Ateneo de Zamboanga University

College of Nursing

A Case Study Submitted in Partial Fulfillment in The Requirement of R.L.E

Abdul, Jaina H.
Luna, John Thomas E.
Manuel, Paula Bianca A.
Magtibay, JoebertS.
Madalim, Sarah T.
Mejia, Maureen Joyce F.
Mufan, Marinel C.
Researchers

Mrs. Lorna de Bien RN MN

Adviser

ACCEPTANCE SHEET
In Fulfillment of the

Requirements for
NURSING CARE MANAGEMENR 103
First semester SY: 2014-2015

THE NURSING CASE STUDY

Entitled

CARING A CLIENT WITH PRIMARY COMPLEX

Taken from

Boalan Lying-in Health Center

Prepared, Defended and Submitted by:
Abdul, Jaina H.
Luna, John Thomas E.
Manuel, Paula Bianca A.
Magtibay, Joebert S.
Madalim, Sarah T.
Mejia, Maureen Joyce F.
Mufan, Marinel C.
Ms. Charlita F. Ahmad RN MN
Chairman

Ms. Grace Lourdes Antolihao RN MN

Member

Mr. Aaron Mendoza RN MN

Member

Adviser: Mrs. Lorna de Bien RN MN

Antonia R. Quilos RN, MN

Araceli S. Pison RN MSPH

Level III Coordinator

Level III Chairperson

Mrs. Ma. Lorna B. Paber, RN, MAN

Dean, College of Nursing

APPROVAL SHEET

This Case study entitled Care of a patient with Primary Complex Prepared and Submitted by

Jaina H. Abdul, John Thomas E. Luna, Paula Bianca A. Manuel, Joebert S. Magtibay,
Sarah T. Madalim, Maureen Joyce F. Mejia, and Marinel C. Mufan in partial fulfillment of
the requirements in Nursing Care Management 103.

Mrs. Lorna de Bien RN MN

Adviser

Approved by the Oral Examination Committee with a grade of ______

Ms. Charlita F. Ahmad RN MN

Chairman

Ms. Grace Lourdes Antolihao RN MN

Member

Mr. Aaron Mendoza RN MN

Member

Accepted in partial fulfillment of the requirement in Nursing Care Management 103

Antonia R. Quilos RN, MN

Araceli S. Pison RN MSPH

Level III Coordinator

Level III Chairperson

Mrs. Ma. Lorna B. Paber, RN, MAN

Dean, College of Nursing

TABLE OF CONTENTS
3

ACKNOWLEDGEMENT
Chapter I: Introduction..
A. Patient and the Problem .1
B. Background of the Client.1
C. Overview of the Disease..1
D. Objectives of the Case Study..4
a. Nurse-Centered Objectives5
b. Patient-Family Centered Objectives.5
E. Anatomy and Physiology...5
Anatomy and Physiology: The Respiratory System..6
F. Pathophysiology..8
Chapter II: Nursing Process.......................
Assessment..
A. Biographic Data..11
B. Comprehensive Nursing History..11
C. Assessment Data Base (ADB).12
D. Physical Assessment.20
Diagnostic Tests......................................
Radiologic Examination ..27
Sputum Test...29
Drug Study
a. Rifampin30
b. Isoniazid 32
c. Pyrazinamide.34
Family Nursing Care Plan
a. Primary Complex36
b. Malnutrition .37
c. Improper Hygiene38
4

Health Teaching Plan on Primary Complex...39

Diet Plan.. 40
Go-Grow- Glow..41
Evaluation42
Findings, Analysis and Conclusion...44
Recommendations45
Bibliography..47

ACKNOWLEDGEMENT
5

In fulfilling our task as student nurses, especially in accomplishing our case

study, we have received many blessing such as meeting great people who helped us by
enlightening our mind in doing this case study. As a group, we wish to thank a number
of people who provided us the possibility to complete this case study.
First and foremost, we would like to express our deepest gratitude for Mrs. Lorna
de Bien, RN, MN, our clinical instructor for this years Case Study for all her moral
support, brilliant ideas and the intense willingness to guide us in this project.
To Mrs. Antonia Quilos, RN, MN, for all the assisting us in our case study and
contributing in stimulating ideas for significant to the concepts in respiratory system;
To Mrs. Concesa Gayo, RN, MN, for all the words of encouragement and
contributions in stimulating ideas for the projects we intended to accomplish;
To Mr. Julius Lapasaran, RN, MAN, for sharing his precious time and effort to
actually take not only our group but also the whole class to deeper details about what
exactly case study is;
To Mrs. Virginia C. Rivera, the district midwife of Boalan-Lying Health Centre and
the Barangay Health Workers in the said area for warmly welcoming us, recognizing our
potentials as student nurses and assisting our group in preparing and selecting our case
patient.
To our respective Families and Friends who showered us with undying love,
motivation and support amidst the challenges of completing this paper who supported
us financially and emotionally.
Lastly, to our Almighty Father for the guidance He up-holds to us. As we embrace
all efforts and struggle, we offer everything to our Almighty God.
To God All the Glory!

I.

Introduction
A. The Patient and the Problem

The researchers target to present a case study on Primary Complex, taken

during the second day of their 3 rd week Related Learning Experience duty on Barangay
Boalan, Zamboanga City.
There were other interesting cases also, however, the researchers further
decided to conduct a comprehensive case study on Tuberculosis. Aside from being an
interesting topic, the researchers would like to conduct an in-depth study on primary
complex to determine further the patients health condition and the events that took
place before and during hospital admission, and to be able to formulate Family Nursing
Care Plans appropriate to the identified problems of the patient in achieving his optimal
level of wellness.
B. Background of the Client
The researchers decided to choose Mr. X as the subject of their study. He was
already under treatment when we found him. Recently, he was initially admitted to
Zamboanga City Medical Center on January 14, 2014 and was diagnosed with
Tuberculosis. The patient is 11 years old Zamboanganueo and is a Roman Catholic.
Like normal children, Mr. X goes to school but in recent times, his father asked for an
excuse to stop his education until he is done recuperating.
Before hospitalization, the patient had poor life style choices. He was fond of
playing outside their house. According to his father he has poor diet. He does not eat
well, despite that they are indigent, and they still provide good food and good nutrition to
their children, yet he does not have proper idea of a good nutrition.
C. Overview of the Disease

Virtually all transmission of Mycobacterium tuberculosis is from person to person,

usually by mucous droplets that become airborne when the ill individual coughs,
sneezes, laughs, sings, or even breathes. Infectiousness is related to certain
characteristics of the person with tuberculosis and to specific environmental factors
such as poor circulation of air. The exact number of organisms required to infect a child
is unknown but is probably small, based on animal experiments. Unlike adults, the vast
majority of children with tuberculosis are not infectious to others. [4] In the early 1900s,
several studies from European orphanages showed that when an adult in the
orphanage had tuberculosis, many of the children developed tuberculosis as well;
however, when only a child had tuberculosis, none of the other children developed the
disease.[5] Subsequent studies from children's hospitals and other environments where
7

children are separated from the adult from whom they acquired the organism have
shown that most children with the classic forms of childhood tuberculosis are not
infectious to others.

However, those children who develop the adult type of

tuberculosis, including upper lobe infiltrates or cavities, and, particularly, having a

positive acid-fast smear of the sputum, can be infectious to others. [9] The age of the
child is not relevant; it is the type of disease the child develops that is important. It is
rare for children < 10 years of age to develop the adult type of tuberculosis, but those
children of any age with extensive infiltrates, sputum production, or cavity on chest x-ray
should be isolated when in health care facilities until it can be determined that they are
not infectious. Because most children who develop tuberculosis disease do so within a
few months of acquiring the infection, one should be sure that the adults accompanying
the child are not the source of the child's infection by performing chest radiographs on
them.
It is commonly asked why young children with the childhood type of tuberculosis
are not infectious. Many children with tuberculosis do not have significant cough. When
cough is present children rarely produce sputum. Even when sputum is produced,
organisms are sparse because they are in low concentration in the endobronchial
secretions of children. In addition, young children lack tussive force necessary to
suspend infectious particles of the correct size in the air.
The portal of entry for M. tuberculosis for almost all children is the respiratory
tract. Ingestion of milk laden with bovine tuberculosis can lead to a gastrointestinal
primary lesion. Rarely, infection of the skin or mucous membrane can occur through an
abrasion, cut, or insect bite.
The tubercle bacilli multiply initially within the alveoli and alveolar ducts. Some of
the bacilli are ingested but not killed by macrophages that carry the organisms through
lymphatic channels to the regional lymph nodes. The major groups of lymph nodes
involved in children are in the hilar region, although paratracheal and subcarinal nodes
also may be involved, depending upon where the organisms lodge in the lung.
As with adults, the incubation period between the time the tubercle bacilli are
inhaled and the development of delayed hypersensitivity is usually between 3 and 12
weeks, most often, 4 to 8 weeks. Some children experience a febrile illness that lasts
from 1 to 3 weeks when hypersensitivity first develops. These children may have mild
cough and other respiratory symptoms. The primary complex of tuberculosis consists of
local reaction in the parenchyma of the lung where the organisms lodge and the
inflammatory reaction of the associated lymph nodes. In most cases, the parenchymal
8

portion of the primary complex heals completely by fibrosis and is of no clinical

significance. Occasionally, the parenchymal lesion continues to enlarge resulting in
focal pneumonitis and thickening of the overlying pleura. The foci in the regional lymph
nodes develop some fibrosis but healing is usually less complete than in the
parenchymal lesion. M. tuberculosismay persist for decades after fibrosis or calcification
of the lymph nodes.
In most cases of initial tuberculosis infection, the child develops a positive
tuberculin skin test, but the lymph nodes remain normal in size, the lung parenchymal
lesion is not visible on chest x-ray, and the child has no symptoms and no
complications. This stage is called tuberculosis infection and most children have a
normal chest radiograph. Occasionally, the child will have evidence of fibrosis or
calcification in the parenchyma or lymph node foci or both. However, in some children,
the lymph nodes become enlarged by the host inflammatory reaction. These lymph
nodes then encroach on the regional bronchus. Partial obstruction caused by external
compression may lead at first to hyperinflation in the distal lung segment. This
compression occasionally causes complete obstruction of the bronchus resulting in
atelectasis of the lung segment. More often, inflamed caseous nodes attach to the
bronchial wall and erode through it, leading to endobronchial tuberculosis and a
fistulous tract. The extrusion of infected caseous material into the bronchus transmits
infection to the lung parenchyma causing bronchial obstruction and further atelectasis.
The resulting lesion, which is a combination of the pneumonitis and atelectasis, is often
referred to as a collapse-consolidation or segmental lesion. If the subcarinal nodes are
involved, the enlargement may cause invasion of adjacent structures such as the
pericardium or esophagus, resulting in pericarditis or a tracheoesophageal fistula,
respectively.
During the development of the parenchymal and lymph node lesions, tubercle
bacilli from the primary complex spread via the bloodstream and lymphatics to many
parts of the body. Sites that are most commonly seeded are the apices of the lungs,
liver, spleen, meninges, peritoneum, lymph nodes, pleura, and bone. This dissemination
can involve either large numbers of bacilli, which leads to disseminated tuberculosis, or
small numbers of bacilli that create microscopic tuberculous foci scattered in the
tissues. Initially, these metastatic foci are clinically inapparent but they can be the origin
of both extra pulmonary tuberculosis and reactivation pulmonary tuberculosis in later
life.
The fairly predictable time table for the events and complications of primary
tuberculosis

infection

in

infants

and

children.

Massive

lymphohematogenous
9

dissemination leading to miliary or disseminated disease occurs in only 0.5 to 2% of

infected children but occurs early after the initial infection. Clinically significant lymph
node or lung tuberculosis usually appears within 3 to 9 months. However, lesions in
bones and joints and kidneys take much longer to develop, often several years after the
infection first occurs. In summary, the vast majority of cases of tuberculosis in children
occur within 1 year of the infection, meaning that tuberculosis disease in a child is a
marker of the recent transmission of the organism.
D. Objective of Case Study
To be able to achieve the goals of care for our patient at the end of this case study, we
have set specific objectives which are as follows;
1. Establish and maintain rapport to achieve optimal well-being of the patient
2. Present a thorough assessment through the Family Nursing Health History
3. Discuss the pathophysiology of the patients condition, usual clinical
manifestation and possible complications of the condition
4. Identify and differentiate risks for tuberculosis
5. Formulate appropriate nursing diagnoses for the patient with tuberculosis
6. Identify and understand different types of medical treatment necessary for the
treatment of tuberculosis
7. To formulate a workable Family Nursing Care plan on the subjective and
objective cues gathered through the nurse-patient interaction to be able to help
the patient recover
8. To discuss the theoretical framework that is related to the clients condition
9. To discuss the normal Anatomy and Physiology of the Respiratory system
10. To explain the Pathophysiology of Tuberculosis
11. To be able to apply the learning and teachings on how to provide counseling
related to clients condition
12. Formulate conclusion based on the findings and enumerated recommendations
concerning tuberculosis
13. Lastly, to evaluate the effectiveness of care and interventions that was given to
the patient

Nurse-Centered Objectives:
10

At the end of the study, the researchers:

1. Shall have familiarized used of effective inter-personal skills to emphasize health
promotion and illness prevention
2. Shall have conducted a comprehensive assessment to the patient as well as the
family and implement care based on the knowledge and skills of the condition
through the utilization of the Assessment Database (ADB)
3. Shall have critical thinking skills necessary for providing safe and effective
nursing care
4. Shall have implanted the learning experience from direct patient care to fellow
nursing students
Patient/Family Centered Objectives:
At the end of this study, the patient/family shall be able to:
1. Verbalize understanding of the disease process and readiness for enhanced
health well-being
2. Increase awareness on the risk factors of tuberculosis
3. Identify possible risk factors that may have contributed to the development of
tuberculosis
4. Identify measures that could minimize the risk of occurrence of the disease
5. Develop the familys support and distinguish their respective roles in improving
patients health status
E. Anatomy and Physiology of the Respiratory System
Gross Anatomy
The surface anatomy of the lungs in anterior and posterior view. There are a
number of key features that allow positioning of the lungs within the chest. The
suprasternal notch is located at the apex of the sternal bone and between the left and
right clavicle. The sternal angle (angle of Louis) is located at the second rib, and is a
small ridge near the apex of the sternum. At the base of the sternum is the xiphoid
process. The nipple in the male lies in the fourth intercostal space, but may be at a
different level in the female. On the posterior wall, the spinous processes of the thoracic
vertebrae can be palpated along the midline. The scapula (shoulder blade) is flat and
triangular and is located on the upper part of the posterior surface of the thorax.
Apart from the first rib, which lies deep to the clavicle, the ribs can be palpated
from below the clavicle. The apex of the lung projects into the neck. Anterior and
Posterior views of the thorax of a male. The major location points on the surface of the
thorax are indicated, along with the sites of the major muscles covering the surface of
the chest wall.
11

Anatomy of the Lungs

The lungs consist of airways (trachea and bronchi) that divide into smaller and
smaller branches until they reach the air sacs, called alveoli. The airways conduct air
down to the alveoli where gas exchange takes place. The lung itself is covered with a
membrane called the visceral (or pulmonary) pleura. The visceral pleura is adjacent to
the lining of the thoracic cavity which is called the parietal pleura. Between the two
membranes is a thin, serous fluid which acts as a lubricant reducing friction as the two
membranes slide across one another when the lungs expand and contract with
respiration. The surface tension of the pleural fluid also couples the visceral and parietal
pleura to one another, thus preventing the lungs from collapsing. Since the potential
exists for a space between the two membranes, this area is called the pleural cavity or
pleura.
RESPIRATION
Respiration is a passive, involuntary activity. Air moves in and out of the thorax
due to pressure changes. When the diaphragm, the major muscle of respiration, is
stimulated, it contracts and moves downward. At the same time, the external intercostal
moves the rib cage up and out. The chest wall and parietal pleura move out, pulling the
visceral pleura and the lung with it. As the volume within the thoracic cavity increases,
the pressure within the lung decreases. Intrapulmonary pressure is now lower than
atmospheric

pressure;

thus

air

flows

into

the

lung

inhalation.

When the diaphragm returns to its normal, relaxed state, the intercostal muscles also
relax and the chest wall moves in. The lungs, with natural elastic recoil, pull inward as
well and air flows out of the lungs exhalation. The lungs should never completely
collapse for there is always a small amount of air, called residual volume, in them.
Under normal conditions, there is always negative pressure in the pleural cavity. This
negative pressure between the two pleurae maintains partial lung expansion by keeping
the lung pulled up against the chest wall. The degree of negativity, however, changes
during respiration. During inhalation, the pressure is approximately 8 cm H2O; during
exhalation, approximately 4 cm H2O. If a patient takes a deeper breath, the
intrapleural pressure will be more negative. Under normal conditions, the mechanical
attachment of the pleurae, plus the residual volume, keep the lungs from collapsing.

NORMAL ANATOMY OF RESPIRATROY SYSTEM

12

ABNORMAL ANATOMY OF RESPIRATROY SYSTEM

PATHOPHYSIOLOGY
TB disease usually occurs in the lungs (pulmonary TB), but it can also occur in
other places in the body (extrapulmonary TB). Miliary TB occurs when tubercle bacilli
13

enter the bloodstream and are carried to all parts of the body, where they grow and
cause disease in multiple sites.
Tuberculosis occurs when individuals inhale bacteria aerosolized by infected
persons. The organism is slow growing and tolerates the intracellular environment,
where it may remain metabolically inert for years before reactivation and disease. The
main determinant of the pathogenicity of tuberculosis is its ability to escape host
defense mechanisms, including macrophages and delayed hypersensitivity responses.
Among the several virulence factors in the mycobacterial cell wall are the cord
factor, lipoarabinomannan (LAM), and a highly immunogenic 65-kd M tuberculosis heat
shock protein. Cord factor is a surface glycolipid present only in virulent strains that
causes M

tuberculosis to

grow

in

serpentine

cords

in

vitro.

LAM

is

heteropolysaccharide that inhibits macrophage activation by interferon-gamma and

induces macrophages to secrete tumor necrosis factor-alpha, which causes fever,
weight loss, and tissue damage.
The infective droplet nucleus is very small, measuring 5 micrometers or less, and
may contain approximately 1-10 bacilli. Although a single organism may cause disease,
5-200 inhaled bacilli are usually necessary for infection. The small size of the droplets
allows them to remain suspended in the air for a prolonged period of time. Primary
infection of the respiratory tract occurs as a result of inhalation of these aerosols. The
risk of infection is increased in small enclosed areas and in areas with poor ventilation.
Upon inhalation, the bacilli are deposited (usually in the mid-lung zone) into the distal
respiratory bronchiole or alveoli, which are subpleural in location. Subsequently, the
alveolar macrophages phagocytose the inhaled bacilli. However, these nave
macrophages are unable to kill the mycobacteria, and the bacilli continue to multiply
unimpeded.
Thereafter, transportation of the infected macrophages to the regional lymph
nodes occurs. Lymphohematogenous dissemination of the mycobacteria to other lymph
nodes, the kidney, epiphyses of long bones, vertebral bodies, juxtaependymal meninges
adjacent to the subarachnoid space, and, occasionally, to the apical posterior areas of
the lungs. In addition, chemotactic factors released by the macrophages attract
circulating monocytes to the site of infection, leading to differentiation of the monocytes
into macrophages and ingestion of free bacilli. Logarithmic multiplication of the
mycobacteria occurs within the macrophage at the primary site of infection.
A cell-mediated immune (CMI) response terminates the unimpeded growth of
the M tuberculosis 2-3 weeks after initial infection. CD4 helper T cells activate the
macrophages to kill the intracellular bacteria with resultant epithelioid granuloma
formation. CD8 suppressor T cells lyse the macrophages infected with the
mycobacteria, resulting in the formation of caseating granulomas. Mycobacteria cannot
14

continue to grow in the acidic extracellular environment, so most infections are

controlled. The only evidence of infection is a positive tuberculin skin test (TST) result.
However, the initial pulmonary site of infection and its adjacent lymph nodes (ie, primary
complex or Ghon focus) sometimes reach sufficient size to develop necrosis and
subsequent radiographic calcification.
Most persons infected with M tuberculosis do not develop active disease. In
healthy individuals, the lifetime risk of developing disease is 5-10%. In certain instances,
such as extremes of age or defects in CMI (eg, human immunodeficiency virus [HIV]
infection, malnutrition, administration

of chemotherapy, prolonged

steroid

use),

tuberculosis may develop. For patients with HIV infection, the risk of developing
tuberculosis is 7-10% per year.
Progression of the primary complex may lead to enlargement of hilar and
mediastinal nodes with resultant bronchial collapse. Progressive primary tuberculosis
may develop when the primary focus cavitates and organisms spread through
contiguous bronchi. Lymphohematogenous dissemination, especially in young patients,
may lead to miliary tuberculosis when caseous material reaches the bloodstream from a
primary focus or a caseating metastatic focus in the wall of a pulmonary vein (Weigert
focus). Tubercular meningitis may also result from hematogenous dissemination. Bacilli
may remain dormant in the apical posterior areas of the lung for several months or
years, with later progression of disease resulting in the development of reactivation-type
tuberculosis (ie, endogenous re-infection tuberculosis).

Pathophysiology Map of Primary Complex

15

Precipitating Factors
- Socio Economic
Factors
- Improper Nutritional
Intake
- Environment (poor
hygiene)

- Age. 11 years old

M. Tuberculosis (tubercle
bacilli) enters the body

Bacteria is ingested by the

Bacteria
invasion at the lung tissue
macrophage
or near pleurae of the lungs

Low immunity/ resistance of

patient
Necrotic degeneration occurs
Drainage of the necrotic materials
into the tracheobroncial trees
Tubercle bacilli
Productionimmunity
of the cavities
filled
develops
(2with cheese
like
mass
of
tubercle
3 weeks of inection)
bacilli, dead WBC, and necrotic
lung tissue.
Tubercle bacilli remain
in the body as long as
living bacilli remains in
the body the immunity
Acquiring
leads to further growth of
5. Loss of
infection
appetite

Arrest of the phagosome w/c result

to bacteria replication

1. Cough and Colds

Alveoli fluid
increase

6. Sudden
weight loss

2. Difficulty in
Breathing
(DOB)

3. Body
malaise
4. Fatigue

Decrease gas
exchange

PRIMARY
COMPLEX
II. NURSING PROCESS
A. Biographic Data

Decrease O2
supply in the
blood

NAME: Derick Bernardo

Decrease O2
AGE: 11 year-old
supply in the
SEX: Male
body tissue
STATUS: Child
ADDRESS: Zone III Boalan, Zamboanga City, Philippines, 7000
RELIGION: Roman Catholic
ETHNIC GROUP: Zamboangueno
OCCUPATION: N/A
DIALECT/LANGUAGE: Chavacano
ACTIVE COMPLAINT/S:
INFECTION
CHIEF
Shortness of Breath (SOB), Cough and Anorexia
MEDICAL DIAGNOSIS: Primary Complex, Pulmonary Tuberculosis
ATTENDING PHYSICIAN: Dr. S. Macrohon
Patient History
HISTORY OF PRESENT ILLNESS:
According to the mother, the patient was exposed to the disease (PTB)
because the father as well as the sister of the patient had tuberculosis and the
father is also a smoker. She believes that it was through droplets that causes the
transmission of the disease to her son. Two weeks prior to admission, the patient
had an unexplained fever and cough for more than two weeks. The patient is
16

currently experiencing chronic cough (>2 weeks) and shortness of breath. He has
as well loss of appetite to eat which leads to his weight loss.
HISTORY OF PAST ILLNESS:
According to the mother, the patient was hospitalized when he was 2month-old and was diagnosed of bronchopneumonia. He was also hospitalized
last January 14, 2014 because of his present illness which is Pulmonary
Tuberculosis.
HISTORY OF FAMILY:
It was verbalized by the mother of the patient that the patients father has
a history of tuberculosis and the other siblings as well.
B. Comprehensive Nursing History
According to the mother of the client, her child, Mr X was sickly and frail
so they often go to Health Center to seek for medical attention. Moreover, the
client was hospitalized before due to primary complex. Chest X- Ray was
performed last June 3, 2014 resulting to Extensive TB with upper cavities. The
client hasnt undergone any surgeries yet. However, he is currently on Multi-Drug
Therapy in which the client is taking several different antibiotics at the same time
to treat TB.

D. Physical Assessment
PEDIATRIC ASSESSMENT TOOL
PHYSCIAL ASSESSMENT
I. SKIN
() WNL
( ) Jaundice

( ) Bruises

( ) Cyanotic

( ) Poor Turgor

( ) Burns

( ) Lesions

( ) Rash

( ) Dry

( ) Birthmarks

( ) Pallor

( ) Absence Pigmentation

( ) Simian Crease

( ) Petichiae

( ) Others: _____________________________________
II. Mental/ Psychosocial
()) WNL
( ) Short attention span
( ) Hyperactive
( ) Withdrawn
() Hypoactive
( ) Aggressive
( ) Others: ______________________________
Family adjustment: ( ) Poor
( ) Fair
()) Good
Parent bonding
() Yes
( ) No
Patient responds when talked to and was not easily distracted. Patient is docile and
cooperates when asked and is not aggressive.
III. Head and Neck
6 months and over
( ) Head Asymmetry
( ) Head Log
( ) Enlarged head

() WNL
( ) Excessive neck skin
( ) Misaligned Trachea
( ) Enlarged thyroid
17

( ) Neck pain
( ) Enlarged lymph nodes
( ) Neck swelling
( ) Neck Webbing
( ) Others: __________________________________
The patient verbalized that he doesnt feel pain on his neck and there was no facial
grimace observed. There was no swelling or enlargement on his head and neck upon
assessment.

IV. Eyes
() WNL
( ) Displaced Position
( ) Redness
( ) Jaundice
( ) Ptosis
( ) Discharge
( ) Strabismus
( ) Swelling
( ) Sunset eyes
( ) Dull cornea
( ) Pale Conjunctiva
( ) Others: ________________________
Follow Object with eyes:
() Yes
( ) No
Wears glasses:
( ) Yes
() No
(Only during School Activities- Medical Check-Up) most recent eye examination
There were no abnormalities observed on patients eyes. The patient has negative
answers to these questions.
V. Ears
() WNL
( ) Displace Position
( ) Pain
( ) Hearing loss
( ) Others: __________________________
( ) Drainage
Patients ears are not displaced and there was no drainage. Patient verbalized that he
doesnt feel any pain in his ears and there was no problem in his hearing as he was
able to interact with us.
VI. Nose
( ) Nasal flaring
( ) Nose bleeds
() Drainage

( ) WNL
( ) Deviated septum
( ) Nasal congestion
( ) Others: ___________________________

VII. Gastro Intestinal Tract

() WNL
( ) Anomalies
( ) GI reflux
( ) Absent bowel sounds
( ) Emesis
( ) Hypoactive bowel sounds
( ) Distension
( ) Hyperactive sounds
( ) Abdominal tenderness
( ) Abdominal girth ________
( ) Ostomy
( ) Diarrhea
( ) Constipation
( ) Others ____________________
Patient with diapers
( ) Yes
() No
Patient is toilet trained
() Yes
( ) No
Stool color Brown
Amount: _________
Frequency 1x/day
There was no abdominal tenderness observed upon inspection. The patient doesnt feel
constipated.
VIII. Nutrition
Diet/ Formula: Regular diet
Route () Oral
( ) Breast
Appetite:
() Good

( ) WNL
Amount: of platter
( ) Bottle
( ) NGT/GT
( )Fair
( ) Poor

IX. Musculoskeletal System

( ) Muscle Conditions
() Poor muscle tone

( ) WNL
( ) Kyphosis
( ) Scoliosis

Frequency: 3X a day

18

( ) Contractures
( ) Trendelenburg Gait
() Limited ROM
( ) Anomalies
( ) Poor gross motor skills
( ) Fractures
( ) Poor fine motor skills
( ) Cast
( ) Others ____________________
X. GU/ Reproductive System
() WNL
( ) Anomalies
( ) Hydrocele
( ) Renal Disease
( ) Vaginal Discharge
( ) Polyuria
( ) Hernia
( ) Labia lesions
( ) Inguinal hernia
( ) Circumcision
( ) Undescended testes
( ) Hypospadias
( ) Others __________________________
The patient does not manifest early problems with his reproductive organs. He does not
experience difficulty in his urination. The patient urinates 3-4 times a day depending on
his fluid intake. He is still uncircumcised as verbalized by his father.
XI. Endocrine System
() WNL
( ) Abnormal growth pattern
( ) Abnormal sexual development
( ) Abnormal hair texture
( ) Others ________________________
Diabetic Insulin dependent
( ) Yes
() No
The patient is not a diabetic Insulin dependent. Patient's growth is average for his age.
XII. Cardiovascular System
() WNL
( ) Congenital Anomalies
( ) Edema (Site: _____________________)
( ) Cyanosis
( ) Poor capillary refill
( ) Pallor
( ) Umbilical Anomalies
( ) Murmur
( ) Hypertensive
( ) Others ______________________
Patients capillary refill is 2-3 seconds and there was no edema observed. The patient
has normal breath sounds. Upon assessment, the patient is not cyanotic and does not
manifest early problems in his cardiovascular system.
XIII. Neurologic System
() WNL
( ) Headache
( ) Tetany
( ) Drowsiness
( ) Weakness
( ) Spasms
( ) Littleness
( ) Abdominal fontanels
( ) Irritability
( ) Seizure
( ) Fixed pupils/ unequal pupils
( ) Tremors
( ) Neurologic disease
( ) Others ___________________________________
Patients LOC Awake and responsive________________________________________
Reflexes appropriate for ages:
() Yes
( ) No
Mental behavioral status: The patient enjoys learning and likes challenges_________
Speech or language difficulties: None________________________________________
Cognitive performance: The patient is not interacting much but he responds by nodding
and smiling to us _______________________________________________________
Social Skills: The patient replies and interacts during the interview_________________
Gross Motor Skills: The patient enjoys playing with friends especially when he doesnt
have class._____________________________________________________________
XIV. Respiratory System
( ) WNL
( ) Rales
( ) Flaring

() Cough
19

( ) Rhonchi
() Dyspnea
( ) Clubbing

( ) Retractions
( ) Cyanosis
() Wheezing

( ) Stridor
( ) Crepitation
( ) Others __________________

XV. Infusion
() None
( ) Intermittent
( ) Continuous
Pump type _________________________________________
Line type ( ) Peripheral
( ) Central
( ) Brands __________ ( ) Gauge _______________
Insertion site _______________________________________
Date Inserted ________________________________________________________
Dressing last change __________________________________________________
Site assessment: ( ) Patent
( ) Redness
( ) Infiltrated
( ) Swelling
( ) Drainage
( ) Out of vein
The Patient does not have an IV Line connected.
XVI. Pain
Presence of Pain () Yes
()No
Onset ___________________
Pain medication None_________
Effective ( ) Yes
( ) No
Location/ Characteristics and frequency of pain:
The patient is experiences discomfort during coughing and difficulty in breathing.
Alleviating Factors: Patient usually takes a takes a complete rest when these signs are
manifested. ___________________________________________________________
Pain Scale: A total of 5/10_________________________________________________
Precipitating factor: Patient usually is interactive but easily gets tired. The added factors
causes the patient discomfort in his respiration and increases the production of phlegm.

XVII Level of Independence

SKILLS
INDEPENDEN
T
Eating

Toileting

Transferring

Walking

Bathing

Dressing

XVIII Limitations

USES DEVICE

HELP OF
ANOTHER

TOTALLY
DEPENDENT

() WLN
20

( ) Contractures
( ) Dyspnea with minimal exertion
( ) Hearing impairment
( ) Growth
( ) Limited endurance
( ) Language delay
( ) Abnormal Speech
( ) Amputation
The patient is not physically disabled. He does not manifest any abnormalities upon
assessment. The patient had no endocrine impairment and his speech is normal.

PEDIATRIC ASSESSMENT TOOL: SCHOOL AGE CHILD 6-12 YEARS OLD

I. History
A. Previous Hospitalizations: January 14,
2014___________________________________________
B. Common Childhood Illness: Coughing, Fever,
Sinusitis___________________________________
C. Allergies or Allergic Responses: No allergies to food or
dust______________________________
D. Immunizations:
Complete_Immuniztaion_____________________________________________
E. Health Status of Family Members: Poor condition, Father has a Tuberculosis and as well
the patients siblings.
________________________________________________________________
II. Developmental Milestones
A Physical Characteristics
Characteristics
6-12 years old

Patients Characteristics

Average Weight

6 years 24 kg (48 lbs)

12 years 38kg (84lbs)

19 kilograms

Average Height

6 years 117cm (46in)

12 years 150 cm (59in)

132 centimeter

Prepubertal Growth
Spurt

10-12 years, girls taller

than boys

Pubic hair for his age

was not yet developed.

Vital Signs
Temperature
Pulse Rate
Respiratory Rate
B/P

37C (98F)
90bpm
21-22bpm
110/70mmHg

36.5C
101 BPM
21BPM
110/70mmHg

B. Behavioral Characteristics
Age
Gross/Fine Motor
Skills

Intellectual

Psychosocial

21

10 years old

>>

>> Understand
casual relationships

>>behaviour is
predictable,
consisted, controlled
>> expands peer
relationships in
cliques

11 years old

>>may be clumsy

>>

>> begins interest in

allowance

E. Diagnostic Test
1. Radiologic Test (Chest X-ray)
Clinical Impression

Medical Implication

22

Extensive Tuberculosis With Upper Cavities This category comprises all findings
typically associated with active pulmonary
TB. An applicant with any of the following
findings must submit sputum specimens for
examination.
1. Infiltrate or consolidation Opacification of airspaces within the
lung parenchyma. Consolidation or
infiltrate can be dense or patchy and
might have irregular, ill-defined, or
hazy borders.
2. Any cavitary lesion - Lucency
(darkened area) within the lung
parenchyma, with or without
irregular margins that might be
surrounded by an area of airspace
consolidation or infiltrates, or by
nodular or fibrotic (reticular)
densities, or both. The walls
surrounding the lucent area can be
thick or thin. Calcification can exist
around a cavity.
3. Nodule with poorly defined margins Round density within the lung
parenchyma, also called a
tuberculoma. Nodules included in
this category are those with margins
that are indistinct or poorly defined
(tree-in-bud sign). The surrounding
haziness can be either subtle or
readily apparent and suggests
coexisting airspace consolidation.
4. Pleural effusion - Presence of a
23

significant amount of fluid within the

pleural space. This finding must be
distinguished from blunting of the
costophrenic angle, which may or
may not represent a small amount
of fluid within the pleural space
(except in children when even minor
blunting must be considered a
finding that can suggest active TB).
5. Hilar or mediastinal
lymphadenopathy (bihilar
lymphadenopathy) - Enlargement of
lymph nodes in one or both hila or
within the mediastinum, with or
without associated atelectasis or
consolidation.
6. Linear, interstitial disease (in
children only) - Prominence of linear,
interstitial (septal) markings.
7. Other - Any other finding suggestive
of active TB, such as miliary TB.
Miliary findings are nodules of millet
size (1 to 2 millimeters) distributed
throughout the parenchyma

2. Sputum Exam
Clinical Result

Medical Implication
24

Positive Sputum Exam

Harmful bacteria or fungi are present. The

most common harmful bacteria in a sputum
culture are those that can
cause bronchitis, pneumonia, or tuberculosis.
If harmful bacteria or fungi grow, the culture is
positive.

EVALUATION
The group is studying the case of Mr. X who was diagnosed of Primary Complex,
last January 14, 2014 and was hospitalized at Zamboanga City Medical Center (ZCMC).
25

We were able to identify three problems; primary complex is related to the condition of
patients location, knowledge deficit on malnutrition and risk for improper hygiene.
During the course of the process of the case study, the patient was the foremost
concern of the group in prioritizing his problems and needs. The group employed a lot of
work in providing quality nursing care to the client. The researchers were provided with
ample time to conclude this case study. Improving and sharpening the skills and proper
decorum was also an aspect of the study that the group trained. With the help of this
case study, the group was able to go beyond the borderline about what they think,
know, and perform in giving quality nursing care. The group was able to broaden their
knowledge about specific topics such as anatomy and physiology of the respiratory
system and as well deeply understand the pathophysiology of primary complex. On the
other hand, the group was able to enumerate and facilitate focal-point interventions in
accordance to patients level of comprehension and ability to comply treatments.
On the process of this case study, the group was able to establish rapport. They
had also done the nursing assessment cephalocaudally and were able to identify all the
patients needs and problems according to their level of priority which guided the group
in formulating the Family Nursing Care Plan. The group focused on a problem that
revolves on the health deficit- Primary Complex, health deficit- Malnutrition, and health
threat- Improper hygiene.
The family nursing care plans were being implemented in the health center
during our visit and related learning experience duty. All the nursing interventions were
able to help the client improve his condition well. The empathy, wisdom and knowledge
that the group gave to the client helped lessen her problems and worries. With the help
of nurse-patient relationship and the rapport that has been established, the patient was
able to relate all his feelings and difficulties as he is struggling to recuperate from this
disease.
At the end of the case study, the group was able to meet their objectives and
goals. The group worked as a team and showed their cooperation to one another like a
family. This case study helped the group in broadening their critical thinking abilities,
improved and added new learning, ideas and information which will be useful for them
in the future. The group gained the sense of responsibility and honesty. They also
learned a lot of things like working as a group, brainstorming and sharing of information
and knowledge with each other, accept all suggestions from people who are more
knowledgeable than us and collaborate with others.
Along the over-all process, the groups came a crossed with some problems that
may affect the case study, these includes the availability of laboratory results, final
diagnosis, medications given during his stay in the hospital, discharge plan and the time
given to interact with the patient to dig in more details to support our case study
26

however, the over-all process of our case study, in spite of the constraints met by the
group, the researchers conclude that this case study met their goals and was a
successful one.

CASE FINDINGS, ANALYSIS, AND CONCLUSION

27

RECOMMENDATIONS
Patient and family members should be given thorough instructions and teachings
to help the patient cope up with his condition. As student nurses, it is an obligation and a
privilege to work closely with the patient and his family to reach the care desired and to
the extent possible, or to facilitate a transfer to the following:
1. Medications The patient is given Isoniazid, Rifampin and Pyrazinamide.
These medications are classified as anti-tubercular. Patient should able to
religiously take this multiple-drug therapy within 6 months. Skipping these
medications will allow the microorganism to resistant to any drug therapies in
the future.
2. Exercises He is encouraged to exercise in short session, such as walking
for twenty (20) minutes or completing two ten minute walks. He is advised
to walk as often as he is able to. He is assured to only do exercises by
doctors approval and to go outside if he has active tuberculosis. He is told
that moderate walking is a good way to start, most especially if he has been
inactive. As he builds his strength, he can slowly increase his walking time,
once his disease is no longer contagious. He is provided with teaching that
exercise can help his body fight the infection, speed the recovery and improve
the mood.
3. Treatment and Therapy He is assessed for hypersensitivity. He is advised
not to skip doses and to take medications for full length of the prescribed
therapy; is informed that urine, feces and sweat are red orange and soft
contact if Rifampin is taken. He is told that the medications must always be
taken as prescribed by the physician; never save antibiotics that are given to
you for another illness. The treatment regimen that is ordered by his physician
must be followed strictly and should not be stopped to prevent from the
aggravation of the condition. He must not wait for the signs and symptoms to
be severe. Consult health care providers at the health center if signs and
symptoms are not diminished.
4. Health teaching He must keep all his medical appointments, take his
medicines as prescribed by his physician, report any side effects after he has
taken the medications, and most especially vision problems. Advise patient to
tell ahead to the physician if he plans to postpone the schedule in order for an
arrangement to be prepared for the next treatment. Provide emotional support
to him that he doesnt have to feel embarrassed about his condition and let
28

him not worry that people may find out. He doesnt have to feel bad if people
wear masks when they go near him. He doesnt need to feel isolated and
alone because he cannot go to school. Encourage his family not to worry
about paying for the treatment. They dont have to be rich to have treatment;
there are always alternative ways to regain normal health condition. They do
not have to be guilty. Patient must not go yet to his school where he can
easily spread the disease, and must be kept in a separate bed room. Inform
family to open windows in the room for this can get rid of tuberculosis from
the air in the room and he must cover his mouth whenever he sneezes or
coughs. Until he has been on antibiotics for about two weeks, he can easily
give off the infection to others. After coughing dispose of the soiled tissue in a
covered container. He must talk to his physician to further educate him about
the precautions and prevention of tuberculosis.

29