Department of Health Center for Health Development No.

DR. PAULINO J. GARCIA MEMORIAL RESEARCH AND MEDICAL CENTER

Cabanatuan City

NURSING DEPARTMENT

CASE STUDY ON MILIARY TUBERCULOSIS

SUBMITTED BY: RN HEALS IV

BERNARDEZ, DAWNERY JUANE SANDOVAL, VHIRONICA SANTIAGO, MICKEL SANTA CRUZ, SHERWIN

I.

Introduction

A. Background of the study

This whole case study is about to discussed Pulmonary Tuberculosis (TB). This case will tackle about the disease, patients health and of course nursing intervention. Miliary 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 worlds 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.

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 Tuberculosis as well as on how it is acquired, factors, signs and symptoms. To be able to know the pathophysiology of Tuberculosis. To be able to know the other problems that the client is suffering right now. To gain more information about patients condition. To apply skills learned to actual handling and caring of a patient who suffered from Tuberculosis. To determine the possible nursing intervention that will be a great help in patients 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 Miliary Tuberculosis. 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, patients family (mother and sister), patients chart, laboratory result, physical assessment, books and internet.

D. Theoretical Framework
FLORENCE NIGHTINGALE ENVIRONMENTAL THEORY
Ai Nutritio Ventilati

Cleanline ss

ENVIRO MR. NMENT ADL

Light

Beddi ng

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 nurses role is to place the client in the best position for nature to act upon him, thus encouraging healing.

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.

II.

Clinical summary

A. General data
Name: Mr. ADL Age: 9 years old Religion: Roman Catholic Civil Status: Single Nationality: Filipino Ethnic Group: Aeta Admitting Diagnosis: Miliary Tuberculosis secondary to Malnutrition 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 familys 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 familys concerned, as verbalized by Mr. ADLs 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 April 21, 2013 in Dr. PJGMRMC, 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 Miliary Tuberculosis last 2012, 1 year ago. He entered a rehabilitation program sponsored by the local government in Nueva Ecija 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 poor nutritional intake and unsanitary environment the disease from the past became active again.

E. Familial history
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 2012, 1 year 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. 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 familys conversation. b. Recreation Pattern Mr. ADL plays basketball with his friends; this is good for recreation. He also has a good voice, according to his sister.

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. SYSTEM General Skin Head Eyes & Ears Nose Throat & Mouth Neck Breast Respiratory CVS GIT GUT Extremities Neurologic Hematologic Endocrine Psychiatric

Generalized body weakness Dry Runny nose, with discharges Dry mouth Difficulty of breathing, dyspnea upon exertion. Cough Dyspnea upon exertion and chest pain Constipated at times, defecate every other day. Joint pain Weakness Excessive night sweating Depression, Ignores kind interview

H. Physical assessment
a. General appearance/survey: Patient appeared weak looking but was somehow coherent in a high fowlers position. 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 patients skin was dry especially on the lower extremities. IVF of D5NM 500 was attached to his right hand.

b. Measurement FIDINGS (Ht, wt) Vital Signs Height: 35 Weight: 25 lbs Temp: 37.50 C PR: 90 bpm RR: 35 bpm BP: 90/60 mmHg NORMAL VALUES BMI Temp: 37 C PR: 60-100 bpm RR: 16-20 bpm BP: 120/80 mmHg ANALYSIS/ INTERPRETATION BMI below normal as a result of malnutrition 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 A. HEAD a. Skull NORMAL FINDINGS Rounded (normocephali c, with frontal, parietal and occipital prominences) Evenly distributed; thick hair; silky resilient hair; no infestation or infection; variable ACTUAL FINDINGS Normoceph alic ANALYSIS/ INTERPRETATI ON Normal findings

b. Hair

Evenly distributed

Typical hair type of men

c. Face

amount of body hair Symmetric Symmetric facial facial features, features palpebral fissures equal in size, symmetric nasolabial folds Round, uniform in Shape is size round; size equal Close symmetrical Protects eyes, anteriorly meet at the medial and lateral corners Smooth and of eye. pale Delicate membrane; covers part of the outer surface of the eyeball Outermost tunic, thick white connective tissue.

Normal findings

d. Eye/vision 4.1 Eyeball 4.2 Lid margins

Normal findings Normal findings

4.3 Conjunctiva

Undernourished, lack of vitamins

4.4 Sclera

Normal findings Appears white

4.5 Pupils

Normal findings

Normal pupil constriction Normal findings

4.6 Eyebrow, lashes, color, symmetry, quality of hair, placement 4.7 Eye movement in all directions

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

Normal findings Hair evenly distributed, intact skin Equal movement

Hair evenly distributed, intact skin Equal movement B. VISION TESTING a. Visual field When looking Client can Normal straight ahead see from his peripheral vision clients can see periphery objects in periphery Able to read newspaper 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; semitranspare nt Responds to moderately loud voice tone Symmetric, normal breathing, able to identify familiar smell Able to read Normal visual newspaper findings Same color as facial skin, pinna recoils after it is folded Wet and sticking cerumen with transparent color Normal ear features

b. Visual acuity C. EARS a. Pinna

b. External canal

Normal findings

c. Hearing acuity

Responds to Normal findings moderately loud voice tone No deformity, (+) difficulty of breathing. With runny nose (+) dyspnea, patient have cough which reflex is not the only way to protect our airways which

D. NOSE

causes patient to have runny nose. E. MOUTH/LIPS a. Gums b. Teeth 32 adult teeth smooth, white yellowish shiny tooth enamel Central position, pale in color Pink and smooth; freely movable Pink and smooth posterior wall F. CHEECKS Pink gums; moist firm texture Dark gums Yellowish with few cavities and some missing teeth Gums darkened due to smoking history Needs dental work

c. Tongue

d. Palate-hard/soft e. Oropharynx/ Tonsil

Central No remarkable position, findings pale in color Pale in color No remarkable findings Pale posterior wall Hollow in appearance No remarkable findings

G. NECK H. CHEST a. Anterior b. Posterior

Lymph nodes Lymph freely movable nodes freely movable Quiet rhythmic (+) and effortless difficulty of respirations; breathing, full symmetric with excursions abnormal sound in the right lower lobe

Indicates malnutrition, due to weight loss Normal findings Presence of crackles caused by fluid often associated with inflammation or infection of the alveoli. Indicates respiratory problems such us TB, Pneumohydroth orax

Localized

I. HEART J. BREAST

Full and symmetric

pain around thoracosto my site. Full and symmetric

No air leak on drainage system: manageable incision pain. Normal findings

K. ABDOMEN

Flat, rounded (convex) or scaphoids Equal in size on both sides of the body; no muscle atrophy; normally firm; smooth coordinated movements Equal in sixe on both sides of the body; no muscle atrophy; normally firm; smooth coordinated movements

Distended, scaphoidal in shape Equal in size but muscular atrophy evident.

L. UPPER EXTREMETIES

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

M. LOWER EXTREMETIES

With muscular atrophy evident.

Client is not well nourished Weakness hinder client from actively moving around.

I. Activities of daily living

Before Hospitalization Skipping meals most of the time, according to the significant others. His fluid preferences are water, softdrinks. During Hospitalization Moderate decrease of the appetite; can consume about of the foods given. Analysis/ Interpretation Due to medication given as side effects such as; Combivent and Rifampicin, there is a decrease of appetite.

a. Fluid & Nutrition

Mr. ADL drinks 34 glass of water a day. He is more on bread in the morning; vegetables and fish most of their meals. b. Elimination

Diet as tolerated was advised to Mr. ADL

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

c. Hygiene & Comfort

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

Usually voids 2-4 times a day. Mr. ADL defecates every other day. There is a decrease bowel movement due to decrease appetite. Dependence related to restricted mobility due to weakness

d. Rest & Sleep

Restricted on The patient takes bed; the patient a bath once a day cant take a bath and brushes his due to weakness teeth twice a day. All hygienic activities are assisted by SO. The patient sleeps more or less than 5 hours a day. The patient sleeps irregularly. 30 minutes of sleeps then awake again.

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

J. Laboratory / Diagnostic Exam

a. Hematology report 2013 April 21,

Test Hemoglobin

Results 110 g/L

Normal Value 140 170 g/L

Hematocrit

0.33

0.40 0.50

WBC

15.2 x 10

5.0 10.0 x 10

Neutrophils Lymphocytes

0.78 0.21

0.45 0.65 0.25 0.40

Monocytes

0.01

0.02 0.06

Platelets

320

150 - 450

Analysis Decrease Insufficient oxygen circulating in the bloodstream. Indicates Anemia due to malnutrition. Decrease Insufficient oxygen circulating in the bloodstream. Indicates Anemia due to malnutrition. Increase Leukocytosis Indicates infection Increase Acute bacterial infection Decrease low absolutely lymphocyte concentration, associated with increase rates of infection Decrease Depleted in overwhelming bacterial infection Normal

b. Chest X-ray 2013

April

21,

Impression: Miliary Tuberculosis

c.Urinalysis 2013 Color: Transparency: Yellow S/I Fubid

April

21,

Chemical Strips Reaction: Specific Gravity: Albumin: 5.2 1.025 (above normal) dehydration and contamination Trace

Microscopic WBC RBC Epithelial Cells Mucus treads Amorphous Urates c. Urinalysis Color: Consistency: Microscopic: WBC RBC Bacteria d. Radiological Report 2013 Impression: Miliary Tuberculosis 8-12 1-3 Rare Moderate Plenty April 22, 2013 Yellowish brown Soft No Ova, parasite seen 4-8 0-1 Plenty bacterial infection April 23,

N. Course in the ward

Date/Time
April 21, 2013 2pm

Focus Admission

Data, Action, Response

Admitted a 9 years old male accompanied by relatives with a complained of difficulty of breathing. Vital signs are taken and recorded with a BP: 90/60 mmHg, HR: 81 bpm, RR: 35 bpm Seen and examined by Dra. Olay Consent signed and secured IVF of D5NM 500 inserted and regulated with 31 gtts/min Laboratory requested To radiology department on the way to pedia ward accompanied by undersigned Endorsed In from ER per wheelchair cuddled by mother with an IVF of D5NM @ 400ml level Conscious and coherent Vital signs are taken and recorded with blood pressure of 90/60 mmHg D febrile 38.5 A : tepid sponge bath done R : temperature subsided to 37.5 NPO was advice Endorsed

7pm

Post transfer
7:30pm

Elevated body
8pm

temperature

11pm 11pm Received on bed with an IVF @ 300cc level Vital signs taken and recorded BP: 90/60 mmHg, PR: 90 bpm, RR: 29 bpm Temperature: 36.6 C With abnormal RR: 29 bpm Diet as tolerated maintained Due medication given and recorded Cefuroxime 100mg TIV after negative skin test Rifampicin 1 tablet before dinner

7 am

April 22, 2013 7am

3 pm

Vital signs recheck with no significance finding Needs attended Endorsed Received on bed alert, coherent, cooperative. With an IVF of D5NM Vital signs taken and recorded Afternoon care rendered Health teaching done Medication given Needs attended No other complaints Endorsed

III. Clinical discussion of the disease

A. 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 Brand Name: CEFTIN Classification Action 2ND generation cephalosporin A 2nd generation cephalosporin that binds to bacterial cell membranes and inhibits cell wall synthesis. 200 mg TIV q8 hours ANST (-) Indication Treatment of susceptible infection due to group B streptococcus, E. coli, H. influenza etc. Adverse Effect Allergic reaction, oral candidiasis, mild diarrhea, mild abdominal cramping. Nursing Consideration Ask the patient if he has a history of allergies to drugs, particularly to cephalosporin and penicillin.

Generic Name: IPRATROPIUM BROMIDE Brand Name: COMBIVENT, DOUNEB Classification Action Anti-cholinergic bronchodilator An anti-cholinergic that blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscles.

q4 hours Indication Nursing Consideration Hypotension, Monitor Vital signs insomnia, metallic or Monitor intake and unpleasant taste, output palpitations, urine reaction. Adverse Effect

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

Generic Name: RIFAMPICIN Brand Name: MYRIN-P FORTE Classification Action Antituberculosis Inhibits RNA synthesis, decreases tubercle bacilli replication

2 Tablets before lunch and 1 tablet before dinner Indication Initial phase treatment and retreatment of all forms of TB in category I and II patients caused by susceptible strains of mycobacterium. Adverse Effect Disorder of the blood and lymphatic system, immune system, metabolism and nutrition, CNS, eye, GI, skin and tissues, renal, fever, dryness of mouth. Nursing Consideration Explain to the patient to expect a orange color of urine. Monitor I & O.

Nursing Care Plan Assessm ent Lack of energy Weakness Poor oral intake

Diagnos is Fatigue related to malnutrition and disease process

P l a n n i n g After a week of confinement, the patient will be able to report/ exhibit strength.

Interventi Evaluati on on Assess vital signs The patient still having body weakness Provide supplement oxygen as Helps reduce indicated. fatigue Referred to comprehensive rehabilitation program or nutritionist Due to patient status, PEG (percutaneous endoscopic gastrostomy) was not done

Assessm ent
Difficulty of breathin g RR of 24rpm Oxygen saturation of 94 %

Diagnos is
Ineffective breathing pattern

P l a n n i n g
After a week of confinement, the patient will be able to exhibit improved ventilation and adequate oxygenation.

Interventi on
Note rate and depth of respiration and use of accessory muscles Auscultate chest Elevate head of bed or client appropriately Administer nebulization as ordered Oxygen Administration Suction secretions as needed

Evaluati on
Difficulty of breathing was lessen Crackles heard in breath Sounds Difficulty of breathing was lessen Difficulty of breathing was lessen Oxygen saturation increased Clears airway

Assessm ent
Limitation of movement Uncoordinated movements of upper extremities Immobility of lower extremities

Diagnos is
Self care deficit, bathing/ hygiene; dressing/ grooming

P l a n n i n g
After a week of confinement, the patients relatives or watchers will be able to perform skills and activities that are necessary for the patient.

Interventi on
Perform hygiene practices (bathing, shampooing, etc.) . Teach relatives also on how to perform hygiene to their patient Encouraging family to show physical and emotional support for the patient in a way that the patient can understand

Evaluati on
The relatives were able to demonstrate the teachings given to them.

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. ADLs religion is Catholic, encourage the patient pray daily, go to church regularly and increase his faith with God Almighty.