A Case Study of

Pulmonary Tuberculosis

In Partial fulfillment of the requirements in NCM 104

Prepared By:

chelle

BSN IV-B

October 17, 2009

I. Introduction

A. Background of the study

This whole case study is about to discussed Pulmonary Tuberculosis (TB) and few of

Pneumothorax and Hydrothorax. This case will tackle about the disease, patient’s health and of

course nursing intervention.

Tuberculosis (abbreviated TB for tubercle bacillus or Tuberculosis) is a common and

often deadly infectious disease caused by mycobacteria, in humans mainly Mycobacterium

tuberculosis. Tuberculosis usually attacks the lungs (as pulmonary TB) 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. Other mycobacteria such as

Mycobacterium bovis, Mycobacterium africanum, Mycobacterium canetti, and Mycobacterium

microti also cause tuberculosis, but these species are less common in humans.

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.

Demographic incidence

Tuberculosis (TB) is a deadly disease. It is the world’s No. 1 cause of death around the

world; about 3 million persons die of TB every year. It is one of the 10 top killer diseases in the

Philippines; 75 Filipinos die of TB every day.

Pneumothorax, or collapsed lung, is a potential medical emergency caused by

accumulation of air or gas in the pleural cavity, occurring as a result of disease or injury, or

spontaneously.

Kind: Closed Pneumothorax – Air escapes in pleural space from a puncture or tear in an

internal respiratory structure such as bronchus, bronchioles, and alveoli.

Classification: Spontaneous – the cause is “Unknown”, could be result of another disease

such as COPD, PTB and Cancer. Chest wall is intact; blebs/bulla is rapture causing collapse

lungs.

A hydrothorax is a condition that results from serous fluid accumulating in the pleural

cavity.

B. Objective

General

The general objective of this case study is to broaden our knowledge about the disease

and develop skills on how to render the best possible care to a patient suffering from

Pulmonary Tuberculosis.

Specific

☺ To be able to define Pulmonary Tuberculosis as well as on how it is acquired, factors,

signs and symptoms.

☺ To be able to know the pathophysiology of Pulmonary Tuberculosis.

☺ To be able to know the other problems that the client is suffering right now not only PTB

but also Pneumothorax and Hydrothorax

☺ To gain more information about patient’s condition.

☺ To apply skills learned in the classrooms to actual handling and caring of a patient who

suffered from Pulmonary Tuberculosis.

☺ To determine the possible nursing intervention that will be a great help in patient’s

prognosis.

☺ To be able to give the appropriate health teaching and better understanding of the

disease to the patient, family and significant others.

C. Scope and delimitation

The scope of this study will focus on Pulmonary Tuberculosis with a few discussions of

pneumothorax and hydrothorax. The study covers the background of the disease, the anatomy,

pathology, mode of transmission, pathophysiology and as well as its complications.

All information needed to come up with this case study was taken from patient, patient’s

family (mother and sister), patient’s chart, laboratory result, physical assessment, books and

internet.

D. Theoretical Framework

“FLORENCE NIGHTINGALE ENVIRONMENTAL THEORY”

Florence Nightingale was born to a wealthy and intellectual family. She was known as

the Lady with the Lamp. She believed she was “called by God to help others … to improve the

well being of mankind”

Nightingale is viewed as the mother of modern nursing. She synthesized information

gathered in many of her life experiences to assist her in the development of modern nursing.

Her contribution to the nursing profession was her “Environmental Theory” in which the

nurse’s role is to place the client in the best position for nature to act upon him, thus

encouraging healing.

ENVIRO NMENT

MR. ADL

VentilationNutrition

BeddingCleanliness

Air

Light

Nightingale viewed the manipulation of the physical environment as a major component

of nursing care. She identified ventilation and warmth, light, noise, variety, bed and bedding,

cleanliness of the rooms and walls, and nutrition as major areas of the environment the nurse

could control. 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. These aspects of physical environment are also influenced by the

social and psychological environment of the individual.

I as a student nurse and part of the medical field, has the role of providing nursing care

with the help of the institutions and personnel involve to cure the illness and lower down the

factors causing the patient’s disease with the help of Nightingale’s Environmental Theory.

II. Clinical summary

A. General data

Name: Mr. ADL

Age: 24 years old

Religion: Roman Catholic

Civil Status: Single

Occupation: Car washer

Nationality: Filipino

Ethnic Group: Ilonggo

Admitting Diagnosis: Pulmonary Tuberculosis, Pneumohyrothorax Right

Sources of Information: Patient, Patient chart and the Significant Others (Mother and

the sister)

Reliability: 90% Reliable

B. Chief complaint

The patient complained of difficulty of breathing.

C. History of present illness

The information that I gathered are second hand as they came from the patient mother

and sister. Due to unknown reason, the patient refused to be interviewed even though

based on my observation; he has a capability to answer my questions.

Last two months, the family observed Mr. ADL is loosing weight and decrease of

appetite but instead of eating foods he his more on vices. Then his condition became

worsened according to family’s observation.

A month prior to admission, the patient condition became more at it worst and his

cough became productive with intermittent spots of blood in the sputum upon coughing.

He also starting to have night sweat started becoming sluggish and spending lots of time

sleeping. He was advice by the family to have a check-up and visit the nearest hospital or

clinic but he refuse everything that his family’s concerned, as verbalized by Mr. ADL’s sister.

Based on the statement of his mother, two days prior to admission Mr. ADL experience

body weakness, fatigue, and on the day of admission last August 21, 2009 in Rizal Provincial

Hospital, suddenly he was complaining of difficulty of breathing, one hour after he ate his

lunch.

D. Past medical history

Referring to the statements made by his sister, Mr. ADL was diagnosed with Pulmonary

Tuberculosis (PTB) last 2004, 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 2005 the patient has 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 (blood

pressure) mga 90/70”, as verbalized by the patient’s sister per word.

E. Familial history

Last 2002, 8 years ago when his father died from heart attack. I observed that Mr. ADL

has a clubbing finger, through the course of interview it was confirm that all of the siblings

have a heart problem.

Then two of his uncle died from respiratory diseases, one is from Tuberculosis and

another is from lung cancer. His sister also said that it was Mr. ADL twice to be confined in a

hospital with a serious condition.

F. Psychosocial health

1. Psychosocial Health

a. Coping Pattern

Patient used silence; he is making an observation to the student nurse who is assigned

to him.

b. Interaction Pattern

The patient ignores my kind interview due to unknown reasons but he cooperated when

I obtain Vital Signs, afternoon care, giving medications, and physical assessment.

c. Cognitive Pattern

According to the mother, Mr. ADL knows already his condition because he already

suffered it before, last 2004, 6 years ago. But this time it is more complicated.

d. Self Concept

In my observation, the patient looks shy. He just mind his own self maybe because he is

still in pain due to Chest tube thoracostomy attached on his right chest.

e. Emotional Pattern

The patient looks sad and weak maybe because of the pain that he is experiencing right

now and the disease that he is suffering.

2. Socio-Cultural Health

a. Cultural Pattern

The patient was evidently proud of his ethnicity during their family’s conversation.

b. Significant Relationship

According to the Mother, she doesn’t have an idea about sexual activity of Mr. ADL; she

only knew that Mr. ADL is single and no girlfriend as of now.

c. Recreation Pattern

Mr. ADL plays basketball with his friends; they also participated in any championship as

one team in their barangay, this is good for recreation. He also has a good voice,

according to his sister.

d. Economic

Mr. ADL is a car washer. He is working since 2006, 4 years ago, week days; it is near to

their house, and earning 150 pesos per day. He shares some of his earnings to his

mother as one of their resources of foods.

3. Spiritual Health

a. Religious Beliefs

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

house, twice a month.

b. Values and valuing

Mr. ADL is close to his mother. He lives with his mother from the time he was born to

the time he is where right now. All 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, these is the reason why he got the

disease Tuberculosis.

G. Review of system

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

SYSTEMGeneral Generalized body weaknessSkin Dry HeadEyes & EarsNose Runny nose, with dischargesThroat & Mouth Dry mouthNeck

BreastRespiratory Difficulty of breathing, dyspnea upon exertion.

Cough CVS Dyspnea upon exertion and chest painGIT Constipated at times, defecate every other

day. GUTExtremities Joint painNeurologic Weakness HematologicEndocrine Excessive night sweating Psychiatric Depression, Ignores kind interview

H. Physical assessment

a. General appearance/survey:

Patient appeared weak looking but was somehow coherent in a high fowlers position

due to CTT attach 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 which

is important. 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.

b. Measurement

FIDINGS NORMAL VALUES ANALYSIS/INTERPRETATION

(Ht, wt) Height: 5’5”Weight: 101 lbs

BMI BMI below normal as a result of malnutrition

Vital Signs Temp: 36.0 CPR: 90 bpmRR: 29 bpmBP: 100/70 mmHg

Temp: 37 CPR: 60-100 bpmRR: 16-20 bpmBP: 120/80 mmHg

With some abnormal findings in the respiratory rate.Increase RR; difficulty of breathing (decrease Oxygen

supply in the body)c. Head to toe Assessment

BODY PARTS NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS/INTERPRETATION

A. HEADa. Skull

b. Hair

c. Face

d. Eye/vision4.1 Eyeball

4.2 Lid margins

4.3 Conjunctiva

Rounded (normocephalic, with frontal, parietal and occipital prominences)

Evenly distributed; thick hair; silky resilient hair; no infestation or infection; variable amount of body hair

Symmetric facial features, palpebral fissures equal in size, symmetric nasolabial folds

Shape is round; size equal

Protects eyes, anteriorly meet at the medial and lateral corners of eye.

Delicate membrane; covers part of the outer surface of the eyeball

Normocephalic

Evenly distributed

Symmetric facial features

Round, uniform in size

Close symmetrical

Smooth and pale

Normal findings

Typical hair type of men

Normal findings

Normal findings

Normal findings

Undernourished, lack of vitamins

4.4 Sclera

4.5 Pupils

4.6 Eyebrow, lashes, color, symmetry, quality of hair, placement

4.7 Eye movement in all directions

Outermost tunic, thick white connective tissue.

Pupils constrict when looking at near objects, pupils converge when object is moved towards the nose

Hair evenly distributed, intact skin

Equal movement

Appears white

Normal pupil constriction

Hair evenly distributed, intact skin

Equal movement

Normal findings

Normal findings

Normal findings

Normal findings

B. VISION TESTINGa. Visual field

b. Visual acuity

When looking straight ahead clients can see objects in periphery

Able to read newspaper

Client can see from his periphery

Able to read newspaper

Normal peripheral vision

Normal visual findings

C. EARSa. Pinna

b. External canal

Same color as facial skin, pinna recoils after it is folded

Dry ear wax grayish-tan color or sticky wet cerumen in various shades of brown/ pearly gray color; semitransparent

Same color as facial skin, pinna recoils after it is folded

Wet and sticking cerumen with transparent color

Normal ear features

Normal findings

c. Hearing acuity Responds to moderately loud voice tone

Responds to moderately loud voice tone

Normal findings

D. NOSE Symmetric, normal breathing, able to identify familiar smell

No deformity, (+) difficulty of breathing. With runny nose

(+) dyspnea, patient have cough which reflex is not the only way to protect our airways which causes patient to have runny nose.

E. MOUTH/LIPSa. Gums

b. Teeth

c. Tongue

d. Palate-hard/soft

e. Oropharynx/ Tonsil

Pink gums; moist firm texture

32 adult teeth smooth, white yellowish shiny tooth enamel

Central position, pale in color

Pink and smooth; freely movable

Pink and smooth posterior wall

Dark gums

Yellowish with few cavities and some missing teeth

Central position, pale in color

Pale in color

Pale posterior wall

Gums darkened due to smoking history

Needs dental work

No remarkable findings

No remarkable findings

No remarkable findings

F. CHEECKS Hollow in appearance

Indicates malnutrition, due to weight loss

G. NECK Lymph nodes freely movable

Lymph nodes freely movable

Normal findings

H. CHESTa. Anteriorb. Posterior

Quiet rhythmic and effortless respirations; full symmetric excursions

(+) difficulty of breathing, with abnormal sound in the right lower lobe

Presence of crackles caused by fluid often associated with inflammation or infection of the alveoli.Indicates respiratory problems such us TB,

I. HEART

J. BREAST

Full and symmetric

Localized pain around thoracostomy site.

Full and symmetric

PneumohydrothoraxNo air leak on drainage system: manageable incision pain.

Normal findings

K. ABDOMEN Flat, rounded (convex) or scaphoids

Flat, scaphoidal in shape

Client is not well nourished.It is also due to weight loss.

L. UPPER EXTREMETIES Equal in size on both sides of the body; no muscle atrophy; normally firm; smooth coordinated movements

Equal in size but muscular atrophy evident.Unable to move freely due to pain in incision site.

Client is not well nourished

Struggling movements due to wounds, incision pain.

M. LOWER EXTREMETIES Equal in sixe on both sides of the body; no muscle atrophy; normally firm; smooth coordinated movements

With muscular atrophy evident.Occationally stands up for short time. (2 days post-op)

Client is not well nourished

Weakness and pain hinder client from actively moving around.

I. Activities of daily living

Before Hospitalization

During Hospitalization

Analysis/Interpretation

a. Fluid & Nutrition

Skipping meals most of the time, according to the significant others. Mr. ADL is more on vices.

His fluid preferences are water, softdrinks and liquor.

Mr. ADL drinks 3-4

Moderate decrease of the appetite; can consume about ½ of the foods given.

Diet as tolerated was advised to Mr. ADL

Due to medication given as side effects such as; Combivent and Rifampicin, there is a decrease of appetite.

The pt was trained to take DAT diet to sustain his nutritional needs.

b. Elimination

c. Safety, Activity & Exercise

d. Hygiene & Comfort

e. Rest & Sleep

f. Substance Abuse

glass of water a day and can consume Liquor of 3-4 beer a day.

He is more on bread in the morning; vegetables and fish most of their meals.

Mr. ADL usually voids large amount of urine, 5-7 x a day. Defecates at least once a day.

Doing his job as a car washer was his form of exercise everyday.

The patient takes a bath once a day and brushes his teeth twice a day.

The patient sleeps more or less than 5 hours a day.

Mr. ADL is more on vices. He is fun of drinking San Miguel Beer and can consume 3-4 glasses everyday. He also smokes at least 12-18 sticks of Hope

Usually voids 2-4 times a day.

Mr. ADL defecates every other day.

There is no exercise at all because of CTT attached on his abdomen. He habitually sits on bed during confinement.

Restricted on bed; the patient can’t take a bath due to CTT done in his right. All hygienic activities are assisted by SO.

The patient sleeps irregularly. 30 minutes of sleeps then awake again.

Restricted on vices during hospital confinement as recommended by the attending physician due to treating of TB.

There is a decrease bowel movement due to decrease appetite.

Patient’s daily exercise is limited because of body weakness and CTT attach on his abdomen.

Dependence related to restricted mobility after surgical procedure.

Due to inadequate rest the patient may have decrease body resistance.

Restricted vices will lead to immediate cure of TB.

g. Sexual Activity

everyday.

According to the Mother, she doesn’t have an idea about sexual activity of Mr. ADL; she only knew that Mr. ADL is single and no girlfriend as of now.

Restricted sexual activity during confinement.

Restricted sexual activity.

J. Laboratory / Diagnostic Exam

a. Hematology report August 21, 2009

Test Results Normal Value AnalysisHemoglobin 110 g/L 140 – 170 g/L Decrease

Insufficient oxygen circulating in the bloodstream.Indicates Anemia due to blood loss after surgery.

Hematocrit 0.33 0.40 – 0.50 DecreaseInsufficient oxygen circulating in the bloodstream.Indicates Anemia due to blood loss after surgery.

WBC 15.2 x 10 5.0 – 10.0 x 10 IncreaseLeukocytosisIndicates infection

Neutrophils 0.78 0.45 – 0.65 IncreaseAcute bacterial infection

Lymphocytes 0.21 0.25 – 0.40 Decreaselow absolutely lymphocyte concentration, associated with increase rates of

infection Monocytes 0.01 0.02 – 0.06 Decrease

Depleted in overwhelming bacterial infection

Platelets 320 150 - 450 Normal

b. Chest X-ray August 21, 2009

Impression: Pulmonary Tuberculosis (PTB)

Right sided Pneumohydrothorax

c. Urinalysis August 21, 2009

Color: YellowTransparency: S/I Fubid

Chemical Strips

Reaction: 5.2Specific Gravity: 1.025 (above normal) – dehydration and

contaminationAlbumin: Trace

Microscopic

WBC 8-12RBC 1-3Epithelial Cells RareMucus treads ModerateAmorphous Urates Plenty

d. RT Hemithorax August 22, 2009

Ultrasound done on the right hemithorax, there is a significant fluid in the right lower

hemithorax. Minimal fluid is seen with leculations noted of about 36cc. Echoes noted within

probably due to air.

Impression: Minimal leculated hydrothorax, right

e. Urinalysis August 22, 2009

Color: Yellowish brownConsistency: SoftMicroscopic: No Ova, parasite seenWBC 4-8RBC 0-1Bacteria Plenty – bacterial infection

f. Radiological Report August 23, 2009

Impression: Pulmonary Tuberculosis, Left

Pneumohydrothorax, Right

K. Surgical procedure

Mr. ADL has a fluid (hydrothorax) in his right lung, but when Chest Tube Thoracostomy

was performed last August 22, 2009, there was no fluid extracted, the fluid was noted in the

right lung.

Chest Tube Thoracostomy Returns (-) pressure to the internal pleural space Remove abnormal accumulation of air Serves as lung while healing is ongoing.The insertion of chest tube permits removal of the air or bloody fluid and allows re-

expansion of the lungs and restoration of the normal negative pressure in the pleural space.

Because air rises, a chest tube inserted to remove air is usually placed anteriorly through the 2nd

ICS. A chest tube inserted to remove fluids is placed posteriorly in the 8 th and 9th ICS because

fluid tends to flow to the bottom of the pleural space.

Chest Drainage Container

A waterseal at the end of a chest tube is essential to allow air to escape through the tube

but prevent air from traveling back up the tube and into the pleural space. The waterseal

drainage system is placed below the level of the patient’s chest, taking advantage of the force

or gravity to promote drainage and prevent backflow of bottle contents into the pleural space.

L. Final diagnosis

PTB with Pneumothorax and Hydrothorax, Right

M. Course in the ward

August 21, 20092:00pm – 10:00pm

Admitted a 24 years old male accompanied by relatives with a complained of difficulty of breathing.

Vital signs are taken and recorded with a BP: 100/70 mmHg, HR: 81 bpm, RR: 35 bpm Seen and examined by Dra. Magtoto Consent signed and secured Tuberculin skin test done; due at 3:30 pm IVF of D5NM 1L + 1 ampule of Lysmix inserted and regulated with 31 gtts/min Laboratory requested by the attending physician such as; Urine analysis, Ultrasound of

right lung, BUN and Creatinine, and chest X-ray Transferred to Charity Medical Ward, bed 22 Endorsed

August 22, 20092:00pm – 10:00pm

Received on bed with an IVF of D5NM 1L + 1 ampule of Lysmix @ 600ml level Conscious and coherent Vital signs are taken and recorded with blood pressure of 100/70 mmHg A febrile 36.5 NPO was advice

2:30pm Consent signed and secured

3:00pm Undergone CTT @ right lung Vital signs recheck Needs attended Endorsed

August 23, 20092:00pm – 10:00pm

Received on bed with an IVF of D5NM 1L + 1 ampule of Moriavit X 8 hours @ consuming level

Vital signs taken and recorded with Blood Pressure of 100/70 mmHg4:00pm

Cefuroxime 200mg TIV after negative skin test6:00pm

Vital signs recheck with no significance finding Needs attended Endorsed

August 24, 20092:00pm – 10:00pm

Received on bed with an IVF of 1L @ 400cc level Vital signs taken and recorded BP: 90/60 mmHg, PR: 90 bpm, RR: 29 bpm and

Temperature: 36.6 C With abnormal RR: 29 bpm Diet as tolerated maintained Due medication given and recorded

4:00pm Cefuroxime 200mg TIV after negative skin test

7:00pm Rifampicin 1 tablet before dinner Vital signs recheck with no significance finding Needs attended Endorsed

August 25, 20092:00pm – 10:00pm

Received on bed alert, coherent, cooperative.

With an IVF of D5NM 1L + 1 ampule of Moriavit @ 700cc level and regulated with 31 gtts/min on the right hand

Vital signs taken and recorded Afternoon care rendered Health teaching done Medication given Needs attended No other complaints Endorsed

III. Clinical discussion of the diseaseA. Anatomy and physiology

UPPER RESPIRATORY TRACT

Respiration is defined in two ways. In common usage, respiration refers to the act of breathing, or inhaling and exhaling. Biologically speaking, respiration strictly means the uptake of oxygen by an organism, its use in the tissues, and the release of carbon dioxide. By either definition, respiration has two main functions: to supply the cells of the body with the oxygen needed for metabolism and to remove carbon dioxide formed as a waste product from metabolism. This lesson describes the components of the 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, piglottis, larynx, and upper trachea; the oesophagus leads to the digestive tract.

One of the features of both the upper and lower respiratory tracts is the mucociliary apparatus that protects the airways from irritating substances, and is composed of the ciliated cells and mucus-producing glands in the nasal epithelium. The glands produce a layer of mucus that traps unwanted particles as they are inhaled. These are swept toward the posterior pharynx, from where they are swallowed, spat out, sneezed, or blown out.

Air passes through each of the structures of the upper respiratory tract on its way to the lower respiratory tract. When a person at rest inhales, air enters via the nose and mouth. The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a tube like structure that

connects the back of the nasal cavity and mouth to the larynx, a passageway for air, and the esophagus, a passageway for food. The pharynx serves as a common hallway for the respiratory and digestive tracts, allowing both air and food to pass through before entering the appropriate passageways.

The pharynx contains a specialised flap-like structure called the epiglottis that lowers over the larynx to prevent the inhalation of food and liquid into the lower respiratory tract.

The larynx, or voice box, is a unique structure that contains the vocal cords, which are essential for human speech. Small and triangular in shape, the larynx extends from the epiglottis to the trachea. The larynx helps control movement of the epiglottis. In addition, the larynx has specialised muscular folds that close it off and also prevent food, foreign objects, and secretions such as saliva from entering the lower respiratory 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.

The first branching point of the respiratory tree occurs at the lower end of the trachea, which divides into two larger airways of the lower respiratory tract called the right bronchus and left bronchus. The wall of each bronchus contains substantial amounts of cartilage that help keep the airway open. Each bronchus enters a lung at a site called the hilum. The bronchi branch sequentially into secondary bronchi and tertiary bronchi.

The tertiary bronchi branch into the bronchioles. The bronchioles branch several times until they arrive at the terminal bronchioles, each of which subsequently branches into two or more respiratory bronchioles.

The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli are bubble-like, elastic, thin-walled structures that are responsible for the lungs’ most vital function: the exchange of oxygen and carbon dioxide.

Each structure of the lower respiratory tract, beginning with the trachea, divides into smaller branches. This branching pattern occurs multiple times, creating multiple branches. In this way, the lower respiratory tract resembles an “upside-down” tree that begins with one trachea “trunk” and ends with more than 250 million alveoli “leaves”. Because of this resemblance, the lower respiratory tract is often referred to as the respiratory tree.

IV. Nursing problem list

Ineffective Airway Clearance

Ineffective Breathing Pattern

Risk for Infection

Imbalanced Nutrition; less than Body Requirements

Activity Intolerance

Impaired Physical Mobility

Anxiety

Nursing Priority:

1. Ineffective Airway Clearance

2. Risk for infection

3. Impaired Physical Mobility

VI. Drug Study

Generic Name: CEFUROXIME 200 mg TIV q8 hours ANST (-)Brand Name: CEFTIN

Classification Action Indication Adverse Effect Nursing Consideration2ND generation cephalosporin

A 2nd generation cephalosporin that binds to bacterial cell membranes and inhibits cell wall synthesis.

Treatment of susceptible infection due to group B streptococcus, E. coli, H. influenza etc.

Allergic reaction, oral candidiasis, mild diarrhea, mild abdominal cramping.

Ask the patient if he has a history of allergies to drugs, particularly to cephalosporin and penicillin.

Generic Name: IPRATROPIUM BROMIDE q4 hoursBrand Name: COMBIVENT, DOUNEB

Classification Action Indication Adverse Effect Nursing Consideration

Anti-cholinergic bronchodilator

An anti-cholinergic that blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscles.

Maintenance treatment of bronchospasm due to chronic obstruction pulmonary disease (COPD), bronchitis, emphysema, asthma.

Hypotension, insomnia, metallic or unpleasant taste, palpitations, urine reaction.

Monitor Vital signsMonitor intake and output

Generic Name: RIFAMPICIN 2 Tablets before lunch and 1 tablet before dinnerBrand Name: MYRIN-P FORTE

Classification Action Indication Adverse Effect Nursing Consideration

Antituberculosis Inhibits RNA synthesis, decreases tubercle bacilli replication

Initial phase treatment and retreatment of all forms of TB in category I and II patients caused by susceptible strains of mycobacterium.

Disorder of the blood and lymphatic system, immune system, metabolism and nutrition, CNS, eye, GI, skin and tissues, renal, fever, dryness of mouth.

Explain to the patient to expect a orange color of urine.

Monitor I & O.

Generic Name: TRAMADOL 50 mg Brand Name: ULTRAM

Classification Action Indication Adverse Effect Nursing Consideration

Analgesic, centrally-acting

An analgesic that binds to mu-opoid receptors and inhibits reuptake of norepinephrine and serotonin. Reduces the intensity of pain stimuli reaching sensory nerve ending.

Uses for management of moderate to moderately severe pain.

CNS: dizziness, vertigo, anxiety, sleep disorder, migraine.GI: nausea and vomiting, constipation, abdominal pain, anorexia.OTHERS: rash, sweating, hypotension, urinary retention.

Monitor vital signs especially Blood pressure.

Monitor input and output.

Assist with ambulation if dizziness and vertigo occurs.

Drug: LYSMIX 20 ml / amp TIDClassification Contents Indication Dossage

Parenteral nutritional products Multivitamins with minerals used as dietary supplements

Per amp- L-lysine monohydrochloride 20mg, L-histamin monoHCl 4mg, dl-methionine 10mg, thiamine HCl (Vit. B1) 1mg, riboflavin (Vit. B2) 100mcg, pyridoxine HCl (Vit. B6) 100mcg, taurine 4mg, dextrose 100mg.

Nutritional supplements Adult: 1 amp BID – TIDLysmix 20 ml x 5’s

Generic Name: AMINO ACID 20ml/ Ampule TIV q8 hrsBrand Name: MORIAVIT

Classification Action Indication Adverse Effect Nursing InterventionCalorics (Nutritional Drug) Provides a substrate for

protein synthesis or increases conservation of existing body protein.

Total Parenteral Nutrition CNS: FeverGI: FlushingGU: Osmotic dieresisMetabolic: electrolytes imbalance, weight gainMusculoskeletal: Osteoporosis

Monitor body temperature every 4 hours.

Obtain baseline electrolyte, glucose, BUN, calcium and phosphorus levels before giving drugs.

VII. Discharge Plan (METHODS)

M- Medications

Medications should be taken as ordered and prescribed by the physician to avoid

complications and help mange the condition of the patient. There are a lot of main anti-

Tuberculosis medications such us: Isoniazid, Fifampicin, Ethambutol and Pyrazinamide.

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.

Start with exercises that you are already comfortable doing. Starting slowly makes it less

likely that you will injure yourself.

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.

Maintained wound integrity on the surgical site.

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 your head when coughing. Keep tissues with you and cover

your mouth when you cough then throws the tissues used in the plastic bag.

Keep your hands clean. Maintain proper hygiene.

Isolate techniques is one of the best way to prevent the speared of the bacteria;

separation of dining ware.

Advise the relatives to clean the environment regularly since it is one of the factor that

contribute to the speared of bacteria.

Discuss to the client and significant others the cardinal signs of infection such as;

redness, heat, induration, swelling and separation of drainage.

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.