I. NURSING HISTORYA. General DataName: XXXAddress: XXXDate of Birth: May 5, 1920 Age: 85 y/o Place of Birth: Catarluha, SamarNationality: Filipino Religion: Catholic Civil Status: WidowDate of Admission: December 4, 2005 Time: 8:05 pmHospital Unit: Medical Ward Room No. 440BAttending Physician: XXXB. Reason for Seeking Health Care

The pt was admitted due to difficulty of breathing.C. History of Present Illness

Before the pt was admitted, a few months ago, she experienced non-productive cough with whitish phlegm. There was no fever. Difficulty of breathingand chest pain noted. She consulted a physician with the assistance of herdaughter-in-law and was given an unrecalled Anti-Koch’s medication. It was takenwith good compliance. The pt also experienced constipation so she was given an enema to pour-out stools. There was no abdominal pain, nausea, and vomiting noted.

One week prior to admission, she still experienced the above symptoms. There was no fever and chest pain. She experienced difficulty of breathing when she was assisted in the bathroom 6 hours prior to admission. She prompted consult, hence, was admitted.D. Past Medical History

The pt had a Diabetes Mellitus but with an unrecalled year. She hasHypertension but with an unrecalled highest and lowest BP. She had also suffered stroke 2 years ago, which made her to be bedridden, and left extremities paralysis. E. Family History

UnremarkableF. Obstetrical/Menstrual History

UnremarkableG. Psychosocial / SocioculturalHistory

The pt is a non-smoker and non-alcoholic beverage drinker. She is currently living with her daughter-in-law and grandson. All her sons and daughters are living outside the country.H. Activities of Daily Living

1. NutritionThe pt is used to eat rice and different kinds of viands. She drinks at least 3-4 glasses

of water everyday.2. Elimination

The pt urinates at least 4 times a day. She is having a difficulty in defecating. 3. Rest

The pt sleeps and wakes up anytime she wanted. She has no definite time of waking up and sleeping4. Hygiene

The pt takes a bath everyday through the help of her daughter-in-

law and grandson.

5. ActivityUpon waking, the pt is used to sit in the wheel chair.

I. PHYSICAL EXAMINATIONVital Signs: T= 36.50C PR= 89 bpm RR=29 bpm BP= 130/80 mm HgHead > symmetrical

> have no masses> normocephalic

Eyes > no redness> eyebrows are bilateral> eyelashes are evenly distributed> eyeballs are aligned normally

Ears > are of equal size> no discharge on the external auditory meatus> no lesions

Nose > symmetric and lies in the midline> no discharges> with O2 inhalation via nasal cannula 2-3lpm but was discontinued the following

dayMouth > no bleeding of gums

> with dry lips> decrease salivation

Neck > no masses> with limited movements> symmetrical

Breast/Chest > no discharges> no lesions> (+) crackles> (-) Wheezes

Abdomen > slightly scaphoid> Umbilicus is in midline and inverted> No scar and lesions> Hypoactive bowel sounds

Extremities > no fracture> Symmetrical> Left upper and lower extremities cannot be moved freely> Right upper and lower extremities can be move freely but with

limitationsSkin > color is light to brown

> No edema> Poor skin integrity> Poor skin turgor> Dehydrated

II. ANATOMY AND PHYSIOLOGY

The left and right lung The two lungs, which fill most of the thorax, are each enclosed within a double membrane known as the pleura. The right lung is the larger, being divided into three lobes, while the left is divided into two lobes. The lobes are further divided into bronchopulmonary segments, each of which has a segmental bronchus.

The bronchi and bronchioles

The trachea branches off into the two main tubes of the lungs – the right and left bronchi. Within the lungs the bronchi branch again, forming secondary and tertiary bronchi, then smaller bronchioles, and finally terminal bronchioles. At the end of the terminal bronchioles are the alveoli.

The alveoli

The alveolar sacs are made up of groups of alveoli at the end of the terminal bronchioles. Each lung contains approximately 300 million alveoli, giving a total surface area of 40—80m2. The epithelial lining of the alveoli consists mainly of type 1 pneumocytes which provide a thin layer for gas exchange. They are connected to type II pneumocytes (from which they are derived) by tight junctions. These tight junctions limit the fluid movement in and out of the alveoli. Although more numerous than the type I pneumocytes, type II pneumocytes cover less epithelium. They contain vacuoles that produce the pulmonary surfactant. The alveoli also contain macrophages which contribute towards the defense mechanisms of the lungs.

Physiology of the lungs

Contraction and relaxation of the muscles of the chest and the diaphragm are responsible for inspiration and expiration. When air is inhaled, the diaphragm contracts and flattens and the intercostal muscles between the ribs contract, pulling the ribcage upwards and outwards. During exhalation, the intercostal muscles and the diaphragm relax, pulling the ribcage down and contracting the lungs. This reduces the volume of the chest and forces the air out of the lungs.

The respiratory centre, located in the brain stem, controls breathing. Although breathing is an involuntary process, the depth and rate of breathing can be altered voluntarily.

Oxygen from inhaled air passes through the alveoli into the bloodstream. The blood is then taken to the left side of the heart via the pulmonary veins, and from here it is pumped around the body. Deoxygenated blood, which returns from the body to the right side of the heart, is pumped back to the lungs via the pulmonary arteries. Carbon dioxide passes from the capillaries, which surround the alveoli, into the alveolar spaces, and is breathed out.

III. DISEASE ENTITYPULMONARY TUBERCULOSISA. Definition

A communicable bacterial disease typically marked by wasting fever, and, and formation of cheesy tubercles often in the lungs (The Merriam-Webster Online Dictionary)

Is a chronic, sub acute, or acute disease that most commonly affects the respiratory system, usually the lungs, but may involve parts of other systems such as the lymphatic, osseous, urogenital, nervous, and gastrointestinal (Compilation of Communicable Diseases in Nursing – SLH)

An acute or chronic infection characterized by pulmonary infiltrates and formation of granulomas with caesation, fibrosis, and cavitation (Medical-Surgical Nursing made Incredibly Easy by Lippincott Williams and Wilkins)

B. Synonym Consumption. Phthisis

C. Infectious Agent The causative agent is Mycobacterium Tuberculosis, discovered by Koch in

1882 The term Mycobacterium is descriptive of the organism, which is a bacterium

that resembles a fungus. The organism multiplies slowly and is characterized as acid-fast aerobic

organism, which can be killed by heat, sunshine, drying, and UV light. Sputum of persons with TB is the most common source of the organism

D. Incubation Period From 2 to 10 weeks

E. Etiology Factors that heavily contributes to the high incidence and mortality rate of TB:

1. Poverty/overcrowded homes2. Energy/Protein undernutrition3. Deficiencies in Vitamin A, D, and C4. Debilitation to intercurrent infections prevalent among poor-

decreased resistance against infection5. Children below five years old- prone to infection due to

inadequate levels of immunity

F. Mode of Transmission TB is an airborne infection transmitted by droplet nuclei; usually from within

the respiratory tract of an infected person who expels them during coughing, sneezing, or singing.

From person-to-person, generally from adult to child and not vice versa nor from child-to-child. The seeder is an infectious case with productive cough freely expelling bacilli, usually an adult member of the household.

Being an airborne infection the common route of entry is the respiratory tract. The initial lesion is therefore pulmonary in location.

When an uninfected susceptible person inhales the droplet containing air, the organism is carried into the lung to the pulmonary alveoli.

G. Pathophysiology

Susceptible person M. bacilli airways to the alveoli transported to the lymph system and bloodstream to other parts of the body and lungs

Inflammatory reaction by the body’s immune system A susceptible person inhales Mycobacterium bacilli and becomes infected.

The bacteria are transported via the lymph system and bloodstream to other parts of the body (kidneys, bones, cerebral cortex) and other areas of the lungs (upper lobes). The body’s immune system responds by initiating an inflammatory reaction.

Phagocytes destroy the bacilli and normal tissue accumulation of

exudates in the alveoli initial infection (2-10wks after exposure) PHAGOCYTES (neutrophils & macrophages) engulf many of the bacteria, &

tubercle bacilli specifically lymphocytes lyse (destroy) the bacilli & normal tissue. This tissue reaction results in the accumulation of exudates in the alveoli, causing bronchopneumonia. The initial infection usually occurs 2-10 weeks after exposure.

Granulomas surrounded by macrophages forms protective wall

Transforms to fibrous tissue mass ( central portion of it is the Ghon tubercle) GRANULOMAS, new tissue masses of live & dead bacilli, are surrounded by

macrophages, which form a protective wall around the granulomas. Granulomas are then transformed to a fibrous tissue mass, the central portion of which is called GHON TUBERCLE.

Bacteria and macrophages necrotic cheesy mass calcified

Bacteria may become dormant Collagenous scar The material (bacteria & macrophages) becomes necrotic, forming a cheesy

mass. This mass may become calcified & form a collagenous scar. At this point, the bacteria become dormant, & there is no further progression of active disease.

After initial exposure & infection, the person may develop active disease because of a compromised or in adequate immune system response. Active disease may also occur with reinfection & activation of dormant bacteria.

Activation of dormant bacteria Ghon tubercle ulcerates

release of cheesy material into the bronchi

ulcerated tubercle heals and forms scar tissue

causes infected lung become more inflamed In this case, the Ghon tubercle ulcerates, releasing the cheesy material into the

bronchi. The bacteria then become airborne, resulting in further spread of the disease. Then, the ulcerated tubercle heals & forms scar tissue. This causes the infected lung to become more inflamed, resulting in further development of bronchopneumonia & tubercle formation.

Unless the process is arrested, it spreads slowly downward to the hilum of the lungs and later extends to the lobes. The process maybe prolonged & characterized by long remission when the disease is arrested, only to be followed by periods of renewed activity. Approximately 10% of people who are initially infected develop active disease.

H. Signs and Symptoms Low-grade fever cough (nonproductive/ mucopurulent) night sweats fatigue Weight loss Hemoptysis

IV. MEDICATIONS

Generic/Brand Name

Action Dose/ Frequency

Indications C/I Adverse Effects Nsg. Management

INH + Pyridoxine (Comprilex) syrup

INH – interferes with DNA synthesis and affects the mycolic acid coating of bacteriumPyridoxine – coenzyme necessary for many metabolic functions affecting CHO, lipid , and CHON utilization in the body

1 tbsp OD before breakfast

Pulmonary tuberculosis

Hepatic and renal disease, convulsive disorders, DM, chronic alcoholism, pregnancy, and lactation

hepatotoxicity; hypersensitivity; skin reactions; tingling; numbness; nausea; vomiting;

- Administer on an empty stomach for maximum effectiveness.- Caution the pt or the relative of the pt not to immerse feet or hands in water without first testing the temperature.- Monitor the effectiveness of comfort and safety measures and compliance with the regimen.

Rifampicin (Rimactane)

Antibiotic (Blocks key metabolic pathways needed for mycobacterium)

100 mg/5 ml, 20 ml OD

Mycobacterial infections

Hypersensitivity to Rifampicin

Reddish-orange secretions in urine, feces, saliva, sputum, sweat, tears; nausea; vomiting; anorexia; headache; abdominal cramping; fatigue;

-Advise client to take the meds on empty stomach 1 hr before or 2 hrs after meals.-Advise not to take alcoholic drinks.-Advise the client that urine and

rash; thrombocytopenia; jaundice

secretions may turn red-orange.-Notify physician for any undesirable effects

Centrum Multivitamins with Minerals (It supplements nutrition to the body to ensure adequate intake of vitamins and minerals)

1 tab OD Complete multivitamin and mineral formula

-Encourage pts to comply with diet recommendations of physician or other health care professionals. -Explain that the best source of vitamins is a well-balanced diet with foods from the four basic food groups

Levofloxacin (Levox)

Bactericidal Antibiotic (Kills bacteria by inhibiting DNA synthesis and cell wall synthesis)

Pneumonia 500 mg via IV OD

Epilepsy, pregnancy, lactation, hypersensitivity to quinolones

Headache; photosensitivity; insomnia; dizziness; palpitations; back pain

-If pt experiences symptoms of excessive CNS stimulation (restlessness, tremor, confusion, hallucinations), stop drug and notify the physician.-Advise pt to take drug with plenty of fluids

-Advise pt to avoid over exposure to light

Nacl (Sodium Chloride)

Replaces sodium and chloride and maintains levels.

Fluid and Electrolyte imbalances

hyponatremia Edema when given too rapidly or in excess; hypernatremia

-Advise the pt to report adverse reactions promptly.

(PRN meds) Paracetamol

Antipyretic (It relieves fever by the central action in the hypothalamic heat-regulating center)

500 mg 1 tab q4o

Mild pain or fever

Hypersensitivity to drug

Rash; urticaria; hepatotoxicity (overdose); renal failure (chronic use)

-If the pt has fever, note presence of associated signs (diaphoresis, tachycardia, and malaise)-Administer with a full glass of water.

Duphalac Laxative (acts as a stool softener by increasing the osmotic pressure and pulling water into the colon)

30 cc HS Treatment of chronic constipation in adults and geriatric pts

Galactosemia, bowel obstruction

Distention; flatulence; diarrhea

-Assess color, consistency, and amount of stool product.-Administer with a full glass of water or juice. May be administered on an empty stomach for rapid results.-Caution pt regarding the side effects

V. LABORATORY EXAMS

CHEST X-RAYDate Performed: December 4, 2005

Result:Previous film not available Hazed infiltrates seen in the right upper lungHaziness noted in the left lower lungsHeart is not enlarged The aorta is prominent and calcified

Comment:PTB, right upper lungPneumonia, left baseArtherosclerostic aorta

URINALYSISDate Performed: December 5, 2005

PHYSICALColor AmberReaction 6.0Transparency TurbidQuantity 20 mLSpecific Gravity 1.025CHEMICALAlbumin (+)Sugar NegativeMICROSCOPIC CELLS Pus Innumerable RBC 18-20/hpf Epithelial Few Bacteria Many

INTERPRETATION:

The amber or yellowish-brownish color of the urine of the pt is due to the effect of her medication (Rifampicin). She has an acidic urine based from the ph level reaction. A normal specific gravity is between 1.003-1.025 which means that the pt is within normal range although it’s on the highest normal value. The urinalysis result may conclude or indicate that the pt has a urinary tract infection based from the cloudy appearance of her urine, and the presence of pus, RBC, epithelial cells, and bacteria. The presence of albumin also indicates infection and diabetes mellitus.

CHEMISTRY

Date Performed: December 6, 2005

TEST RESULT NORMAL VALUESChloride 98.20 98-109 mmol/LSodium 132 137-145 mmol/LPotassium 3.3 3.5-5.1 mmol/L

INTERPRETATION:

The pt has low sodium and potassium level in the body while its chloride is on the lowest level of the normal values. This lab results shows that the pt is experiencing fluid and electrolyte imbalance in the body may be due to inadequate intake of fluids and food.

HEMATOLOGY

Date Performed: December 6, 2005

TEST RESULT UNIT NORMAL VALUES

Leukocyte 6.90 10^9/L 5.0 – 10.00Erythrocytes 3.22 10^12/L M: 4.6-6.2

F: 12.0-17.0Hgb 9.5 g/dl M: 12.0-17.0

F: 11.0-15.0Hct 28.00 % M: 40.0-54.0

F: 37.0-47.0ThrombocyteLymphocyteMonocyteGranulocyte

36518.8002.90078.300

10^9/L%%%

150-45020.0-40.00.0-7.050.0-70.0

INTERPRETATION:

The decrease of the patient’s erythrocyte, hemoglobin, and hematocrit may indicate anemia. This may also is a factor why the pt is experiencing fatigue and difficulty of breathing because she lacks the portion of the protein in the blood which binds with oxygen in the lungs. The decrease of lymphocyte may interpret that the patient’s body cannot totally fight of the infection so there is an increase of granulocyte as a support to fight off the foreign substances in the body.

VI. NURSING CARE PLANCUES BACKGROUND

KNOWLEDGENURSING DIAGNOSIS

NURSING GOAL NURSING INTERVENTION

RATIONALE EVALUATION

SUBJECTIVE:“Nahihirapan sya na huminga”, as verbalized by the relative of the pt since she do not totally speak at all.

Ineffective Breathing Pattern – the state in which an individual’s inhalation and/or exhalation pattern does not enable adequate pulmonary inflation or emptying

Ineffective Breathing Pattern related to altered oxygen supply as manifested by increased respiratory rate (29 bpm)

At the end of my duty, the pt must be able to demonstrate improved ventilation, adequate oxygenation, absence of signs and symptoms of respiratory distress

> Elevate the head of the bed as needed.

> Administer inhalation 2-3 lpm via nasal cannula, as ordered by the physician.> Reposition pt. frequently if immobility is a factor.> Maintain an adequate intake and output of fluids and secretions.> Monitor vital signs

> Promote physiologic/ psychologic ease of maximal inspiration> Supplies oxygen in the body

> Promotes ventilation>Mobilizes secretions

> Provides baseline data

Goal met; The pt was relieved somehow. Her O2 inhalation was already discontinued.

OBJECTIVE:> Bedridden

> Constipation

Impaired Physical Mobility – a state in which the individual experiences a limitation of ability for independent physical movement

Altered Bowel Elimination – a state in which an individual experiences difficulty, disturbance in bowel elimination

Constipation – a state in which an individual experiences a change in normal bowel habits characterized by a decreased in frequency

Impaired Physical Mobility related to past stroke as manifested by inability to purposefully move within the physical environment including mobility, transfer, and ambulation

Alteration in Bowel elimination: Constipation related to lack of exercise, inadequate intake diet and fluid intake as manifested by decreased bowel sounds and absence of stool passage for two weeks

At the end of my duty, the pt must be able to maintain position of function and skin integrity and to prevent bed sores

At the end of my duty, the pt must be able to establish/ return to normal patterns of bowel functioning.

> Turn the pt side to side and position her for optimum comfort

> Provide for safety measures (e.g. side rails up)> Encourage to increase oral fluid intake and intake of high fiber diet

> Encourage balanced diet high in fiber and bulk, as appropriate> Turn the pt side to side every 2 hours> Promote increase oral fluid intake including fruit juices. Suggest intake of warm fluids upon arising>Administer laxatives, as prescribed by the physician.

> Facilitate ventilation and prevent skin breakdown> Prevents injury

>Prevents constipation

> These interventions is done to promote bowel functioning and defecation

Goal partially met; The pt is still on bed and was able to maintain skin integrity.

Goal partially met; The pt is still having a hard time in defecating but the same intervention is still established by the relative as advised by the health care provider.

> Inability to receive or communicate a sense of understanding

and/or passage of dry hard stools

Impaired Social Interaction – the state in which an individual participates in an insufficient or excessive quantity or ineffective quality of social exchange

(All information and ideas on this section are from Nurse’s Pocket Guide: Nursing Diagnoses with Interventions by Doenges and Moorhouse fourth edition)

Impaired Social Interaction related to communication barriers (stroke) as manifested by observed inability to receive or communicate a satisfying sense of belonging, caring and interest

At the end of my duty, the pt must be involved in achieving positive changes in social behaviors and interpersonal relationships and give self-positive reinforcement for changes that are achieved.

> Establish therapeutic relationship using positive regard for the patient

> Observe and describe social/ interpersonal behaviors in objective terms, noting body language and behaviors towards HC provider

> Provide positive reinforcement towards the case of the pt

> Provides easiness and trust on the part of the pt

> Provides baseline on the patterns of behavior of the pt as to when and how the HC provider would approach her

> To improve social behaviors and interactions

Goal partially met; The pt. still do not speak and tends to stare at one place most of the time but she was able to follow to the HC provider’s instruction