding condition, treatment, prevention, self care, and

discharge needs related to lack of exposure to or misinterpretation of information

as evidenced by request for information.

P1> After 2-3 hours of nursing intervention, patient will be able to initiate lifestyle

changes and participate in treatment regimen to improve general well-being and

reduced risk of reactivation of TB.

E1> Goal met, patient verbalized understanding of causative factors and necessary

interventions.

88

VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

1. Client’s Daily Progress Chart

DAYS Admission

12-19-09

Day 2

12-20-09

Day 3

12-21-09

Day 4

12-22-09

Day 5

12-23-09

Day 6

12-24-09

Day 7

12-25-09

Discharge

12-26-09

Nursing Problems

1. Ineffective airway

clearance r/t retained

secretions.

2. Impaired gas

exchange r/t ventilation

perfusion imbalance.

3. Imbalance nutrition:

less than body

requirements r/t

inability to ingest

adequate nutrients.

4. Knowledge deficit

regarding condition,

treatment, prevention,

self care, and

89

discharge needs

related to lack of

exposure to or

misinterpretation of

information as

evidenced by request

for information.

5. Impaired gas

exchange r/t ventilation

perfusion imbalance.

Vital Signs

Temperature 36.8°C 36.6C 36.5°C 36.4°C 36.2°C 36.2C 36.4C 36.2C

Cardiac Rate 132 bpm, 128 bpm 125 bpm 124 bpm 120bpm 128 bpm 120bpm 120 bpm

Respiratory Rate 30 cpm 29 cpm 27 cpm 28 cpm 22 cpm 22 cpm 22 cpm 22 cpm

Dx/Lab Procedures

Complete Blood Count #1:

Hgb: 130

Hct: .39

WBC: 9.0

Neutro:0.6

1

Lympho:

0.53

90

Chest X-ray There are

hazy and

patchy

infiltrations

in both

lung fields.

Nodular

densities

in the

retrocardia

c space.

The heart

is normal

in size by

configurati

on,

diaphragm

s,

costopenic

angles

and the

visualized

bones are

intact.

91

Medical Management

IVF: D5 .3NaCl

Nebulization

Drugs

Cefuroxime 250mg/IV

q 8

Amikacin 15mg/ IV q 8

Hydrocortisone

150mg/IV q6

Ampicillin 100 mg/IV

q6

Rifampicin110 mg

(Stock dose: 200 mg/5

ml) = 2.75 ml OD

Pyrazinamide Oral

200 mg (stock dose:

250 mg/5 ml) = 4 ml

Isoniazid Oral

100 mg = 5 ml OD

92

VII. Discharge Planning

The patient was discharged on December 26, 2009. The doctor gave the MGH order at

9:00 am and after settling the bill, the patient was able to go home at 4:00 pm. The

patient was wearing a clean white shirt and brown shorts. His hair was combed but there

was dirt under his fingernails. His vital signs were: T- 36.2°C, HR- 120 bpm, RR- 22

bpm. He was afebrile, with no complaints of pain, with no presence of jaundice.

M > Rifampicin 200/5 syrup 2.75ml OD Pre breakfast x 6 mos.

> Isoniazid 100/5 syrup 5 ml OD Pre breakfast x 6 mos.

> Pyrazinamide 250/5 syrup 4 ml OD pre breakfast x 2 mos.

> Bronchorex ½ tsp TID

> CTAX P ½ tsp BID

>Prednisone 10 mg/5 ml ½ tsp BID

Health teachings:

Instructed patient to take medication with full glass of water. To

enhance absorption.

Instructed patient no to take the medication with milk.

Instructed patient to report blurring of vision, severe gastrointestinal

symptoms, headache, muscle pain, weakness.

Instructed patient to store the medication in a cool environment in tight

container protected from light.

E > Complete bed rest

> Limit activities

Encouraged patient to do deep breathing exercise to promote proper

lung expansion and facilitate proper carbon dioxide elimination.

Instructed patient to avoid strenous activities to avoid fatigue and

instructed patient to resume usual ADLs gradually and as tolerated

93

T > Instructed to follow medical regimen

Instructed patient about the improtance of complying to treatment

regimen.

Instructed patient to do proper handwashing

H > Instructed SO to increase fluid intake

> Advised SO in proper positioning of patient while feeding to prevent

aspiration

> Instructed SO about the strict compliance of therapeutic regimen

O > Advised to have a follow up check-up after 2 weeks

D > Bottle feeding aspiration precaution

> Increase intake of foods high in protein

VII. SUMMARY OF FINDINGS

The nurse researcher was able to know the background of the disease condition

(Koch’s Infection), Know the reasons why such diagnostic procedures and treatments

are performed, Know the progress of the disease, Cooperate in the necessary medical

and nursing interventions, Know the reasons why the patient experiences the signs and

symptoms of the diseases, Know preventive measures in response to the disease so as

to prevent deterioration of the patient’s condition and Participate willingly in the care of

his conditions such as adhering to health teachings provided, Have the necessary

awareness for the condition’s familial tendency and thus perform appropriate activities

that may prevent eventual progress of the disease (for the client’s significant others).

The nurse researcher was able perform a comprehensive assessment of the

patient, enumerate the signs and symptoms of Koch’s Infection, identify and list

diagnostic procedures that would help in the diagnosis of Koch’s Infection, Identify

nursing problems utilizing the subjective and objective cues based on the patient’s

response, Perform appropriate therapeutic interventions for each of the formulated

nursing diagnosis, Have a background of the disease condition, Known the current

94

trends about the disease, Know the incidence, prevalence and mortality rate of the

disease, Identify factors present to the patient that predisposed him to the said disease,

Explain briefly the anatomy and physiology of the disease, Gain proper knowledge and

understanding about the existing disease condition, it’s pathophysiology, sociology and

etiology involved in its acquisition and progression, Identify the difference modifiable and

non-modifiable factors for the occurrence of the disease, Identify the different early

clinical manifestations of the disease condition, Analyze the different laboratory and

diagnostic procedures, their indications to the disease and identify the nursing

interventions before, during and after the performance of the said procedures, Identify

the different signs and symptoms manifested by the client who have had Koch’s

Infection and explain how these signs and symptoms occur, Identify the common

complications of Koch’s Infection and the appropriate preventive measures, Explain the

different treatments or medical modalities and their importance, and different nursing

interventions during the performance of the said procedure, Identify common

medications used as a treatment for the diseases, their mechanism of action, adverse

affects and nursing interventions before, during and after the administration of the

medications, appropriate nursing diagnoses and their corresponding effects for the

disease conditions, Render appropriate nursing interventions to prevent complications of

the disease.

IX. CONCLUSION

Prognosis depends largely on the extent of the disease. Primary, dormant or

limited secondary tuberculosis responds very well to chemotherapy. As with this case of

Primary tuberculosis or Primary Koch’s infection in a one year old child, prognosis is

good as long as the entire course of medication is taken by the patient. There is also a

need to trace and screen contacts or anyone who is in close contact with the patient.

Patient with tuberculosis needs to be isolated while infectious but in this case the patient

can not infect other people especially adults. Since adults have stronger immune

system than children do. But the patient can infect children of his same age because

they have weak immune system. We also have to stress out to the patient or significant

other the importance of having plenty of rest and eating a balanced meal. Once the

patient has completed the entire course of treatment, he should maintain or keep his

95

immune system as healthy as possible. The patient had improved breathing patterns

and lesser secretions when he was discharged.

Primary tuberculosis used to be one of the greatest killers – attacking anyone

who is at risk. Treatment with medications for a period of 6 months has made it possible

to save countless lives.

In this case study, the nurse researcher learned about the disease process, the

microorganism that causes tuberculosis. Also the anatomy and pathophysiology of the

disease as well as the proper management of the disease. The client’s family also was

able to demonstrate behaviors, understanding on how to prevent the recurrence of the

disease and compliance to health teachings given.

Lastly, the nurse researcher concluded that prevention is better than cure,

because it is easier to prevent a disease than to cure it.

X. RECOMMENDATION

Diagnosis of childhood tuberculosis still presents a problem because of paucity of

specific sign and symptoms clinical evidence and difficulty in sputum collection.

Tubercullin Testing seems to be an important diagnostic tool. Since a majority of our

population. Whether used in hospital, health centers, the test needs careful training of

medical health providerl and adaption of precise and sophisticated technique.

The findings suggest that the researchers offer these recommendations:

1. Physicians, nurses, other health care providers and the people should have an

orientation on the signs and symptoms and the different factors that contribute in

the disease condition.

2. To those who are at risk of acquiring the disease, that they may be able to know

the signs, symptoms, factors that aggravate and alleviate the disease condition

and different treatment options that they may account into.

96

3. To the patient’s significant others, they must give support and help the patient in

achieving optimum nutrition as well as to provide support and effective coping

mechanisms to reduce stress and depression.

4. Student Nurses, caring for patients, must provide holistic care to help the patient

achieve optimum well being and maintain health.

XI LEARNING DERIVED

As a professional nurse, this study showed me the importance of early detection

of diseases that may lead to more serious conditions if it is not properly managed or

treated. Giving care to a patient whether pediatric, geriatric, a medical case or surgical

case makes no difference. Rendering care to everyone who needs it is a real sense of

responsibility. In making this case study, I was able to work well because I know for

myself that I did my best for my patient. We can say that nursing is significant

therapeutic and dynamic process. It is therefore significant for the nurse caring for the

patient to wholeheartedly understand what he is doing like in carrying out some basic

skills in relation to identified goals, comfort and care, interventions and prevention of

illness.

Bibliography

Smeltzer, Suzane, et al.2000.Brunner and Suddrath’s text book of Medical Surgical

Nursing. 11th Edition.

Diseases 3rd Edition spring house .2000.

Seeley, Tate, Stephen.2004.Essentials of Anatomy and Physiology 5th ed.

Nowak, Thomas., Gordon handford.Pathophysiology Concepts and applications for

health care professionals.3rd ed.

2007.Mims.11th ed.

Luxner,karla.2005. Delmar Maternal and infants care plans.2nd ed.

Elkin,perry,potter.2004.Nursing Intervensions and clinical skills.3rd edition

97

Schnell, Leeuwen, Kranprits. Davis’ Comprehensive Handbook of Laboratory and

Diagnostic Tests with Nursing Implications.2003

www.wikipedia.com

www.yahoohealth.com

www.google.com

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