Communicable

and

Infectious
diseases
 8
Section UPH – Dr. Jose G. Tamayo Medical
University
COLLEGE OF NURSING
STO. Niño, Biñan, Laguna

Introduction

Patient’s Profile

Physical Assessment
PULMONARY
Anatomy and Physiology

Pathophysiology

Medical Management
TUBERCULOSI
Laboratory and Diagnostics
S LEVEL IV
January 2008
INTRODUCTION
 TUBERCULOSIS
Is a disease caused by bacteria that attacks
the lungs, or any part of the body such as the
kidney, spine and brain. If not treated properly,
TB can be fatal.

It is spread through the air from one person

to another. the bacteria are put into the air
when a person with active TB of the lungs or
throat coughs or sneezes. People nearby may
breathe in these bacteria and become infected.
Mycobacterium Tuberculosis - primarily infective
agent
 TUBERCULOSIS

Symptoms of Active TB may include:

Bad cough that last longer than 2 weeks
Pain in the chest
Coughing up of blood or sputum
Weakness or fatigue
Weight loss
Fever
Usually has a positive skin test
Sweating at night
May spread TB to others
x-ray or positive sputum smear or culture
 RISK FACTORS FOR TB:
Infected with HIV
Close contact with someone who has an active TB
Person without adequate health care
Living in the crowded or unsanitary living conditions
Have been with TB bacteria in the past two years
Infants and young children
People who injected illegal drugs
People with weak immune system
Elderly
Those that were not treated properly for TB in the
past
 Examination of the lungs by
stethoscope can reveal crackles.
Enlarge tender lymph nodes may be
present in the neck or other areas.
Fluids may be detectable around a
lung. Clubbing of the fingers or toes
may be present.
Test may include:

>chest x-ray >thoracentesis

>sputum cultures >bronchoscopy
>tuberculin skin test
The goal or treatment for pulmonary
tuberculosis is to cure the infection with drugs
that fight the tuberculosis bacteria. The initial
treatment may involve a combination of many
drugs, it is continued until lab tests show which
medicine works best. Treatment usually last for
six (6) months but longer treatment may be
needed for person with AIDS or whose disease
responds slowly.
PATIENT’S PROFILE
NAME : Mr.I.R
ADDRESS : Peter Street,
Dasmariñas Cavite
SEX : Male
CIVIL STATUS : Married
DATE OF BIRTH : September 6, 1972
AGE : 36 yrs old
CITIZENSHIP : Filipino
RELIGION : Iglesia ni Cristo
DATE OF ADMISSION : January 4, 2008
TIME OF ADMISSION : 10:55AM
PERSONAL DATA
Patient is Mr. I.R, a 36 years old male from
Peter St. Dasmariñas Cavite. He is married,
an Iglesia ni Cristo. He is a former employee
of a printing company for one and a half
year, and worked as a financial encoder in a
soda factory for five years and currently
works as a tricycle driver. He was admitted
at University of Perpetual Help Medical
Hospital last January 4, 2008 at 10:55am.

CHIEF COMPLAINT
Difficulty of Breathing
HISTORY OF PRESENT ILLNESS
Few days Prior to admission. Patient had
episode of difficulty of breathing associated with
non productive cough, temporarily relieved by
Oxygen inhalation. Patient previously admitted
in Trecemarteres Hospital, where in the patient
was diagnose of PTB, Pneumonia.
2 Days PTA patient seek consultation for
follow up to a private Medical Doctor where
patient was prescribed home medications.
4 hrs. PTA patient has recurrent difficulty of
breathing, patient mentioned to seek
consultation at University of Perpetual Help
Medical Hospital hence admitted.
PAST MEDICAL HISTORY
- September 1997 patient sought consultation
and was diagnosed with PTB- Masinog
Hospital
- December 16,2007 –Patient was admitted
with the same diagnosis
– at Trecemarteres Hospital
- Patient has a history of allergy
to shrimp paste
- No known allergies to drugs
FAMILY HISTORY
Mother = (+) HPN (+) PTB
(+) DM ( -) CA
Father = (-) HPN (+) PTB
(-) DM (-) CA
SOCIAL HISTORY
Patient is a cigarette smoker for
20 pack years, an alcoholic beverage
drinker, consumes about 6-8 bottles
per drinking spree. The patient’s usual
hobbies are drawing, singing and
playing billiards.
 PHYSICAL
ASSESSMENT
General appearance: Vital Signs:
• Thin body build BP=120/80mmHg
• Dresses appropriately RR=32cpm
• No body odor PR=116bpm
• Weak in appearance T=38.1°C

Mental Status:
Conscious and coherent
Pleasant
Cooperative
Oriented to time place and person
Uses simple words as means of communication
Skin:
• Color : fair complexion
• Uniformity : generally uniform
• Skin moisture : present in skin folds
and axilla
• Skin turgor : dry skin with poor skin
turgor
• Temperature : warm to touch
Nails
•Nail plate : convex curvature,
160° angle
•Nail condition : rough, thick,
and brittle
•Nail bed color : brown
•Texture : smooth texture
•Capillary refill : within 2 seconds
Head and face
•Skull : rounded and smooth contour
•Hair texture : black, fine and evenly
distributed, silky and
resilient, no infection and
infestation
•Scalp : fair in complexion, no lesion
and tenderness
•Facial movements : symmetric facial movement.
Can elevate and lower
eyebrows, close the eyes,
smile and puff cheek, show
teeth and stick out tongue.
Eyes
•Peri-orbital area : thick eyebrows, black in color
•Eyelashes : equally distributed, curled
slightly outward
•Eye lids : skin intact, no discharge and
discoloration closed symmetrically
•Conjunctiva : pale palpebral conjunctiva
Bilateral blink response and
symmetric firm eyeballs
•Pupils : equal in size and have both brisk
reaction to light and
accommodation, 2-3mm on
both right and left
•Iris : flat and round
Ears
Auricles: fair complexion, symmetrical
elastic, and mobile when pinch, and
aligned with the outer cantus of the eyes.

Nose
With O2 inhalation at 3-5 lpm via nasal cannula
•External nose: fair complexion, symmetric and
not tender
•Nasal septum: intact and in midline
•Nasal cavity: pink colored mucosa
Mouth and Pharynx
•Lips : dark lips, dry mucous membrane
•Teeth : yellowish in color
•Gums : dark in color and moist
•Tongue : in midline, slightly rough with whitish
coating, moves freely and non-
tender, smooth tongue base with
prominent veins.
•Pharynx : pink and smooth
•Uvula : is in midline
Presence of gag reflex
Neck
•Neck muscles : equal in size
•Muscle strength : has resistance to pressure
Normal head flexion (chin to chest)
Head extension (chin points up)

•Lateral flexion: right and left

•Lateral rotation: right and left
•Trachea: midline
Chest

•Shape : symmetrical
•Spinal alignment : normal
•Breathing Pattern: Rate= Tachypneic
Breath sounds= positive
crackles on right lung field
•Heart sounds : normal, no murmur
•Anterior and posterior lung expansion:
decreased lung expansion
Abdomen

•Color: fair in complexion

•Contour: symmetrical

•Auscultation: normal bowel sounds,

presence of muscles guarding

•Palpation: soft, flat, non-tender

Upper Extremities
No physical deformities noted.
•Muscles strength : normal and has resistance
to force
•Pulses : radial and brachial pulses
are normal and palpable
•Range of motion: shoulder can extend, abduct,
adduct, and rotate
Elbows can flex and extend. Wrist can flex
and extend. Phalanges abduct, adduct flex,
and extend. Pronation and supination of the
forearms.
•Right arm: with IVF D5 NM x 12 hours
Lower extremities

No physical deformities on both leg noted.

•Pulses: popliteal, posterior tibial and

dorsalis pedis are normal and palpable.

•Range of motion: normal on both leg

ANATOMY AND
PHYSIOLOGY
THE RESPIRATORY SYSTEM
Pathophysiology
 Risk factors:
•Smoking – 2 packs/day
•Nature of work- employee
of printing company,
finance encoder, tricycle
driver
•Alcohol
•Family History
•Low nutritional status
 Depressed immune system

Inhaled Mycobacterium bacilli/

air borne transmission through
nasal entry

Pass down the bronchial tree and

transmitted to the alveoli

Deposited and begin

to multiply

Transported through
bronchi
Inflammatory reaction occur

( DOB, COUGH, LOW

GRADE FEVER IN THE
AFTERNOON)

Phagocytes (neutrophils and

macrophages) engulf many of
the bacteria

Accumulation of exudates in the

alveoli causing
bronchopneumonia

Granuloma formation
surrounded by macrophages
 Phagocytes (neutrophils
and macrophages) engulf
many of the bacteria

Accumulation of exudates in the alveoli

causing bronchopneumonia

Granuloma formation surrounded by macrophages

fibrous tissue mass (ghon’s tubercle)

necrotic, forming a cheesy mass

calcified – form collageneous scar

 Become dormant – no further
progressive of active disease

After initial exposure and

infection, patient develop
active disease because of
weak immune system
response

Active disease occur due to reinfection

and activating dormant bacteria

Ghon’s tubercle ulcerates

Release cheesy material

into the bronchi
 Bacteria becomes airborne –
further spread of disease

Ulcerated tubercle heals

and forms scar tissue

Causes recurrence of
bronchopneumonia and tubercle
formation.
 Medical
management
 DOCTOR’S ORDER RATIONALE
Jan. 4, 08 4pm
Bp:100/60
HR:120 Pls. Admit patient to For proper medical
RR: 32 ROC under the service management and treatment
T: 36.2
of Dr. B and for further evaluation

Secure consent and For legal purposes and in

management order for the patient to
know all management and
treatment to be done

NPO temporarily except Due to episodes of difficulty

meds of breathing

VF: D5Nm 1L x 12° For maintenance of fluid

and electrolytes
 DOCTOR’S RATIONALE
ORDER
LABS: CBC, CBC- to evaluate level of blood
Serum component
K,
ALT, Serum K- evaluate electrolyte imbalance
Crea ,
U/A ALT- evaluate level of liver enzymes
CXR- PA
upright U/A- evaluate urine chemistry
FT4, TSH
2D ECO CXR- determine lung abnormalities

2D ECO- to view the heart (cross

sectional)
 DOCTOR’S ORDER RATIONALE
Meds:
Combivent neb. q4°

Lanoxin 0.25mg/ tab, 1

Tab OD

Myrin P Forte 3 Tabs

OD

Ventolin Expectorant
10cc TID
 DOCTOR’S ORDER RATIONALE
Refer to Dr. O for pulmo

O2 inhalation at 3 LPM Provide better oxygenation

via NC
Serve as baseline and
Monitor V/S q 2° and evaluate abnormality
record
To determine fluid balance
Record I and O q shift

Refer accordingly
 DOCTOR’S ORDER RATIONALE
Jan. 4, 08 7pm

Lanoxin 0.25mg/ tab,

1 Tab OD
Myrin P Forte 3
Tabs OD
Jan. 4, 08 11:58pm

Ventolin Expectorant
10cc TID
 DOCTOR’S ORDER RATIONALE
Jan.5, 082:05am

Refer to Dr. O for pulmo Provide better

O2 inhalation at 3 LPM via oxygenation
NC
Jan.5, 08 10:50am

Monitor V/S q 2° and Serve as baseline and

record evaluate abnormality

Record I and O q shift To determine fluid

balance
Refer accordingly
 DOCTOR’S ORDER RATIONALE
Jan.5, 08 10:50am

May have Soft diet w/ SAP To prevent aspiration

Vigocid 2.25mg IV q8°

ANST(-)

Give solu-cortef 150mg IV now then

q8°

IVF to FF: D5Nm 1L x 12 For maintenance of fluid

and electrolytes
For sputum AFB smear x3
Taken to isolate
microorganism that is
causing infection

Streptomycin SO41g IM OD ANST (-)

 DOCTOR’S ORDER RATIONALE
Jan.5, 08 10:50am

Avelox 400mg 1 tab OD

Start side drip: D5W 250cc + 1

amp Aminophylline @
10mgtts/min

Jan.5, 08 4:20pm
Spiriva 1g OD

Jan.6, 08 3pm
Continue Meds. For maintenance of fluid
IVF to FF: D5Nm 1L x 12 and electrolytes
 DOCTOR’S ORDER RATIONALE
Jan. 7, 08 10:35

Consume Meds.
Appevon 1 tab BID

Aminophylline drip: D5W 250cc + 1 Act as bronchodilator

amp Aminophylline @ 10mgtts/min

Consume Aminophylline drip

then shift to Ansimar 400mg
Tab BID

Heraclene 1 cap TID

Request chest CT-SCAN w/ To confirm how extensive

contrast the damaged
 DOCTOR’S ORDER RATIONALE
Jan. 9, 08 12:30am

Repeat CBC

Decrease Solu-cortef to 100 mg

IV q 8

IVF to FF: D5Nm 1L x 12° For maintenance of fluid

and electrolytes
NPO temporarily while dyspneic Due to episodes of difficulty
of breathing
Refer transfer

ABG now and refer Identify the specific acid-

base disturbance
Combivent Neb. q 30mins for 3
doses then 2 doses for q 2° then q
4° thereafter
 DOCTOR’S ORDER RATIONALE
Jan. 9, 08 1:00am
CBR w/o BRP’s
Jan. 9, 08 2:20am
Lactulose 30cc ODHS hold for BM > 3x a
day

Jan. 9, 08 4am
Resume Aminophylline drip: D5W 250cc + 1
amp Aminophylline @ 10mgtts/min

Jan. 9, 08 10am
Solu-cortef 150mg IV q 8 x 3 doses
Discontinue Ansimar
 DOCTOR’S ORDER RATIONALE
Jan. 9, 08 3:30pm

Continue other Meds.

V/S q 1 until stable
Decrease myocardial O2
Inc. O2 inhalation to 5Lpm
demand
via NC

Jan. 10, 08 11:45am

For possible intubation
Standby intubation set at
bedside

Repeat ABG at 6am

 DOCTOR’S ORDER RATIONALE
Jan. 9, 08 2:40pm

Transfer patient to ICU now For f

Inc. O2 inhalation to 10Lpm

Jan. 9, 08 7:10pm

Continue Solu-cortef 150mg IV

for 8°

Ranitidine 50mg IV q 8 while on

NPO

Place high back rest Facilitate breathing, for

better lung expansion
 DOCTOR’S ORDER RATIONALE
Jan. 11, 08 7:10am

Dec. O2 to 5Lpm

Watch out for DOB and

episodes of desaturation

Please limit visitor

Provide privacy
Jan. 11, 08 11:10am

May have soft diet w/ sap

Transfer to room
disposition c/o Dr. B and
Dr. O
IVF to FF: D5Nm 1L x 12
 DOCTOR’S ORDER RATIONALE
Jan. 11, 08 11:10am

Pulmo:
Repeat CXR- PA CXR- determine lung
Repeat ABG abnormalities
Identify the specific acid-base
shift IV Ranitidine to oral 150mg disturbance

may have DAT

no BRP’s

refer if there will be episode of DOB

Dec. O2 at 2Lpm via NC

Consume Aminophylline drip then shift Indicate improvement of

to Ansimar 400mg/tab, 1 tab BID condition
Indicate improvement of
Pulmo: condition
Maintain nebulization q 4°
Laboratory and
diagnostics
Roentgenological Findings
Examination: Chest PA
Date: January 4, 2008
This are fibronodular, fibrohazed, confluent hazed
and fibro exudates infiltrates on the right lung field. There
are confluent hazed densities with almost homogeneity of
the left lung showing some patches and cystic lucencies on
the left upper and midlung fields. These are tracheal and
mediastinal shift to the left. The cardiac borders, left
hemidiaphragm and sulcus are obscured. The heart size
cannot be properly evaluated. There are pleuro-
diaphragmatic adhesions on the right.
Conclusion:
The findings are highly suggestive of Pulmonary
Tuberculosis, Bilateral, Extensive with Partial Volume loss
of the left lung.
One has to rule in or rule out fibrothorax, left, pleuro-
diaphragmatic adhesions, right.
Roentgenological Findings
Examination: Chest PA
Date: January 10, 2008

There are fibrohazed confluent hazed and fibro

exudates infiltrates on the right lung field. There is an
almost homogeneous left lung with patches and cystic
lucencies. There are tracheal and mediastinal shift to the
left. The cardiac borders, left hemidiaphragm and sulcus
are obscured. The heart size cannot be properly
evaluated.

Conclusion:
The findings are highly suggestive of Pulmonary
Tuberculosis, Bilateral, Extensive with Partial Volume
loss of the left lung.
Bacteriology
Examination: AFB Smear
Date: January 6, 2008

Specimen : Sputum

Microscopy :
Sputum #1 (1/6/08)
Sputum #2 (1/7/08)
Sputum #3 (1/8/08)

No AFB seen in 500

visual fields .
 HEMATOLOGY
January 4, 2008

RESULTS INTERPRETATION SIGNIFICANCE

Hemoglobin 109 gm/l Low Decrease oxygen

supply from the lungs to
the tissues
Hematocrit 0.33 Low May be due to
nutritional deficiency
RBC 4.0 x 1012/l Normal

WBC 16.3 x 109/l High Indicates presence of

infection.
Differential 0.84 High Indicates bacterial
Count infection.
Segmenters
Lymphocytes 0.16 Low Depressed immune
system
 HEMATOLOGY
January 10, 2008
RESULTS INTERPRETATION SIGNIFICANCE
Hemoglobin 133 gm/l Normal

Hematocrit 0.40 Normal

RBC 4.5 x 1012/l Normal

WBC 17.1 x 109/l High Indicates

presence of
infection.
Differential 0.92 High Indicates
Count bacterial
Segmenters infection.
Lymphocytes 0.08 Low Depressed
immune
system.
 URINALYSIS (January 5,2008 )
PARAMETER RESULT INTERPRETATION
Color Yellow NORMAL

Transparenc Slightly Precipitation of calcium phosphate; not

y turbid pathological.
REACTION 6.0
(pH)
Protein trace Excretion of 10-100 mg each 24 hour is
normal but this amount is not detected by
usual tests.
Specific 1.015 NORMAL
Gravity
Glucose (-) NORMAL

Pus 1-210-20/hpf Indicates bacterial infection of the urinary

tract. The presence of occasional pus cells
may be normal per high power field; if
accompanied by red cells, pus cells
indicates inflammation.
RBC 1-3/hpt NORMAL
EPITHELIAL Few NORMAL
CELLS
MUCUS Few In most circumstances its presence has no
THREADS clinical significance
 Clinical Chemistry Report
Priority: Routine Fluid: Serum
Date: January 4, 2008
Test Normal Result Interpretation Significance
Range
Creatinine 71.0-133.0 60.4 Low Due to small
mmol/L stature
debilitation,
decreased
muscle mass ,
some complex
cases of hepatic
disease
Potassuim 3.50-5.10 4.41 Normal
mmol/L
ALT 21-72 28 u/L Normal
 Blood Gas Analysis
Date: January 4, 2008 Time: 12nn
Age: 36y/o
Respiratory Rate: 30bpm Temperature: 37°C
Patient Values Normal Values
Ph 7.459 7.35-7.45
pCO2 30 35-45mmHg
PO2 100
HCO3 21.5 22-26mmol/L
O2 SAT 98.2٪ 95-100٪
O2 Content 22.4 20ml/dL

Interpretation: Fully Compensated Respiratory Alkalosis

 Blood Gas Analysis
Date: January 9, 2008 Time: 12:35am
RR: 36bpm Temp: 35°C

Patient Values Normal Values

Ph 7.514 7.35-7.45
pCO2 31.9 35-45mmHg
PO2 53
HCO3 26.3 22-26mmol/L
O2 SAT 92.8٪ 95-100٪
O2 Content 27.4 20ml/dL

Interpretation: Partially Compensated Respiratory Alkalosis

Blood Gas Analysis
Date: January 9,2008 Time: 6:00am
RR: 28bpm Temp: 3 7°C

Patient Values Normal Values

Ph 7.446 7.35-7.45
pCO2 38.2 35-45mmHg
PO2 138
HCO3 25.5 22-26mmol/L
O2 SAT 92.2% 95-100٪
O2 Content 22.7 20ml/dL

Interpretation: Normal ABG

Blood Gas Analysis
Date: January 11, 2008 Time: 6am
RR: 19bpm Temp: 37°C

Patient Values Normal Values

Ph 7.410 7.35-7.45
pCO2 42 35-45mmHg
PO2 147
HCO3 5.8 22-26mmol/L
O2 SAT 99.3% 95-100٪

Interpretation: Normal ABG

 ECG Findings
Date: January 4,2008

Sinus Tachycardia