TABLE OF CONTENTS

Page
I. Introduction
A. Overview of the Case 2
B. Objective of the Study 2
C. Scope and Limitation of the Study 3
II. Health History
A. Profile of Patient 4
B. Family and Personal Health History 5
C. History of Present Illness 5
D. Chief Complain 6
III. Developmental Data 7
IV. Medical Management
A. Medical Orders and Laboratory Results 10
B. Drug Study 13
V. Pathophysiology with Anatomy and Physiology 16
VI. Nursing Assessment
(System Review and Nursing Assessment II) 25

VII. Nursing Management

A. Ideal Nursing Management (NCP) 26
B. Actual Nursing Management (SOAPIE) 31
VIII. Referrals and Follow-up 35
IX. Evaluation and Implications 36
X. Documentation 37
XI. Bibliography 38
XII. Rating scale 39

I. INTRODUCTION
 Tuberculosis is a common and often deadly infectious disease caused by

mycobacteria, 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.

The typical symptoms of tuberculosis are a chronic cough with blood-

tinged sputum, fever, night sweats and weight loss. Infection of other organs

cause a wide range of symptoms. The diagnosis relies on radiology (commonly

chest X-rays), a tuberculin skin test, blood tests, as well as microscopic

examination and microbiological culture of bodily fluids. Tuberculosis treatment is

difficult and requires long courses of multiple antibiotics. Contacts are also

screened and treated if necessary. Antibiotic resistance is a growing problem in

(extensively) multi-drug-resistant tuberculosis. Prevention relies on screening

programs and vaccination, usually with Bacillus Calmette-Guérin (BCG vaccine).

Tuberculosis is spread through the air, when people who have the disease

cough, sneeze or spit. One third of the world's current population have been

infected with M. tuberculosis, and new infections occur at a rate of one per

second.[1] However, most of these cases will not develop the full-blown disease;

asymptomatic, latent infection is most common.

2
Scope of the Study

 The study focuses on surgical Ward patient, admitted at Polymedic

General Hospital, Cagayan de Oro City, having the diagnosis of

Pulmonary Tuberculosis.

 Nature, causes, signs & symptoms, pathophysiology, medical

management, nursing management, and prognosis of the disease.

 Involves the ideal and actual nursing intervention appropriate to address

the needs of Mrs. Nelia S. Castillano, the drug study of the medications

given to her, the health teachings as well as referrals for Mrs. Nelia S.

Castillano

 Assessment of Mrs. Nelia S. Castillano personal health history, and history

of present illness.

Limitation of the Study

 Limited only to the history of the patient which is comprised of the patient’s

profile, family and personal health history, chief complaint and history of

present illness.

 Information being collected from the patient during the patient assessment

and from her watchers.

 The patient was only taken cared of for 2 days, starting from the 2nd day of

her admission at Polymedic Genaral Hospital, Cagayan de Oro City.

II. Health History

3
 CLIENT’S PROFILE

Client’s Name:

Age:

Address:

Civil Status:

Sex:

Nationality: Filipino

Religion: Roman Catholic

Educational Attainment: High School Graduate

Height: 5’2”

Weight: 45 kg

Occupation: House wife

Income: none

Informant:

Date of Admission: August 4, 2008

Time of Admission: 6:45 pm

Chief Complaint: Cough, Loss of appetite, Presence of blood in the sputum

Admitting Diagnosis: Koch Pulmonary Infection Pneumonia

Attending Physician:

HISTORY OF PRESENT ILLNESS

Chief Complaint: cough

4
 Mrs. X a 56 yr. old female, Roman Catholic , Housewife, residing at

Western Wao, Lanao Del Sur was admitted at Polymedic General Hospital

for the first time last August 4, 2008.

Two weeks prior to admission onset of cough productive with

yellowish phlegm, + night sweats, + low grade fever, + poor appetite, this

day noted blood stitched sputum hemophysis with back pain, associated

with mass at left lower lip noted since 1986 when the area was constantly

traumatized any protruding one tooth and later develop a mass, no

bleeding noted.

Personal Health History

In relation to the health history of the family,. has not undergone any

previous hospitalization.

Family History

(-) Hypertension

(-) Diabetes Mellitus

(+) Tuberculosis of Husband

Past Medical History

Patient Mrs. X., who is 56 yrs. Old, was admitted to Polymedic

General Hospital last August 4, 2008 at 6:45 pm with chief complaint of

cough, loss of appetite, presence of blood in the sputum.

5
 Mrs. X has not undergone previous hospitalization. She is a non-

smoker, and non-alcoholic beverage drinker. She did not undergo any

surgery and has no known food and drug allergies.

Chief Complaint

Two weeks prior to admission onset of cough productive with

yellowish phlegm, + night sweats, + low grade fever, + poor appetite, this

day noted blood stitched sputum hemophysis with back pain, associated

with mass at left lower lip noted since 1986 when the area was constantly

traumatized any protruding one tooth and later develop a mass, no

bleeding noted.

6
III. DEVELOPMENTAL THEORY

 Erik Erikson’s Theory of Psychosocial Development

Erik H. Erikson (1963-1964), adapted and expanded Freud’s theory of

development to include the entire lifespan, believing eight stages of

development.

Erikson envision life as a sequence of levels of achievement. Each stage

signals a task that must be achieved. The resolution of task can be complete,

partial, or unsuccessful. Erikson believes that the greater the task achievement,

the healthier the personality of the person; failure to achieve a task influence s a

person’s ability to achieve the next task. These developmental tasks can be

viewed as a series of crises, and successful resolution of these crises is

supportive to the person’s ego. Failure to resolve the crises is damaging to the

ego.

Erikson’s eight stages reflect both positive and negative aspect of the

critical life periods. The resolution of the conflicts at each stage enables the

person to function effectively in society. Each phase has kits own developmental

task, and individual must find a balance between.

According to Erik Erikson’s developmental task. Mrs. Nelia S. Castillano,

56 years old, belongs to developmental task of older age, with a central task of

integrity versus despair. As I observed, he was kin the positive resolution of

development at her stage because according to his daughter he has a good

relationship with his parent’s, brothers and sisters and most especially with his

husband and children, she had raised them well and really tried her best to

7
support his children, she was a loving mother and even though he experienced

an illness on her older stage of life, still she was able to show courage and

strength while admitted in the hospital. she has a positive coping mechanism skill

especially in participating during administration of medication.

 Robert J. Havighurst Developmental Task Theory

Havighurst (1900-1991) theorized that the developmental task one must

accomplish throughout life. He described developmental task as doing those

things that make up health and satisfactory growth kin society. The task are

organically and socially determined. Accomplishing task at a lower level, or at an

earlier stage, is the first step in the progression toward accomplishing task at

later age.

A developmental task is a task which arises at or about a certain period in

the life of individual, successful achievements of which leads to his happiness

and to success with later task, while failure leads to unhappiness in the

individual, disapproval by society, and difficulty with later task.

According to Havighurst developmental theory, Mrs..Nelia S. Castillano 56

years of age, belongs to a period of middle age which was achieving adult civic

and social responsibility since she is a house wife blessed with six children and a

supportive husband and family.

 Jean Piaget Cognitive Developmental Task Theory

Piaget’s believes that cognitive structures are complete during the formal

operations period, from roughly 11 to 15 years. From the time formal operations

characterize thinking throughout adulthood and are applied to more areas.

8
Egocentrism continue to decline; however these changes in its content and

stability.

Some may use post-formal operations strategies to assist them in

understanding the contradictions that exist in both personal and physical aspects

of reality. The experiences of the professional, social and personal life in the

middle-aged persons will be reflected in their cognitive performance. The middle-

aged adult can imagine, anticipate, plan and hope.

The patient is very positive, she always anticipate things that goes on

smoothly and righteously. Despite of her, sickness she still keep her self happy

and strong.

 Sigmund Freud Psychosocial Developmental Task.

Psychosocial Development refers to the development of personality. It can

be considered se the outward expression of the inner self. It encompasses a

persons temperament, feelings, character, traits, independence, self-esteem, self

concept, behavior, ability to interact with others, and ability to adapt to life

changes.

The culminating stage of Psychosocial Development is Genital Stage ( 13

years and after ) were energy is directed toward attaining a mature sexual

relationship. This stage involves a reactivation of the pregenital impulses. These

impulses are usually displaced and the individual passes are usually displaced

and the individual passes to the genital stage or maturity. An inability to resolve

conflicts can result in sexual problems, such as frigidity, impotence and the

inability to have satisfactory sexual relationship.

9
 Our patients 56 years old, in her age right now, he encountered many things that

made her strong.

IV. MEDICAL MANAGEMENT

A. LABORATORIES
CHEMISTRY
Date: 08-05-08

Result Normal range Rationale

Creatinine 0.90 0.70 within normal range

Fasting Blood Sugar 92.60 60-100mg/dL within normal limit

X-RAY
Date: 08-05-08

Impression: There is homogenous opacification of the right middle lobe. The rest
of the lung field are clear the heart is not enlarged. Midline structures are
not displaced. The diaphragms are intact te rest of the included structures
are unremarkable.

• Pneumonia with lobar consolidation, right middle lobe.

URINALYSIS
Date: 08-05-08

Specimen Result
Color straw
Appearance clear
Glucose (-) Negative
Protein (-) Negative
Reaction 6.0
Specific gravity 1.005

Microscopic:

10
 WBC 6-8
RBC 3-6
Epithelial mucous threads none
Urates none
Bacteria none

HEMATOLOGY
Date: 08-05-08

Result Normal range Rationale

WBC 9.61 8-10 normal

RBC 4.41 3.69-5.90 normal
Hemoglobin *11.4 11.70-14.00 LOW
Hematocrit 37.0 34 - 44 normal
MCV 83.9 70-97 normal
MCH *25.9 26.10-33.30 LOW
MCHC *30.8 32-35
LOW
Platelet count 262 150-390 normal

Differential Count:
Neutrophils *70.7 55-62
Lymphocytes *19.0 20-40
Monocytes 5.8 4-10
Eosinophils 4.4 1-6
Basophils 0.1 0.50-1.0
RDW-CV 13.3 11.5-14.5

11
B. MEDICAL ORDERS WITH RATIONALE

DOCTOR’S ORDER

August 4, 2008
 Please admit at room of choice  To provide care and close
under my service monitoring.
 Secure consent  Consent is essential for any
treatment; routine procedures are
covered by a consent signed at
admission.

 DAT  To restore caloric needs

 TPR q 4 hours  Provide a baseline data for care.
During this period of time,
complications (hypotension,
shock, pulmonary edema) may
possibly develop.

 I and O q shift  Accurate intake and output

records detect early fluid excess
or imbalances.

Laboratories:
o Creatinine  To assess kidney function.
 Chest X-ray (done)  To check lung status since patient
complained shortness of breath.

 Urinalysis  A standard procedure; used to

check abnormalities in the renal
system

 Medications:
 Moxifloxacin 400g Slow IV  This medication is Bactericidal:
drip OD, ANST interferes with DNA replication, repair,
transcription, and recombination in
susceptible gram negative and gram-
positive bacteria, preventing cell
production and leading to cell death.

 Sinecod 1tab TID PO  This medication is for acute cough

of any etiology for pre or post cough
sedation

12
  Hemostan 500mg 1cap TID  This medication is anti- hemorrhage
and anti- fibrolyic for effective in
various clinica and surgical cases

B. DRUG STUDY

MOXIFLOXACIN (Avelox)

Date Ordered
August 4, 2008

Classification
Antibiotic

Doses/Frequency/ Route
IV drip OD ANST (-)

Mechanism of Action
Bactericidal: interferes with DNA replication, repair, transcription,
and recombination in susceptible gram negative and gram-positive
bacteria, preventing cell production and leading to cell death.

Specific Indication
Treatment of adults with CAP caused by susceptible strains.

Contraindication
Contraindicated in presence of allergy to flouroquinolones.

Side Effects
• Headache
• Dizziness
• Insomnia
• Fatigue
• Nausea
• Diarrhea

Nursing Management
• Take drug once a day for a period required. If antacids are being
taken, take drug 4H before or at least 8H after the antacid.

13
 SINECOD
Date ordered
August 4, 2008

Classification
Butamirate Citrate

Dose/ Frequency/ Route

1tab TID PO

Mechanism of Action
This medication is for acute cough of any etiology for pre or post cough
sedation

Specific Indication
Cough

Contraindication
Pregnancy and lactation

Side effects
• drowsiness
• nausea
• vomiting
• rash
• urticaria
• Liver damage

Nursing Management
• Assess patient’s fever: temperature, before and during therapy
• Assess allergic reactions: rash, urticaria. If these occur, drug may
have to be discontinued

14
 HEMOSTAN

Date Ordered
August 4, 2008

Classification
Haemostatics

Doses/Frequency/ Route
500mg 1Cap TID

Mechanism of Action
This medication is anti- hemorrhage and anti-fibrolyic for effective in
various clinica and surgical cases

Specific Indication
Used to reduce hemorrhage or presence of blood due to cough

Contraindication
There are no known contraindications

Side Effects
• Head ache .

Nursing Management
• Take medicine with juice for easily absorption

15
 V. PATHOPHYSIOLOGY with Anatomy and Physiology

Definition: Tuberculosis is a highly infectious chronic disease caused by the

tubercle bacilli, Mycobacterium tuberculosis.

Predisposing factors
• Close contact with someone who has
Precipitating factors
active TB specifically wife
Inhalation of air-borne nuclei
 Immunocompromised status
containing tubercle bacilli
(weak immune system)

Bacteria are transmitted through the

airways to the bronchioles and alveoli

Deposition and multiplication in the

apices of the lungs

Bacilli transported via the lymph system and

bloodstream to other parts of the body

Inflammatory reaction fever

Low-grade fever: 37.9oC

Neutrophils and macrophages engulf

many bacteria
TB-specific lymphocytes lyse the
bacilli and normal tissue

• Productive cough w/
Production of exudates greenish sputum
in the alveoli • Phlegm crackles on
R Lung

Partial occlusion of the 16

bronchi or alveoli
17
 Interferes with the Dyspnea
diffusion of oxygen Shortness
and carbon dioxide of breath

Areas of the lungs are dyspnea

inadequately ventilated

Tachypnea
Decreased Oxygen-carrying 34CPM
capacity (Hypoxemia) dyspnea

Tissue hypoxia Pallor

Fatigue
Weakness
tachycardia
dizziness

Low grade
Development of active disease fever
after initial exposure and Night sweats
infection Anorexia
Weight loss

Ulceration of Ghon tubercle Hemoptysis

Release of cheesy material into Productive

the bronchi cough of more
than 2 weeks
Whitish
phlegm
Ghon tubercle heals forming scar
tissue
Parenchymal
lesions on
CXR

Inflammation of infected lungs

Spreading to the hilum of the lungs Dyspnea

and later extends to adjacent lobes Easy fatigability

18
ANATOMY AND PHYSIOLOGY

Respiratory System

The respiratory system consists of the airways, the lungs, and the
respiratory muscles that mediate the movement of air into and out of the body.
Within the alveolar system of the lungs, molecules of oxygen and carbon dioxide
are passively exchanged, by diffusion, between the gaseous environment and
the blood. Thus, the respiratory system facilitates oxygenation of the blood with a
concomitant removal of carbon dioxide and other gaseous metabolic wastes from
the circulation. The system also helps to maintain the acid-base balance of the
body through the efficient removal of carbon dioxide from the blood.

Structure of the Respiratory System

19
 Upper airways

 Nasal Cavity

The nasal cavity (or nasal fossa) is a large air-filled space above and
behind the nose in the middle of the face.The nasal cavity conditions the air to be
received by the areas of the respiratory tract and nose. Owing to the large
surface area provided by the conchae, the air passing through the nasal cavity is
warmed or cooled to within 1 degree of body temperature. In addition, the air is
humidified, and dust and other particulate matter is removed by vibrissae, short,
thick hairs, present in the vestibule. The cilia of the respiratory epithelium move
the particulate matter towards the pharynx where it is swallowed.

 Pharynx

The pharynx is the part of the neck and throat situated immediately
posterior to the mouth and nasal cavity, and cranial, or superior, to the
esophagus, larynx, and trachea.It is part of the digestive system and respiratory
system of many organisms.Because both food and air pass through the pharynx,
a flap of connective tissue called the epiglottis closes over the trachea when food
is swallowed to prevent choking or aspiration. In humans the pharynx is
important in vocalization.

20
  Larynx

The larynx (plural larynges), colloquially known as the voicebox, is an

organ in the neck of mammals involved in protection of the trachea and sound
production. The larynx houses the vocal folds, and is situated just below where
the tract of the pharynx splits into the trachea and the esophagus

Sound is generated in the larynx, and that is where pitch and volume are
manipulated. The strength of expiration from the lungs also contributes to
loudness, and is necessary for the vocal folds to produce speech. During
swallowing, the backward motion of the tongue forces the epiglottis over the
laryngeal opening to prevent swallowed material from entering the lungs; the
larynx is also pulled upwards to assist this process. Stimulation of the larynx by
ingested matter produces a strong cough reflex to protect the lungs.

Lower airways

 Trachea

The trachea extends from the larynx to the level of the 7th thoracic
vertebrae, where it divides 2 main bronchi, which is called the carina. It is a
flexible, muscular 12-cm long air passage with c shaped cartilaginous rings.
Along with other regions of the lower airways it is lined pseudo stratified
columnar epithelium that contains goblet cells and Celia. Because the Celia beat
upward, they tend to carry foreign particles and excessive mucus away from the
lungs to the pharynx. The trachea (windpipe) divides into two main bronchi the
left and the right, at the level of the sternal angle.

21
  Bronchi and Bronchioles

A bronchus is a caliber of airway in the respiratory tract that conducts air

into the lungs. No gas exchange takes place in this part of the lungs. . The right
main bronchus is wider, shorter, and more vertical than the left main bronchus.
The right main bronchus subdivides into three segmental bronchi while the left
main bronchus divides into two. The lobar bronchi divide into tertiary bronchi.
Each of the segmental bronchi supplies a bronchopulmonary segment. A
bronchopulmonary segment is a division of a lung that is separated from the rest
of the lung by a connective tissue septum.

 Lungs

The trachea divides into the two main bronchi that enter the roots of the
lungs. The bronchi continue to divide within the lung, and after multiple divisions,
give rise to bronchioles. The bronchial tree continues branching until it reaches
the level of terminal bronchioles, which lead to alveolar sacks. Alveolar sacs are
made up of clusters of alveoli, like individual grapes within a bunch. The
individual alveoli are tightly wrapped in blood vessels, and it is here that gas
exchange actually occurs. Deoxygenated blood from the heart is pumped
through the pulmonary artery to the lungs, where oxygen diffuses into blood and
is exchanged for carbon dioxide in the hemoglobin of the erythrocytes. The
oxygen-rich blood returns to the heart via the pulmonary veins to be pumped
back into systemic circulation.

Human lungs are located in two cavities on either side of the heart.
Though similar in appearance, the two are not identical. Both are separated into

22
lobes, with three lobes on the right and two on the left. The lobes are further
divided into lobules, hexagonal divisions of the lungs that are the smallest
subdivision visible to the naked eye. The connective tissue that divides lobules is
often blackened in smokers and city dwellers. The medial border of the right lung
is nearly vertical, while the left lung contains a cardiac notch. The cardiac notch
is a concave impression molded to accommodate the shape of the heart. Lungs
are to a certain extent 'overbuilt' and have a tremendous reserve volume as
compared to the oxygen exchange requirements when at rest. This is the reason
that individuals can smoke for years without having a noticeable decrease in lung
function while still or moving slowly; in situations like these only a small portion of
the lungs are actually perfused with blood for gas exchange. As oxygen
requirements increase due to exercise, a greater volume of the lungs is perfused,
allowing the body to match its CO2/O2 exchange requirements.

 Alveoli

An alveolus is an anatomical structure that has the form of a hollow cavity.

Mainly found in the lung, the pulmonary alveoli are spherical outcroppings of the
respiratory bronchioles and are the primary sites of gas exchange with the blood.
The lungs contain about 300 million alveoli[2]., representing a total surface area of
approx. 70-90 square meters (m2). Each alveolus is wrapped in a fine mesh of
capillaries covering about 70% of its area. The alveoli have radii of about 0.05
mm but increase to around 0.1 mm during inhalation. The alveoli consist of an
epithelial layer and extracellular matrix surrounded by capillaries. In some
alveolar walls there are pores between alveoli. There are three major alveolar
cell types in the alveolar wall.

• Type I cells that form the structure of an alveolar wall

• Type II cells that secrete surfactant to lower the surface tension of water
and allows the membrane to separate thereby increasing the capability to
exchange gases. Surfactant is continuously released by exocytosis. It
forms an underlying aqueous protein-containing hypophase and an

23
 overlying phospholipids film composed primarily of dipalmitoyl
phosphatidylcholine.
• Macrophages that destroy foreign material, such as bacteria.

 Diaphragm

The Diaphragm is a dome-shaped musculofibrous septum which

separates the thoracic from the abdominal cavity, its convex upper surface
forming the floor of the former, and its concave under surface the roof of the
latter. Its peripheral part consists of muscular fibers which take origin from the
circumference of the thoracic outlet and converge to be inserted into a central
tendon. The diaphragm is crucial for breathing and respiration. During inhalation,
the diaphragm contracts, thus enlarging the thoracic cavity (the external
intercostals muscles also participate in this enlargement). This reduces intra-
thoracic pressure: in other words, enlarging the cavity creates suction that draws
air into the lungs. When the diaphragm relaxes, air is exhaled by elastic recoil of
the lung and the tissues lining the thoracic cavity in conjunction with the
abdominal muscles which act as an antagonist paired with the diaphragm's
contraction an antagonist paired with the diaphragm's contraction.

24
 The Lungs

1: Trachea

2: Pulmonary artery

3: Pulmonary vein

4: Alveolar duct

5: Alveoli

6: Cardiac notch

7: Bronchioles

8: Tertiary bronchi

9: Secondary bronchi

10: Primary bronchi

11: Larynx

25
Name:Nelia S. Castillano Blood Pressure: 120/80mmHg
Temp: 36.8˚C Pulse Rate: 88 bpm
Respiratory Rate: 22cpm Weight: 45kgs.
Height: 5’2 cm

EENT
[ ] impaired vision [ ] blind
[ ] pain redden [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf Mass at left lower lip
[ ] burning [ ] edema [ ] lesion teeth
Assess eyes ears nose
since she was 35 years
[ ] throat for abnormality [ x ] no problem old
• When the area was
RESP:
[ ] asymmetric [ ] tachypnea [ ] barrel chest traumatize any
[ ] apnea [ ] rales [ x ] cough protruding 1 loose
[ ] bradypnea [ ] shallow [ ] rhonchi tooth and later
[x ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ x] wheezing develop a mass
[ ] pain [ ] cyanotic
Assess resp. rate, rhythm, pulse blood
[ ] breath sounds, comfort [ ] no problem

CARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] mur mur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
[x] No problem

GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
[ ] dyspagea [ ] rigidity [ ] pain
Assess abdomen, bowel habits, swallowing
Bowel sounds, comfort [x ] no problem

GENITO – URINARY AND GYNE

[ ] pain [ ] urine [ ] color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nucturia Cough
[ ] gyne bleeding [ ] discharge [ x ] no problem
Assess urine frequency, control, color, odor, comfort

NEURO:
[ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure
[ ] lethargic [ ] assess motor, function, sensation, LOC,
strength [ ] grip, gait, coordination, speech
[x] no problem

MUSCULOSKELETAL and SKIN:

[ ] appliance [ ] stiffness [ ] itching [ ] petechie
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] flushed
[ ] atrophy [ ] pain [ ] ecchymosis
[ ] diaphoretic moist
Assess mobility, motion gait, alignment, joint function
Skin color, texture, turgor, integrity
[x ] no problem

26
VII. NURSING MANAGEMENT
A. Ideal Nursing Care Plan
1. NURSING DIAGNOSIS: Ineffective airway clearance related to copious
tracheobronchial secretions.
Independent Interventions:
1. Assess respiratory function, e.g.,
breath sounds, rate, rhythm and
depth; use of accessory
muscles; ability to expectorate
mucous/cough effectively;
character, amount of sputum,
presence of hemoptysis.
2. Place patient in semi or high
Fowler’s position. Assist patient
with coughing and deep
breathing exercises.
3. Clear secretions from mouth and
trachea; suction as necessary.
4. Maintain fluid intake of at least
1. Diminished breath sounds may
reflect atelectasis. Rhonchi,
wheezes indicate accumulation
of secretions/inability to clear
airways that may lead to use of
accessory muscles and
increased work of breathing.
Secretions may be very thick
because of the infection. Blood-
tinged or frankly bloody sputum
results from tissue breakdown
(cavitations) in the lungs or
bronchial ulceration.
2. Positioning helps maximize lung
expansion and decreases
respiratory effort. Maximal
ventilation may open atelectic
areas, promote movement of
secretions into larger airways for
expectoration.
3. Prevents obstruction/aspiration.
Suctioning may be necessary if
patient is unable to expectorate
secretions.
4. High fluid intake helps to thin
27
 2500 ml/day. and loosens pulmonary
secretions, making them easier
to clear.
5. Elevate head of the bed/ change 5. To take advantage of gravity
position every 2 hours and prn. decreasing pressure on the
diaphragm.
6. Apply chest physiotherapy every 6. To remove bronchial secretions,
after nebulization. improve ventilation, and increase
the efficiency of the respiratory
muscles.
7. Instruct client to avoid intake of 7. These can stimulate cough
very hot or cold foods/fluids.

Dependent Intervention:
8. Administer humidify air/oxygen 8. Prevents drying of mucous
as prescribed by the physician. membranes; helps to thin
secretions.
9. Administer medications as 9.
indicated:
 Mucolytic agents  Mucolytic agents reduce
the thickness and
stickiness of pulmonary
secretions to facilitate
clearance.
 Bronchodilators  Bronchodilators increase
lumen size of the
trcaheobronchial tree,
thus decreasing
resistance to airflow.
 Corticosteriod  May be useful in
presence of extensive

28
 involvement with profound
hypoxemia and when
inflammatory response is
life-threatening.

2. NURSING DIAGNOSIS: Risk for impaired gas exchange related

to thick viscous secretions.
Independent Intervention:
1. Assess for dyspnea, tachypnea; 1. Pulmonary tuberculosis can
abnormal/diminished breath cause a wide range of effects in
sounds; increasing respiratory the lungs ranging from a small
effort; limited chest wall patch of bronchopneumonia to
expansion; and fatigue. diffuse intense inflammation,
caseous necrosis, pleural
effusion, and extensive fibrosis,
resulting in profound symptoms
of respiratory distress.

2. Evaluate change in level of 2. Accumulation of

consciousness. Note cyanosis secretions/airway compromise
and/or change in skin color, can impair oxygenation of vital
including mucous membranes organs and tissue.
and nail beds.
3. Demonstrate/encourage pursed- 3. Creates resistance against out
lip breathing during inhalation. flowing air, to prevent
collapse/narrowing of the
airways, thereby helping to
distribute air throughout the
lungs and relieving/reducing
shortness of breath.

29
 4. Promote bedrest/activity 4. Reducing oxygen
restriction and assist with and consumption/demand during
care activities as necessary. periods of respiratory
compromise may reduce
Dependent Intervention: severity of symptoms.

5. Monitor serial ABG’s 5. Decreased oxygen content

(PaO2), and/or saturation, or
increased PaCO2 indicates need
for/change in therapeutic
regimen.
6. Provide supplemental Oxygen. 6. Aids in correcting the hypoxemia
that may occur secondary to
decreased ventilation/diminished
alveolar lung surface.

3. NURSING DIAGNOSIS: Altered Nutrition: less than body requirements related to

anorexia.
Independent Intervention:
1. Assess and document patient’s 1. Useful in defining degree/extent
nutiritional status upon of problem and appropriate
admission, noting skin turgor, intervention.
current weight and degree of
weight loss, integrity of oral
mucosa, ability/inability to
swallow, presence of bowel
tones, history of
nausea/vomiting or diarrhea.
2. Ascertain patient’s usual dietary 2. Helpful in identifying specific
patterns, likes/dislikes. needs/strengths. Correlation of

30
 individual preferences may
improve dietary intake.
3. Encourage and provide for 3. Helps to conserve energy
frequent rest periods. especially when metabolic
requirements are increased with
fever.
4. Provide oral care before and 4. Reduces bad taste left from
after respiratory treatments. sputum or medication used for
respiratory treatments that can
stimulate vomiting center.
5. Encourage small frequent meals 5. Maximizes nutrient intake
with foods high in protein and without undue fatigue form
carbohydrates. energy expenditure from eating
large meals and reduces gastric
irritation.
6. Encourage significant others to 6. Creates a more normal social
bring foods from home and to environment during meal time
share meals with patient unless and helps meet personal,
contraindication. cultural preferences.

Dependent Intervention
7. Refer for dietary consult. 7. Provides assistance in planning
a diet with nutrient adequate to
meet patient’s metabolic
requirement and dietary
preferences.
8. Consult with respiratory therapy 8. May help to reduce the
to schedule treatment 1-2 hours incidence of nausea and
before/after meals. vomiting associated with
medications, or the effects of
respiratory treatments on a full

31
 stomach.
9. Monitor laboratory studies, eg., 9. Low values reflect malnutrition
BUN, serum protein and and indicate need to change in
albumin. therapeutic regimen
10. Administer antipyretics as 10. Fever increases metabolism and
appropriate. therefore calories consumption.

B. Actual Nursing Care Plan

1st Priority
S “Galisud ko ug ginhawa usahay”
O  Productive cough with crackles and wheezing sound.
 Shortness of breath
 Green mucoid sputum
A Ineffective airway clearance related to presence of copious
tracheobronchial secretion
P Short term: At the end of 15-20 minutes, the patient will be able to maintain
adequate airway patency.

Long term: At the end of 8 hours, the patient will be able to demonstrate
reduction of congestion with clear breath sound and noiseless respiration.
I Independent:
1. Patient was positioned in semi fowler to high fowler’s position.
2. Patient was assisted during coughing and deep breathing exercise.
3. Provided with adequate rest periods between activities
Dependent:
1. Administer medication as needed.
E After 15 minutes, the patient was able to maintain adequate ventilation.

32
 2nd Priority
S NONE
O  Increase respiratory effort
 Poor capillary refill;3 seconds
 Dyspnea (6/10)
A Risk for impaired gas exchange related to thick viscous secretion
P Short term: At the end of 15-20 minutes, patient will be able to report
decrease dyspnea.

Long term: At the end of 8 hours, the patient will be able demonstrate
adequate oxygenation of tissues and improve ventilation.
I Independent:
1. Demonstrate pursed-lip breathing during exhalation
2. Elevate head of bed as patient requires/tolerated.
3. Provide adequate bedrest and limit activity
4. Monitor Serial ABG/ Pulse oximetry.

E After 20 minutes, the patient was able to report improve Breathing.

3rd
Priority
S “Nigamay gyud ako timbang karon kay dili kayo ko ganahan ug kaon”
O  Weight loss
 Poor skin turgor
 Dry oral mucosa
A Altered nutrition; less than body requirements related to anorexia
P Short term: At the end of 8 hours, the patient will be able to receive
adequate nutrients to maintain balance health.

Long term: At the end of 1 week, the patient will be able to initiate behavior
changes to regain and maintain appropriate weight..
I Independent:

33
 1. Instruct the patient to eat in upright position.
2. Instruct the significant others to feed the client food rich in iron,
protient and vitamin C.
3. Provide a clean and a pleasant environment conducive for eating.
4. Monitor patient intake and output
5. Provide frequent rest periods.

E After 8 hours, the patient was able to receive adequate nutrients to

maintain balance health.

4th Priority
S “Ang una gyud nga Gi-TB sa amoa kay akong bana tapos wala ko nakabalo
bahin ana nga sakit.” As verbalized by the patient.

O  Lack of information
 Expressing feelings of concerns

Knowledge deficit related to unfamiliarity with disease process and new

A treatment methods.

P At the end of 2 hours client will be able to verbalize understanding of

disease process and treatment regimen.

I Independent:
1. The client and significant others were taught for the following:
detection, transmission, signs/symptoms of relapse, and importance
2. Emphasized the importance of good nutrition. To help him motivates
to take action and to strengthen the immune system to prevent
complication.
3. Encouraged client and significant others to verbalized concerns, and
answers questions factually. Provide opportunity to correct
misconceptions and alleviate anxiety.
4. Emphasized the importance of maintaining high-protein,
carbohydrate and adequate fluid intake. Meeting metabolic needs

34
 helps minimize fatigue and promote recovery
5. Provided a position of comfort and a quite environment for the client
during interaction/discussion. This allows patient to concentrate on
what is being discussed.
E At the end of 2 hours, client was able to verbalized understanding of the
disease process, treatment regimen, and preventive measures to reduce
the risk of complications.

VIII. Referrals and Follow up

For the health problems of S.N. who has PTB, he should be referred accordingly

to any hospital institution whenever symptoms of Dyspnea occur. Patient should

contact his physician for immediate management of his disease. The patient

should be instructed to have his follow-up check-up with his attending physician

in the exact day at the exact time of schedule, even if he feels better, after being

discharged from the hospital

IX. Evaluation and Implication

During the 2nd day nursing care of the patient, Mr. X’ was able to manifest

stable vital signs and signs and symptoms that may lead to the progress of the

physical well-being of the patient.

35
 After rendering health care service and doing necessary interventions to

the patient. An improvement of Mr. X’s health status was observed as evidenced

by normal vital signs and verbalization of normal breathing pattern.

At the end of the shift, the interventions and procedures done to the

patient were successful and the patient was able to participate actively to the

treatment regimen.

The disease of the patient implies that pulmonary tuberculosis develops in

the minority of people whose immune systems do not successfully contain the

primary infection. In this case, the disease may occur within weeks after the

primary infection. Pulmonary tuberculosis may also lie dominant for years and

reappear after the initial infection is contained.

X. Documentation

36
37
XI. Bibliography

Douges, M.E. et.al., (2002). Nurse’s pocket guide: diagnosis, interventions

& rationales. (8th Edition). Philadelphia: F.A. Davis Company.

Douges, M.E. et.al., (2002). Nursing care plan: guidelines for

individualizing patient care (6th Edition) Philadelphia: F.A. Davis Company.

Gulandick, M. et.al., Nursing care plan. (3rd Edition)

Ignatavicius, D.D. & Workman, M.L. (2006). Medical-surgical nursing:

critical thinking for collaborative care. (5th Edition). St. Louis, Missouri: Elsevier

Saunders.

Kozier, B. et.al., (2004). Fundamentals of nursing: concepts, process &

practice. (7th Edition). Philippines: Pearson Education South Asia PTE Ltd.

38
 Smeltzer, S.C. & Bare, B.G. (2004).Textbook of medical-surgical

nursing(10th Edition, Volume 2). Philadelphia: Lippincott Williams and Wilkins. pp

553-538.

Spratto, G.R. & Woods, A.L. (1994). Nurse’s drug reference. USA: Delmar

Publishers Incorporated.

Ulrich & Canale. (2005). Nursing care planning guides. (6th Edition).

XII. Rating Scale

A. WRITTEN WEIGHT RATING

39
I. Introduction 5
a. Overview of the Case
b. Objective of the Study
c. Scope and Limitation of the Study
II. Health History 5
a. Profile of the Patient
b. Family and Personal Health History
c. Chief Complaint
III. Developmental Data 5
IV. Medical Management 20
a. Medical Orders with Rationale (10)
b. Drug Study (10)
V. Pathophysiology with anatomy and physiology 10
VI. Nursing Assessment 10
a. Nursing System Review Chart 30
b. Nursing Assessment II (10)
VII. Nursing Management (20)
a. Ideal Nursing Management
b. Actual Nursing Management
VIII. Referrals and Follow-up 5
IX. Evaluation and Implication 5
X. Documentation 5
a. Documentation of Evidence of Care for 1 Week
Rotation
b. Organization/Grammar/Bibliography
Total Score
Equivalent Grade

40
41