Introduction Pulmonary tuberculosis is an infectious disease caused by slow- growing bacteria that resembles a fungus, Mycobacterium tuberculosis, which

is usually spread from person to person by droplet nuclei through the air. The lung is the usual infection site but the disease can occur elsewhere in the body. Typically, the bacteria from lesion (tubercle) in the alveoli. The lesion may heal, leaving scar tissue; may continue as an active granuloma, heal, then reactivate or may progress to necrosis, liquefaction, sloughing, and cavitations of lung tissue. The initial lesion may disseminate bacteria directly to adjacent tissue, through the blood stream, the lymphatic system, or the bronchi. Most people who become infected do not develop clinical illness because the bodys immune system brings the infection under control. However, the incidence of tuberculosis (especially drug resistant varieties) is rising. Alcoholics, the homeless and patients infected with the human immunodeficiency virus (HIV) are especially at risk. Complications of tuberculosis include pneumonia, pleural effusion, and extra pulmonary disease. Tuberculosis has been a serious public health problem for a long time , tuberculosis continues to be a deadly disease .

CHAPTER 1

a. Personal Data Name: PATIENT X Age: 78 YEARS OLD Address: 1909 f.Barona , tondo Manila Date of birth: Dec.16, 1932 Civil Status: Married Sex: male Occupation: NONE Religion: Dating Daan Nationality: Filipino

Date of admission: sept.6,201 b.Chief Complaint: the patient was admitted at Gat andress at 2:10 in the morning due to the complaint of difficulty of breathing (DOB). She was attended at the Emergency department and had taken a clinical history and physical assessment. Shewas transferred at the Medical Ward particularly in the isolation room of the hospital for further evaluation of the complaint. She wasattended by Dr. San Jose, a resident physician of the said hospital.difficulty of breathing admitting Diagnosis: PTBIV with pneumonia c. History of present illness; Patients condition started about 6 months prior to consultation, as onset of cough, non-productive and an intermittent feverusually in the afternoon, moderate grade temperature which are not documented. According to her it was relieved by an intake of paracetamol.One week prior to admission the patient experienced worsening of the condition, she had productive cough non-bloody withwhitish secretions. There is also difficulty of breathing and vomiting. The patient cant eat properly because she has no appetite for food.She also experience stabbing pain on her chest according to the assessment it is 6/10 and it radiates to his back. The patient only tookparacetamol for her fever. On the day of September 19, 2008 she was rushed to the hospital because of difficulty of breathing. Previouslywhen she started experiencing these conditions, she does not seek for any medical care from the physician because according to her it is stilltolerable d. Past medical history; The patient had upper respiratory tract infection when she was a child, she cannot remember. Previously she was not hospitalized.She does not have complete immunizations because according to her it is not available in their place during those days, She has no history of hypertension and Diabetes mellitus. Whenever she had any flu or cough, she uses herbal plants. She does not have any regular medical anddental check-ups. She does not have allergies to what ever kind of foods and medications as far as she knows. Whenever she had fever shetakes Paracetamol and Bioflu. She does experience any severe accidents

e.family history

PHYSICAL ASSESSMENT Normal Findings Generally fine, smooth, firm and even - Skin texture resilient and moist - Capillary refill test: immediate return of color (2-3 sec) - Limbs not tender - Symmetric in size Skin turgor returns rapidly to its previous shape and position No primary and secondary lesions noted .No edema noted Skull Generally round, with prominences in the frontal and occipital area. (Normocephalic). No tenderness noted upon palpation. Scalp Lighter in color than the complexion. Can be moist or oily. No scars noted. Free from lice, nits and dandruff. No lesions should be noted. No tenderness nor masses on palpation. Hair Can be black, brown or Actual Findings The client has a white complexion. Dry skin is noted. A capillary refill of 3 seconds was noted.

Skin

The clients head has a round smooth skull contour. The hair is thick, white, oily and fine which is evenly distributed. The scalp is smooth and firm. No lesions noted.

Head (Skull, Scalp, Hair)

Face

burgundy depending on the race. Evenly distributed covers the whole scalp (No evidences of Alopecia) Maybe thick or thin, coarse or smooth. Neither brittle nor dry. -Symmetric or slightly asymmetricfacial features; -palpebral fissures equal in size, -symmetric nasolabial folds -Symmetric facial movements Eyebrows Symmetrical and in line with each other. Maybe black, brown or blond depending on race. Evenly distributed. Eyes Evenly placed and inline with each other. Non-protruding. Equal palpebral fissure. Eyelashes Color dependent on race. Evenly distributed. Turned outward. The ear lobes are bean shaped, parallel, and symmetrical. The upper connection of the ear lobe is parallel with the outer canthus of the eye. Skin is same in color as in the complexion. No lesions noted on inspection. The auricles are has a firm cartilage on palpation. The pinna recoils when folded. There is no pain or tenderness on the palpation of the auricles and mastoid process. The ear canal has normally some cerumen of inspection. No discharges or lesions noted at the ear canal.

He has Symmetric facial features; Periorbital area slightly puffy but non-tender; symmetric nasolabial folds.Symmetric facial movements His eyes are symmetrical, blue in color, almond shape. Pupils constrict when diverted to light and dilates when he gazes afar, conjunctivas are pink. Eyelashes are equally distributed and skin around the eyes is intact. The eyes involuntarily blink.

Eyes

Ears are symmetrical with no discharge. The clients auricles have the same color as the facial skin. It is mobile, firm, and not tender. The pinna recoils often as it is folded. Client can hear with ease when spoken softly.He can hear better in his left earlobe.

Ears

Nose

Mouth

Neck

On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in color Nose - Symmetric and straight - No discharge or flaring - Uniform color - Not tender and no lesions - Patent nares - Mucosa is pink - Clear, watery discharge - Nasal septum intact and in midline Facial Sinuses - Not tender Teeth and Gums - 32 adult teeth - Smooth, white, shiny tooth enamel - Pink gums (bluish or dark patches in dark-skinned clients) - Moist, firm texture to gums - Smooth, intact dentures Tongue/Floor of the Mouth - Central position - Pink color (some brown on borders for dark-skinned clients); moist; slightly rough; thin whitish coating - Moves freely; no tenderness - No prominent veins and palpable nodules Uvula - Midline Oropharynx and Tonsils - Pink and smooth posterior wall - No discharge 1.The neck is straight. 2.No visible mass or lumps. 3. Symmetrical 4.No jugular venous distension (suggestive of cardiac congestion)

External nose is symmetric and straight. It appears oily. Nasal hairs are present upon inspection. Nasal septum is not deviated. Both nostrils are patent as each nostrils are being ocluded. No discharge, tenderness and lesions noted. The sinuses are well outlined after transillumination.

He has a complete set of teeth with minimal dental caries noted. Oral mucosa and gingival are pink in color, moist, and there were no lesions or inflammation noted. Tongue is pinkish with thin whitish coating and free of swelling and lesions.

The clients head is coordinated with smooth movements and no discomfort. The neck supports the head properly. No presence of abnormal swelling or masses. Lymph nodes are not palpable. No nodules

5. The trachea is palpable. It is positioned in the line and straight. Lymph nodes 1.May not be palpable. Maybe normally palpable in thin clients. 2. Non tender if palpable. 3. Firm with smooth rounded surface. 4. Slightly movable. 5. The thyroid is initially observed by standing in front of the client and asking the client to swallow. Thyroid 1. Normally the thyroid is non palpable. 2. Isthmus maybe visible in a thin neck. Posterior Thorax - Chest symmetric --Absence of abnormalsounds like wheezing and crackles Normal rate (12-25 bpm) - Spine vertically aligned - Skin intact; uniform temperature - Chest wall intact; no tenderness; no masses - Full and symmetric chest expansion (3-5cm gap) - Bilateral symmetry of vocal fremitus Anterior Thorax - Quiet, rhythmic, and effortless respirations - Full symmetric excursion - Bronchial and tubular breath sounds upon auscultation on trachea No murmurs,crackles,gallops noted.

are palpable.

He has a regular rhythm with a 22 breaths per minute. Breath sounds are clear on both lungs upon auscultation. Excursion shows a 3-cm gap during inspiration. No signs of swelling or masses noted.

Thorax and Lungs

Heart

-Cardiac rate is 80 bpm.Blood pressure is 130/90 mmHg - No murmurs,crackles,gallops

Breast

Abdomen

- Rounded shape, slightly unequal in size - Same skin color as abdomen - Skin smooth and intact Areola - Round/oval or bilaterally the same - Color varies (pink to dark brown) Nipples - Round, everted, and equal in size Axilla - No tenderness, masses, or nodules Inspection - Unblemished skin - Uniform color - Flat, rounded (convex), or scaphoid (concave) - Symmetric contour - Symmetric movements caused by respiration - No visible vascular pattern Auscultation - Audible bowel sounds Palpation - No tenderness; relaxed abdomen with smooth, consistent tension -Absence of edema -Even color and smooth texture -Unlimited movements such as adduction,abduction etc - Absence of edema -Even color and smooth texture -Unlimited movements such as adduction,abduction etc - Conscious and coherent

noted. The clients breast are rounded in shape, slightly unequal in size, and generally symmetric and not enlarged. The skin color of the breast was the same color as of the abdomen. The breast nipples are erect and not inverted. No tenderness noted.

The abdomen is uniform in color. Its rounded and has a symmetric contour.Symmetric movements caused by respiration.Audible bowel sounds.No tenderness was palpated.

Upper Extremities

No edema noted.Even color and smooth texture.Unlimited movements such as adduction,abduction but with slightly pain in the IV site. No edema noted .Even color and smooth texture -Unlimited movements such as adduction,abduction etc The patient is conscious and very

Lower Extremities Neurologic

Assessment

- Able to respond to reflex tests - Able to distinguish different sensory functions.

responsiv upon interaction. He was able to answer directly and clearly all questions rendered.. Reflexes such as Blinking reflex and deep tendon reflex are present. He was able to distinguish touch, pain, hot, and cold. .

Gordons Functional Health Pattern Before Hospitalization He always goes to the health center whenever he feels sick, and takes the medications on time. He usually eats 5-6 times a day. He loves eating fruits and vegetables. And usually drinks 4-5 glass of water a day. He usually urinates 3-4 times a day and defecates at least once a day. He spends his time watching TV, reading newspapers, sleeping and eating. He loves completing the puzzle in the newspaper. He usually sleeps 6-7 hours a day. During Hospitalization He always takes the medication on time and he realized the good effect of always consulting a doctor. He only eats 3-4 times a day, Diet as tolerated, And water demand was increased due to his present condition, usually 8-10 glass a day. He urinates 5-6 times a day and defecates once a day. He just spend his time talking with his wife, eating ,listening to radio, ,reading newspaper and sleeping He has 7-8 hours of sleep a day and can sleep very well. He was still active and alert,talkative,responds very well to every question we asks.Can speak and communicate well. He just take sponge

Health Perception/Management Nutritional-Metabolic Pattern

Elimination Pattern

Activity-Exercise pattern

Sleep-Rest Pattern

Cognitive-Perceptual Pattern He was very active ,responsive , and very talkative.Can understand and speaks well. Self Perception/Concept He takes a bath

everyday,always wellgroomed & puts on gel.He has a high self-esteem Role-Relationship Pattern He was the only child,very responsible & always trying to help his parents.Living with his parents happily. Refused to answer Whenever he feels stressed or has a problem, he just completes the answer in the puzzle, Read the newspaper and sometimes go to somewhere to relieve the stress The client goes to church twice a week with his family & always pray.

bath,slightly wellgroomed,no gel,still has high self-esteem. He cant do the thing he used to do at home,his mother was very loving and caring,his father visited him often due to his work. Not Applicable He just eat and sleep as much as he can to relieve stress

Sexuality-Reproductive Pattern Coping-Stress Tolerance

Value-Belief Pattern

He cant go to church but he still pray & has strong faith in God.

Chapter 2 Diagnostic procedures laboratory

Chapter3 anatomy and physiology

UPPER RESPIRATORY TRACT Respiration is defined in two ways. In common usage, respiration refers to the act of breathing, or inhaling and exhaling. Biologically speaking, respiration strictly means the uptake of oxygen by an organism, its use in the tissues, and the release of carbon dioxide. By either definition, respiration has two main functions: to supply the cells of the body with the oxygen needed for metabolism and to remove carbon dioxide formed as a waste product from metabolism. This lesson describes the components of the upper respiratory tract.

The upper respiratory tract conducts air from outside the body to the lower respiratory tract and helps protect the body from irritating substances. The upper respiratory tract consists of the following structures: The nasal cavity, the mouth, the pharynx, the epiglottis, the larynx, and the upper trachea. The oesophagus leads to the digestive tract. One of the features of both the upper and lower respiratory tracts is the mucociliary apparatus that protects the airways from irritating substances, and is composed of the ciliated cells and mucus-producing glands in the nasal epithelium. The glands produce a layer of mucus that traps unwanted particles as they are inhaled. These are swept toward the posterior pharynx, from where they are either swallowed, spat out, sneezed, or blown out. Air passes through each of the structures of the upper respiratory tract on its way to the lower respiratory tract. When a person at rest inhales, air enters via the nose and mouth. The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a tube like structure that connects the back of the nasal cavity and mouth to the larynx, a passageway for air, and the esophagus, a passageway for food. The pharynx serves as a common hallway for the respiratory and digestive tracts, allowing both air and food to pass through before entering the appropriate passageways. The pharynx contains a specialised flap-like structure called the epiglottis that lowers over the larynx to prevent the inhalation of food and liquid into the lower respiratory tract. The larynx, or voice box, is a unique structure that contains the vocal cords, which are essential for human speech. Small and triangular in shape, the larynx extends from the epiglottis to the trachea. The larynx helps control movement of the epiglottis. In addition, the larynx has specialised muscular folds that close it off and also prevent food, foreign objects, and secretions such as saliva from entering the lower respiratory tract.

LOWER RESPIRATORY TRACT The lower respiratory tract begins with the trachea, which is just below the larynx. The trachea, or windpipe, is a hollow, flexible, but sturdy air tube that contains C-shaped cartilage in its walls. The inner portion of the trachea is called the lumen. The first branching point of the respiratory tree occurs at the lower end of the trachea, which divides into two larger airways of the lower respiratory tract called the right bronchus and left bronchus. The wall of each bronchus contains substantial amounts of cartilage that help keep the airway open. Each bronchus enters a lung at a site called the hilum. The bronchi branch sequentially into secondary bronchi and tertiary bronchi.

The tertiary bronchi branch into the bronchioles. The bronchioles branch several times until they arrive at the terminal bronchioles, each of which subsequently branches into two or more respiratory bronchioles. The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli are bubble-like, elastic, thin-walled structures that are responsible for the lungs most vital function: the exchange of oxygen and carbon dioxide. Each structure of the lower respiratory tract, beginning with the trachea, divides into smaller branches. This branching pattern occurs multiple times, creating multiple branches. In this way, the lower respiratory tract resembles an upside-down tree that begins with one trachea trunk and ends with more than 250 million alveoli leaves. Because of this resemblance, the lower respiratory tract is often referred to as the respiratory tree. In descending order, these generations of branches include: trachea right bronchus and left bronchus secondary bronchi tertiary bronchi bronchioles terminal bronchioles respiratory bronchioles alveoli

THE LUNGS

The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity. There are two lungs that occupy a significant portion of this cavity. The diaphragm is a broad, dome-shaped muscle that separates the thoracic and abdominal cavities and generates most of the work of breathing. The inter-costal muscles, located between the ribs, also aid in respiration. The internal intercostal muscles lie close to the lungs and are covered by the external intercostal muscles. The lungs are cone-shaped organs that are soft, spongy and normally pink. The lungs cannot expand or contract on their own, but their softness allows them to change shape in response to breathing. The lungs rely on expansion and contraction of the thoracic cavity to actually generate inhalation and exhalation. This process requires contraction of the diaphragm. To facilitate the movements associated with respiration, each lung is enclosed by the pleura, a membrane consisting of two layers, the parietal pleura and the visceral pleura. The parietal pleura comprise the outer layer and are attached to the chest wall. The visceral pleura are directly attached to the outer surface of each lung. The two pleural layers are separated by a normally tiny space called the pleural cavity. A thin film of serous or watery

fluid called pleural fluid lines and lubricates the pleural cavity. This fluid prevents friction and holds the pleural surfaces together during inhalation and exhalation. PREDISPOSING FACTORS 1. Malnutrition 2. Overcrowding 3. Alcoholism 4. Ingestion of infected cattle 5. Virulence 6. Over fatigue SIGNS AND SYMPTOMS 1. Productive Cough yellowish in color 2. Low fever 3. Night sweats 4. Dyspnea 5. Anorexia, general body malaise, weight loss 6. Chest/back pain 7. Hemoptysis

PATHOPHYSIOLOGY

V. Pathogenecity What is Pulmonary tuberculosis? Pulmonary tuberculosis (TB) is a contagious bacterial infection that mainly involves the lungs, but may spread to other organs. Causative Organism Pulmonary TB is caused by M. tuberculosis which is a rod-shaped bacteria with a waxy capsule. It is non-motile (requires external forces, such as coughing for example, to move from place to place), does not form spores, and is aerobic. Risk Factors -Old Age

-Infants -Children -Alcoholism -Low Socio economic Status -Drug addicts -HIV positive -People with weakened immune systems -Severely malnourished -People with frequent contact to the infected individual -Have poor nutrition -Live in crowded or unsanitary living conditions -Healthcare workers

Symptoms: Cough (sometimes producing phlegm) Coughing up blood Excessive sweating, especially at night Fatigue Fever Unintentional weight loss Pallor: Breathing difficulty Chest pain Wheezing Transmission Mycobacterium tuberculosis is spread by small airborne droplets, called droplet nuclei, generated by the coughing, sneezing, talking, or singing of a person with pulmonary or laryngeal tuberculosis. These minuscule droplets can remain airborne for minutes to hours after expectoration.

Stages of Tuberculosis: Latent Tuberculosis Mycobacterium tuberculosis organisms can be enclosed, as previously described, but are difficult to completely eliminate. Persons with latent tuberculosis have no signs or symptoms of the disease, do not feel sick, and are not infectious, however viable bacilli can persist in the necrotic material for years or even a lifetime, and if the immune system later becomes compromised, as it does in many critically ill patients, the disease can be reactivated. Primary Disease Primary pulmonary tuberculosis is often asymptomatic, so that the results of diagnostic tests. are the only evidence of the disease.. Associated paratracheal lymphadenopathy may occur because the bacilli spread from the lungs through the lymphatic system. If the primary lesion enlarges, pleural effusion develops, because the bacilli infiltrate the pleural space from an adjacent area. The effusionmay remain small and resolve spontaneously, or it may become large enough toinduce symptoms such as fever, pleuritic chest pain, and dyspnea. Primary Progressive Tuberculosis When a patient progresses to active tuberculosis, early signs and symptoms are often nonspecific. Manifestations often include progressive fatigue, malaise, weight loss, and a low-grade fever accompanied by chills and night sweats. a classic feature of tuberculosis, is due to the lack of appetite and the altered metabolism associated with the inflammatory and immune responses. Wasting involves the loss of both fat and lean tissue; the decreased muscle mass contributes to the fatigue. Although the cough may initially be nonproductive, it advances to a productive cough of purulent sputum.. Hemoptysis can be due to destruction of a patent vessel located in the wall of the cavity, the rupture of a dilated vessel in a cavity, or the formation of an aspergilloma in an old cavity. Hematologic studies might reveal anemia, which is the cause of the weakness and fatigue. Possible Complications: Pulmonary TB can cause -permanent lung damage if not treated early. -extra pulmonary tuberculosis (TB spread to areas of the body outside of the lungs) -tuberculosis pneumonia (massive lobular or lobar pneumonia) -pleuritis (infection & inflammation of tissue covering the lungs.

Chapter iv NURSING CARE PLAN

DRUG STUDY

CHAPTER V EVALUATION OF THE ACTUAL NSG PROBLEM DISCHARGE PLANNING