ACKNOWLEDGEMENT4

BACKGROUND ....................................................................................................................... 5 GENERAL OBJECTIVES ............................................................................................................ 6

SPECIFIC OBJECTIVES ......................................................................................................................6

PATIENTS PROFILE ................................................................................................................ 7 CHIEF COMPLAIN: .................................................................................................................. 8 HISTORY TAKING ................................................................................................................... 9

HISTORY OF PRESENT ILLNESS: .......................................................................................................9 PAST HEALTH HISTORY: ................................................................................................................ 10 FAMILY TREE ................................................................................................................................ 11 PERSONAL HEALTH HISTORY: ....................................................................................................... 12 ENVIRONMENTAL HISTORY .......................................................................................................... 13

PHYSICAL ASSESSMENT........................................................................................................ 14 DEVELOPMENTAL TASK OF ADOLESCENT ............................................................................. 19 DISEASE PROCESS ................................................................................................................ 23

ANATOMY AND PHYSIOLOGY (DIGESTIVE SYSTEM) ....................................................................... 23 DIGESTIVE ORGANS...................................................................................................................... 24 ACCESSORY GLANDS/ ORGANS ..................................................................................................... 27 ANATOMY AND PHYSIOLOGY (Peritoneal Anatomy) ..................................................................... 27 TYPES OF PERITONEUM................................................................................................................ 28 ABDOMINAL TUBERCULOSIS WITH PERFORATION PERITONITIS .................................................... 29
PERFORATION PERITONITIS ...............................................................................................................................29 ABDOMINAL TUBERCULOSIS ..............................................................................................................................30

PATHOPHYISIOLOGY .................................................................................................................... 32 SIGN AND SYMPTOMS ................................................................................................................. 35 DIAGNOSIS AND INVETIGATIONS .................................................................................................. 37
LABORATORY EXAMS .........................................................................................................................................41

TREATMENT................................................................................................................................. 44
(MEDICAL MANAGEMENT) ................................................................................................................................44 SURGICAL MANAGEMENT ..................................................................................................................................45 MANAGEMENT AFTER PERIOTISNIS: ..................................................................................................................45 OPERATIVE PROCEDURE NOTE ..........................................................................................................................46

HISTOPATHOLOGICAL EXAMINATION REPORT: .................................................................................................47 FECAL DIVERSION PROCEDURE .........................................................................................................................47

NURSING MANAGEMENT: ............................................................................................................ 48

APPLICATION OF NURSING THEORY ..................................................................................... 48

NURSING PROCESS: ...................................................................................................................... 51 Nursing Care Plan......................................................................................................................... 53

DRUG STUDY ....................................................................................................................... 67 DAILY PROGRESS NOTE: ....................................................................................................... 88 DIVERSIONAL THERAPY USED IN MY PATIENT TO MINIMIZE STRESS: .................................... 91 HEALTH TEACHING PROVIDED TO MY PATIENT DURING HOSPITALIZATION: ......................... 92 DISCHARGE TEACHING: ........................................................................................................ 93 WHAT I LEARNED FROM MY CASE STUDY: ............................................................................ 95 SUMMARY OF MY CASE STUDY ............................................................................................ 96 CONCLUSION ....................................................................................................................... 97 BIBLIOGRAPHY .................................................................................................................... 98

ACKNOWLEDGEMENT
This Nursing concept hospital based case report on Abdominal tuberculosis with Perforation Peritonitis" has been completed within 8 weeks period in Bir Hospital, Mahaboudha in Male Surgical Ward. This is a great opportunity for me to perform a case study in National Academy Of Medical Sciences, Bir Hospital through which I was able to gain a lot of knowledge as well as skills of nursing care. I would like to express my sincere thanks and appreciation to all those people whose voluntary efforts helped me complete this case study. I would like to thank my respected teachers, Madam Pramila Shakya, Coordinator Madam Jayalaxmi Shakya, Madam Bandana Thapa, Madam Nibaran Joshi and other associated teachers for their continuous supervision, direction, guidance, support and encouragement throughout the case study period. I would like to express my gratitude to the director, matron and ward in-charge of Bir hospital for granting me permission to conduct case study. I am also grateful to all the staffs and doctors concerned to the care of my patients for their help and kind cooperation, without whom, this case study would not have been completed. My sincere thanks go to my colleagues, seniors and juniors for their valuable suggestions and help and to the library staffs of NAMS, BHNC for providing me necessary books and materials as well as staffs of Central Library Bir Hospital for providing me valuable time and books.

Finally, I express my genuine gratitude to the patient Mr. Yubraj Patamagar and his family for providing me valuable information, time and cooperation that helped me to successfully study the case, thus providing me a better insight on Abdominal Tuberculosis.

BACKGROUND
Throughout the world tuberculosis is associated with poverty, deprivation, and human immunodeficiency virus infection. Abdominal tuberculosis is usually of insidious onset with diverse symptoms and signs. A few present with acute complications of perforation, obstruction, or bleeding. The diagnosis is difficult, especially in areas where the disease is less common, as many patients do not have evidence of pulmonary tuberculosis or a positive skin test. However, in developing countries like Nepal where Tuberculosis is still prevalent ,the diagnosis of abdominal tuberculosis or even its complication like perforations is not that tricky. Peritoneum is one of the most common extra-pulmonary sites of tuberculoses infection and due to perforation of bowel in the people having intestinal tuberculosis, peritoneum is infected without doubt. The diagnosis of this disease, however, remains a challenge because of its insidious nature, the variability of its presentation and the limitations of available diagnostic tests. A high index of suspicion is needed whenever confronted with unexplained ascites, particularly in high-risk patients. Laparoscopy combined with peritoneal biopsy is effective for the diagnosis of tuberculous causing perforation peritonitis in 75 to 85% of cases. Peritoneal tuberculosis is treated with antituberculous drugs for a period of eight to nine months or according to the case. In my case study, the above proclamation still remaining true, one more aspect can be added to the cause where complication of pulmonary tuberculosis spreading in other areas (eg intestine) has remained undetected until complications (perforation peritonitis )occurred , and this may not be solely due to poverty or lack of diagnostic facilities but partly due to modernization in sociocultural side as well. This is further illustrated in my study here.

GENERAL OBJECTIVES
To provide holistic care to patient through nursing process using proper nursing theories and practices considering the socio cultural background and traditional philosophy of the patient with the help of basic science and fundamental nursing knowledge.

SPECIFIC OBJECTIVES
1. To gain specific knowledge about specific disease. 2. To identify the cause, pathophysiology, clinical features and diagnostic evaluation of abdominal tuberculosis and perforation peritonitis. 3. To prevent patient from complication of the disease. 4. To gain new facts and ideas about the disease. 5. To gain better and clearer understanding on the nature, course, physical and emotional changes and signs and symptoms related to abdominal tuberculosis. 6. To establish rapport and gain the trust and co-operation of the patient and immediate family members. 7. To gather factual health assessment of the patient and perform proper assessment of the patient. 8. To disseminate information to the patient as well as her relative about the illness and ways of caring the patient. 9. To evaluate daily progress of patient health and effectiveness of treatment. 10. To minimize the stress of the patient and her family by providing adequate information and using appropriate diversional therapy. 11. To be able to formulate related nursing diagnosis from the patients health data and to the current problems the patient experiences and to come out with different nursing interventions effective for the patient to improve and progress on the most possible time. 12. To encourage patient and his family members to be involved in discharge planning and follow up visits.

PATIENTS PROFILE
Biographic data:
Name of the patient: Age /sex: Address: Marital status: Date of birth: Religion: Occupation: Educational status: Hospital data: Hospital: Date of admission: In Patient no: Ward: Bed no: Unit: Provisional Diagnosis: Final Diagnosis: Date of surgery: Surgery: Bir Hospital 2070/02/25 85513 Male Surgical Ward 91 Surgery Unit III ( Dr. Yawan Chandra Shivakoti) Kochs abdomen with obstruction Abdominal tuberculosis with Perforation peritonitis 2070/02/25 Exploratory Laparotomy with anstomosis with proximal Ileostomy done for multiple perforation viscera. Yub Raj Patamagar 17 years/ male Ason, Kathmandu , Nepal Unmarried 2053/08/24 Hindu Student SLC

CHIEF COMPLAIN: (On admission, 2070/02/25)

Distention of abdomen x 3 days Pain abdomen x 3 days No passage of stool x 3 days Vomiting x 3 days Poor scanty micturation

BODY MASS INDEX Reference: Underweight = <18.5 Normal weight = 18.5 24.9 Overweight = 25 29.9 Obesity = BMI of 30 or greater

Patients value: Weight: 32 kg. Height: 5 ft. 1inch Formula: BMI= Conversion: 703 = (constant value in BMI) 32 kg. = (2.20 lb/ 1 kg) =70.4lb. 5 ft. = (12 inches/ 1 ft.) =60 inches + 1 inch = 61 inches Solution; BM I= ___70.4 lb. x 703__ = 49491.2 lb. = 13.30 (61inches)2 3721 BMI= 13.3 Patient is Underweight mass (lb.) x 703___ [height (inches)] squared

HISTORY TAKING
HISTORY OF PRESENT ILLNESS:
Patient had been experiencing low grade fever and cough on and off since one month (since Baisakh, 2070). He had weakness and had episodes of blood in stool occasionally. He took some Ayurved medication (powder form, no name identified) which made him feel better. He also took some medications and antibiotics for fever from nearby medical clinic. He had also been losing weight (approximately 42 kgs before 2 mths of admission, and 32 kgs 1 week after admission). On 2070/02/19 he was taken to Samudayik Sahari Swastha Clinic,in Jyatha Kathmandu by her aunt, as no progress was seen in his health and he seemed more deteriorating. The clinician suggested that it might be Tuberculosis and advised Laboratory tests like Sputum for AFB, stool R/E, and also widal test. Since Tuberculosis was suggested, the family took him to Sukraraj Tropical & Infectious Disease Hospital Teku where the Sputum AFB was done and ATT was started (2070/02/24). On 2070/02/25 patient came in emergency ward with distention of whole abdomen, severe abdomen pain increasing on movement and difficulty to swallow food or medications. In emergency, His GCS was 15/15. His vital signs were: Temperature: 980 F Respiration: 24/ min On Examination: Distention of whole abdomen. Bowel sound absent Umbilicus central, hernia orifices intact Board rigidity (+) Normal anal tone, empty anal canal Pulse: 70 bpm Blood Pressure: 110/70 mm of Hg

ER diagnosis: ? Kochs abdomen with obstruction After investigations: Perfotaion Peritonitis/ PTB Investigations: CBC,LFT,PT, INR, Blood grouping, Blood sugar, Urea , Cretenine, Na, K, Serum amaylase, Urine R/E , HIV I and II, HBsAG, HCV, X-ray abdomen (erect and supine),USG abdomen and pelvis were done. Emergency Exploratory Laparotomy surgery was performed and later admitted to Male Surgical Ward, Bed number 91.

PAST HEALTH HISTORY: Childhood Illness:

Patient was weak health wise since childhood. He used to have diarrhea and indigestion problems on and off several times in a year. According to his fathers information, he was born at home and it was normal delivery without any complication. His mother died when he was 8 years old who was diagnosed of PTB (refused treatment). He did not have any major disease but he is wearing glasses for shortsightedness since 2067.

Childhood immunization:
Patients father claims that he has his son immunized completely according to EPI schedule. Patient confirms that he also had three doses of Hepatitis B vaccine taken at school.

History of hospitalization or surgery:

No history of hospitalization or any kind of surgery.

Accidents and injuries:

He was involved in an incident when he was hit hard on head with a football when he was 14 years old. He used to work part time as a ball boy in football games in Dasrath Rangashala. He was unconscious for a moment and regained consciousness but dint seeks any medical treatment.

Medications:
Patient used over the counter drugs for headache, fever and cough occasionally.

Family history:
Patient is the second child and has a brother 2 years older than him. He lives with his father who is good in health but has hypotension ( checks Blood pressure in nearby clinic sometimes) maintained by diet. His mother died when he was 8 years old who had Pulmonary Tuberculosis. She was being treated in Bir hospital but she refused treatment several times and used to discontinue medications or hospital visits.

FAMILY TREE
MATERNAL SIDE

PATERNAL SIDE

FATHER

MOTHER

1st sibling

PATEINT

LEGENDS: MALE DECEASED MALE PATIENT

FEMALE FEMALE DECEASED

PERSONAL HEALTH HISTORY:

Lifestyle: He in non- alcoholic, non- smoker, no drug user. Diet: He is non- vegetarian. He describes that his diet pattern is not as normal. He drinks a glass of milk or tea every morning with biscuits or puff pastry. Then he eats rice and curry around 2 or 3pm in the afternoon. Most of the time he eats noodles or some light snacks for dinner and takes rice hardly ever. On Saturdays, he eats restaurant foods/ fast foods like pizza, momo, and carbonated drink*----s with friends and doesnot eat at home. Since a month or two, he has been eating lesser, and has stopped eating out with friends even on staurdays. Sleep and rest pattern: Before hospitalization, he usually slept between 10:30 to 11 pm and woke up around 7 to 8 am. However, since hospitalization he claims that his sleep has been disturbed as he has leaking ileostomy bags sometimes and also gets disturbed in a hospital environment. He is unable to take nap during day time. Elimination pattern: Before hospitalization he used to urinate 7-8 times a day and had a bowel movement every day. He frequently had diarrhea so some days he used to pass stool 4-5 times a day. Few episodes of blood in stool were seen one month back. He also had scanty urine 3-4 days prior to admission. During hospital--ization he had difficulty passing urine on the day when Foleys catheter was removed, but later urinated normally. Activities with daily living: He did not have problems in daily activities like bathing, eating, dressing or locomotion but he experienced some weakness and left his part time job after 1 year of working as a ball boy. However, he is now dependent for his daily activities as he cannot walk or sit for a long time due to weakness post surgery. Recreational activities and hobbies: He loves video games and has craze over online gaming. He participates in online tournaments and spends hours in cyber house with his friends. He agrees that he saves his pocket money given for lunch and spends it playing video games /computer games instead. Sometimes he loses track of time and ignores lunch or breakfast.

Social data Family relationship/ friendship: In regards to his family relationship, he has strong family ties. He is loved by his father and supported greatly by his elder brother. He has also very close relationship with his paternal relations i.e. his aunts, uncles. He shares friends with his brother and has a close relationship with them too. Ethnic affiliation: Although he is open minded, he respects his values and cultures. He is Hindu by religion and visits temple occasionally. Educational history: He is an average student and took morning classes in school. He attended SLC but could not pass all the subjects. Economic history: His family is able to afford the necessities of household and has been able to support his studies till date.

ENVIRONMENTAL HISTORY
According to the patient, he lives in a rented house. There are two rooms and a flower shop in next house. His father, brother and himself share a single room as their bedroom and kitchen. They use the other room as storage of flower shop. The toilet is water sealed type. But they have scarcity of water so they buy water jars for drinking water and use Boring-underground water for washing and cleaning purposes.

Patterns of health care

According to patient and his family the first choice for their health problems is modern medicine. They visit nearby clinic or seek doctors help in need. However, they also take medicines from Ayurveda sometimes.

PHYSICAL ASSESSMENT
Date of assessment: 2070/03/04 (Tuesday) Assessed lying in the bed (in supine position). VITAL SIGNS: Temperature: 980F Respiration: 26/min GENERAL APPEARANCE: General Condition: Patient was weak and tired in appearance. Gait: unstable, could not support own body on standing or sitting position Nutritional Status: Very thin body structure, looked mal nourished. Hygiene: skin surface seemed unclean. But clean clothes. Speech and behavior: Clear and understandable speech. Gives appropriate reaction to the situation. INTEGUMENTARY SYSTEM SKIN Inspection: Palpation: Warm and soft skin with even temperature all over her body. No sign of edema or dehydration on examination. Good skin turgor. Fair complexion without cyanosis, uniform distribution of colour. 1st degree bedsore noted on sacral region. No rashes or skin abrasions around Ileostomy region (Ileostomy post surgery) Pulse: 84/ min Blood Pressure: 100/70 mm of Hg

HEAD AND FACE Inspection:

 Even distribution of hair over the scalp. No dandruff or lice present. Symmetric facial features. Palpation: No swelling, lump or injury over scalp or forehead. No tenderness over the sinuses.

LYMPH NODES No any palpable lymph nodes present over the body nderness over the sinuses. EYES AND VISION: Both eyes were symmetrical in shape, size and location with equal movements. No bulging of eyes. No redness or discharge from the eyes. Patient has shortsightedness and wears glasses.(power: -2), discontinues during hospitalization. Eye Brows: symmetrical, well distributed. No eye brows fall. Eye Lids: No redness, edema, lesion or dropping. Eye Lashes: outward and upward curled. Conjunctiva: transparent Pupil: Bi lateral equal (approx 2mm) and responsive to light. Lens: transparent Sclera: No any signs of anemia or jaundice.

EARS AND HEARING: Inspection: Normal shape, size and symmetry. Top of pinna meets eyes at the line of outer canthus of the eyes. No lump, lesion or discharge. No redness, mass or foreign body present on the external auditory canal.

Palpation: No any tenderness or swelling present on the mastoid bone.

Hearing activity: normal and can hear the sound of normal conversation.

NOSE: Medially located. Nostrils uniform in size& do not flare on respiration. Nasal septum is not deviated. No lesion, redness, tenderness or blockage of nasal pathways. Intact smelling sense.

MOUTH AND THROAT: Lips: Looks dry. No cracks or angular stomatitis. Gums: pink without bleeding or swelling. Teeth: 28 teeth are present in total number. No dental caries. Tongue: positioned centrally, free movement. Moist, no tongue tie present. Can identify the sense of taste. No signs of injury. But slight dryness of tongue. Palate and uvula: dry and pink. No any signs of injury in palate and uvula located in midline of the throat. Throat: tonsils are not inflamed. Positive gag reflex upon touching the posterior part of the tongue with the use of tongue depressor.

NECK Inspection Neck muscles are equal with the head positioned at the centre Able to flex, extend and hyperextend his head when asked to do so.

Palpation No visible or palpable thyroid, salivary glands and lymph nodes.

CHEST RESPIRATORY SYSTEM Inspection: Trachea and sternum are vertically aligned. Equal expansion of chest bilaterally during inspiration and expiration. Diameters of chest not measured but none deformity of chest was visible. No respiratory distress observed.

Palpation:

 No tenderness, lumps or depression present along the ribs. Percussion: Resonant sound heard over the lungs. Dull sound over the heart.

Auscultation: Clear breathe sounds present over all areas of lungs with no added breathe sounds (wheezes, crepitation, rhonchus). Bronchial breathe sounds over trachea heard where inspiration was shorter than expiration. Broncho vesicular breathe sounds lateral to the trachea heard where inspiration and expiration both are equal. Vesicular sound was present over peripheral areas of the lungs over entire lungs field where expiration was shorter than inspiration.

CARDIOVACULAR SYSTEM Inspection Palms of hands appear pink.

Palpation Capillary refill time is less than 2 sec. Peripheral pulses (brachial, radial, femoral, posterior tibial and dorsalis pedis) were palpable.

Auscultation Regular heart beat with rate of 86/min. S1S2 (lub/ dup) present with no other added sounds or heart murmer. Apex beat heart on fifth intercostals space mid clavicular line. Apex beat is symmetrical with other peripheral pulses i.e. 86 per minute

ABDOMEN Inspection: Cylindrical in shape. Vertical incision sutured post Laparotomy. No soakage and sign of infection over the wound surface. Dressing has been applied and changed daily.

GASTROINTESTINAL SYSTEM Inspection /subjective data: Is on normal diet but eats soft food in very little amount3/4 times a day. Diarrhea on ileostomy. Nausea, vomiting, heart burn was absent.

Auscultation: Gurgling peristalsis movement audible on all the four quadrants. 10 per minute. Palpation: Pain on touch due to surgical wound. Abdomen soft and tender. Liver: no tenderness or palpable per abdomen. Spleen: no tenderness or palpable per abdomen.

Percussion: Not perfomed due to surgical wound and ileostomy presence.

GENITOURINARY SYSTEM BACK Inspection: No any deformity on the back is seen (Kyphosis, scoliosis or lordosis). 1st degree bedsore on sacral region. History of painful micturation but at present normal urination. Costo-vertebral tenderness absent. Clear urine drains more than 2500 ml per day (self voiding)

Palpation: Bilateral equal expansion of back during respiration. No tenderness.

Percussion: Resonance sound present over the back.

Auscultation:

Breath sounds are heard in all areas of the lungs. Inspiration longer than aspiration.

MUSCULOSKELETAL SYSTEM Both upper and lower extremities are of equal size, shape and symmetrical without any deformity. No redness, swelling or any tenderness. Difficulty to Full range of motion of left extremities due to weakness and pain. Capillary refill: less than 2 sec Color of nail bed: pink Peripheral pulses: present Normal temperature of extremities on palpation. No bone or joint deformity

NEUROMUSCULAR SYSTEM GCS 15/15 Level of consciousness: conscious and oriented to time, place and person Equal strength & co-ordination on right and left sides of extremities. Sensory and motor functions are intact. Bicep and triceps, brachioradialis, abdominal reflex, knee-jerk, Achilles and plantar reflexes are present. Patient shows normal response to stimuli.

DEVELOPMENTAL TASK OF ADOLESCENT

(13-20 YEARS OF AGE)

Developmental Tasks:
Developmental tasks is defined as the task which arises at certain periods during the life span of an individual, the successful accomplishment of which leads to satisfaction and success with later life while the failure leads to dissatisfaction and difficulty with later life. Growth and development during adolescent period. Biologic growth

Physical growth: During adolescent a tremendous increase in physical size occurs in short period. Growth spurs begins early in girls than in boys Start from 10-14 years in girls, in boys starts from 12-16 years. Growth in height stops around 16-17 years on girls (epiphyseal closure) Growth in height stops around 21-25 years in boys. Increased shoulder width in boys and broader hip development in girls. The muscle growth both in quantity and quality are greater in boys than in girls. Oestrogen brings soft skin, increase vascularity in girls. Androgenic hormone produce increased thickening and darkening of skin, increased active sebaceous and sweat glands (apocrine gland) Effect of gonadal hormone makes hair coarse and dark.

Physiologic changes: Size of the heart, blood volume and BP increases to supply blood to increase body size. Boys have higher blood volume that girls due to more muscle mass. Pulse rate, respiration rate decreases, but BMR increases similar like adult.

Hormonal changes: Pubertal events are caused by hormonal influences and controlled by anterior pituitary gland. It causes stimulation of the gonads which has dual function: Production and release of gametes (sperms in the male and ova on the female) Secretion of the sex appropriate hormone. In female: estrogen and progesterone (ovaries) In male: testosterone (testes)

Sexual maturation: Includes primary sex characteristics. Related to development of external and internal organs that carry out reproductive function. Voice alteration, development of facial and pubertal hair, fat deposition.

Sequence of maturation in boys: The first pubescent changes in boys are testicular enlargement with thinning, reddening and increased looseness of the scrotum during 9.5- 14 years. Growth of pubic hair, auxiliary hair, facial hair after 2 years of pubic hair. Rapid increase in health.

Muscular development, changes in larynx and voice along with grown of penis. Nocturnal emission: the beginning of nocturnal emission seminal fluid at periodical interval is the signal to reveal the onset of spermatogenesis. Abrupt declaration of linear growth.

Puberty delay in boys considered when there is no enlargement of the testes or scrotal changes by 13.5- 14 years of age or genital growth is not complete 4 years after the testicle to begin enlarge. Boys reaction to puberty Increase in height and weight is usually a welcome event to adolescent boys who had been embarrassed for several months due to lag in their physical growth in comparison to their girl mates. The development of secondary sex characteristic especially the growth of facial and body hair has psychological and social meaning of masculine sex role. The enlargement of reproductive organs in boys may produce embarrassment

Psychological Development
According to Erickson , the psychological crisis that adolescents face between age 13 and 18 is identity versus role confusion See themselves as distinct individuals unique and separate from other individual. Adolescents strains to attain autonomy from the family and develop a sense of personal identity as opposed to role diffusion. Sense of group identity appears to be essential to the development of a sense of personal identity. They achieve a sense of group identity and individual identity.

Emotional development
Uncertain in their emotional state between childlike behavior and considerable maturity. Unpredictable mood swings.

Better control their emotions in later adolescence. Social development

They have feeling of immortality and exemption from the consequence of risk behavior, which can be an important developmental function toward independence although viewed as negative. Acceptance by peers, close friends and secure love of family are essential for inter personal maturation. They resist parental control. And frequent conflicts can occur.

Peers become important source of advice and support and also provide them strength power and belongingness. They spend their leisure time in group, music, movies and other fun.

Development tasks during adolescence.

The task is to achieve some degree of intimacy, as opposed to remaining in isolation. Intimacy is the ability to be close to others, as a lover, a friend and as a participant in society. It includes not only the love between two lover/ husband and wife, the love between friends/ co-workers and the love of ones neighbor as well. Developing more mature relations with the same sex age mates and learning new relationship with members of the opposite sex. Accepting the changing body size, shape and function and understanding the Achieving a satisfying and socially acceptable feminine or masculine role. Achieving emotional independence from parents and other adults. Preparing for economic career to be economically independent. Acquiring a set of values and ethical system as a guide to his/her ideology and behavior. Achieving socially responsible behavior. Developing the intellectual and work skills and social sensitivities of competent citizens. Preparing for marriage and family life.

Developmental tasks in relation to my patients:

Yubraj Patamagar seems to have achieved social maturity, he has moved from the parental environment to outside peer group environment. He spends most of the time with the same sex age mates. He has also tried to achieve economical independence from his family by trying to work part time jobs. Emotional changes like unpredictable mood swings , has been noticed during hospital stay. He also verbalizes and expresses that he has enthusiasm to gain new experiences. Sometimes he gets depressed and withdrawn because of the crisis situation he is facing in his disease process, but he also demonstrates mature emotions later on. He is positive about life.

DISEASE PROCESS
My patient has the Diagnosis of abdominal tuberculosis that caused perforation of peritonitis. First, the anatomy and physiology of the related system in illustrated and then follows the entire disease process.

ANATOMY AND PHYSIOLOGY (DIGESTIVE SYSTEM)

The digestive tract, also called the alimentary canal or gastrointestinal (GI) tract, consists of a long continuous tube that extends from the mouth to the anus. It includes the mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The tongue and teeth are accessory structures located in the mouth. The salivary glands, liver, gallbladder, and pancreas are major accessory organs that have a role in digestion. Food undergoes three types of processes in the body: Digestion Absorption Elimination Digestion and absorption occur in the digestive tract. After the nutrients are absorbed, they are available to all cells in the body and are utilized by the body cells in metabolism. The digestive system prepares nutrients for utilization by body cells through six activities, or functions. Ingestion: The first activity of the digestive system is to take in food through the mouth. This process, called ingestion, has to take place before anything else can happen. Mechanical Digestion: The large pieces of food that are ingested have to be broken into smaller particles that can be acted upon by various enzymes. Chemical Digestion: Through a process called hydrolysis, uses water and digestive enzymes to break down the complex molecules. Digestive enzymes speed up the hydrolysis process, which is otherwise very slow. Movements: After ingestion and mastication, the food particles move from the mouth into the pharynx, then into the esophagus. This movement is deglutition, or swallowing. Mixing movements occur in the stomach as a result of smooth muscle contraction Absorption: The simple molecules that result from chemical digestion pass through cell membranes of the lining in the small intestine into the blood or lymph capillaries. This process is called absorption Elimination: The food molecules that cannot be digested or absorbed need to be eliminated from the body. The removal of indigestible wastes through the anus, in the form of feces, is defecation or elimination.

DIGESTIVE ORGANS
The digestive system is a group of organs (Buccal cavity (mouth), pharynx, esophagus, stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components of food, with digestive juices, into tiny nutrients which can be absorbed to generate energy for the body.

The Buccal Cavity: Food enters the mouth and is chewed by the teeth, turned over and mixed with saliva by the tongue. The sensations of smell and taste from the food sets up reflexes which stimulate the salivary glands. The Salivary glands: Saliva lubricates the food enabling it to be swallowed and contains the enzyme ptyalin which serves to begin to break down starch. The Pharynx: Situated at the back of the nose and oral cavity receives the softened food mass or bolus by the tongue pushing it against the palate which initiates the swallowing action.

The Esophagus: The esophagus travels through the neck and thorax, behind the trachea and in front of the aorta. The food is moved by rhythmical muscular contractions known as peristalsis (wave-like motions) caused by contractions in longitudinal and circular bands of muscle. The Stomach: The stomach lies below the diaphragm and to the left of the liver. It is the widest part of the alimentary canal and acts as a reservoir for the food where it may remain for between
2 and 6 hours. Here the food is churned over and mixed with various hormones, enzymes including pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of which are also secreted further down the digestive tract.

Anatomy of Small Intestine (related to disease process): The small intestine measures about 7m and is continuous from pyloric sphincter to large intestine at illeocecal valve. The small intestine, because of its structure, provides a vast lining through which further absorption takes place. Mobility of small intestine: Rhythmic segmentation (mixing movement): it mixes the chyme to digestive juices and exposes it to absorptive surface. Peristalsis (wave of rhythmic contraction and relaxation) of longitudinal and circular smooth muscles. It makes propelling force that moves digested food down the length of the tract.

Parts of small intestine Duodenum : It is C shaped, proximal part of small intestine which is widest and shortest. It is curved around the head of pancreas .it contains glands which secrete the mucous. Neuroendocrine cells present on duodenal mucosa secrete secretin and cholestokin. Jejunum : It is middle part of the small intestine and has a thick wall, wide lumen and is more vascular than other parts of the small intestine. It has villi, which are more abundant. It also contains intestinal gland which produce water, electrolytes and mucous. Largest amount of absorption occur through this part. Ileum : It is the distal largest part of the small intestine. It has thin wall, and it is the narrowest lumen which is less vascular among the parts of small intestine. It has short and thin villi. It contains the payers patches (lymphoid follicles) which is responsible for local intestinal immunity.

Digestive enzyme of small intestine.: the enzymes are sucrose , maltose , lipase which helps is final digestion of fat , carbohydrate, and protein. Digested form of food in small intestine is chyle.

Note: The ileocecal junction is a sphincter or valve connecting the end of the small intestine (the ileum) with the beginning of the large intestine (the cecum). Function of small intestine Complete the digestion of food with the help of intestinal juices, pancreatic juices, and bile. Complete absorption of nutrients. Local intestinal immunity by payers patches against various ingested bacteria and virus.

The Large Intestine: The large intestine averages about 1.5m long and comprises the cecum, appendix, colon, and rectum. After food is passed into the cecum a reflex action in response to the pressure causes the contraction of the ileo-colic valve preventing any food returning to the ileum. Here most of the water is absorbed, much of which was not ingested, but secreted by digestive glands further up the digestive tract. Vermiform appendix: Blind tube arising from the posterior wall of the cecum. About 2 cm, below the ileo-cecal valve. Its sub-mucosa contains numerous lymphoid follicles so it is called the abdominal tonsils. It helps in immune response due to presence of lymphoid tissue. Rectum: Distal portion of the large intestine, between the sigmoid colon and anus. Desire of defecation occurs when the feces reaches the rectum. Anus: Extends from rectum, about 3.8 cm in length.

ACCESSORY GLANDS/ ORGANS

The Pancreas: The Pancreas is connected to the duodenum via two ducts and has two main functions: To produce enzymes to aid the process of digestion To release insulin directly into the blood stream for the purpose of controlling blood sugar levels

The Liver: The liver, which acts as a large reservoir and filter for blood, occupies the upper right portion of abdomen and has several important functions: 1. Secretion of bile to the gall bladder 2. Carbohydrate, protein and fat metabolism. 3. The storage of glycogen ready for conversion into glucose when energy is required. 4. Storage of vitamins (A, D, E, K) 5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria. 6. Reservoir of blood. 30% of blood is reserved here. The Gall Bladder: The gall bladder stores and concentrates bile which emulsifies fats making them easier to break down by the pancreatic juices. Spleen: It acts as a reservoir, functions as phagocytosis. It is also called graveyard of RBCs.

ANATOMY AND PHYSIOLOGY (Peritoneal Anatomy)

The peritoneum is the serous membrane that lines the abdominal cavity. It lies directly beneath the abdominal musculature (rectus abdominis and transverse abdominis). Peritoneum is made up of layers of mesothelial cells. Mesothelial cells are simple squamous and of mesodermal origin, they have microvilli on their surface and are very fragile but regenerate very quickly. There are two layers of peritoneum lining the abdomen. 1. The outer layer, called the parietal peritoneum, is attached to the abdominal wall and the pelvic walls. 2. The inner layer, the visceral peritoneum, is wrapped around the internal organs that are located inside the intra-peritoneal space. It is thinner than the parietal peritoneum. The potential space between these two layers is the peritoneal cavity; it is filled with a small amount (about 50 ml) of slippery serous fluid that allows the two layers to slide freely over each other.

Peritoneal Fluid:
A small quantity of peritoneal fluid is produced by mesothelial cells. It fills the potential space formed by the two layers of peritoneum and allows the two layers to slide over each other freely. Peritoneal fluid is also produced as a transudate which coats the serosal surface of viscera to facilitate frictionless movement e.g. during peristalsis. It is in equilibrium with plasma but doesn't contain high molecular weight molecules like fibrinogen. The fluid is constantly being produced and resorbed through the large surface area of the peritoneum, for this reason drugs are sometimes administered by intraperitoneal injection. Bacterial toxins are also absorbed readily and can cause inflammation of the peritoneum; peritonitis. Organs are described as retroperitoneal if they are located behind the parietal peritoneum. Retroperitoneal organs include: the kidneys, adrenal glands, ureters, urinary bladder, part of the oesophagus, rectum, ovaries, uterus, aorta and caudal Vena Cava. Organs are intraperitoneal if they are enclosed by a fold of visceral peritoneum. Intraperitoneal organs include: small intestine, large intestine, liver, gall bladder, pancreas and spleen.

TYPES OF PERITONEUM
The peritoneum doubles up to form the following suspensory structures: Mesentery, from viscera to the dorsal abdominal wall. Omentum from the stomach to other viscera and ligament, from viscera not involved in digestion to the abdominal wall or to other viscera that are not involved in digestion (e.g.ligaments of the liver). A mesentery suspends the small and large bowel from the posterior peritoneal cavity by way of a double layer of peritoneum. It acts as a channel for neurovascular and lymphatic structures between the organ and posterior abdominal wall. A ligament is also formed by two layers of the peritoneum; it supports a structure within the peritoneal cavity and is named according to the structures it connects. An omentum refers to a double-layered extension of ligaments of the peritoneum joining the stomach and proximal duodenum to other adjacent structures, the greater and lesser omentum extending from the greater and lesser curvatures of the stomach respectively.

Fig.: Sagittal CT peritoneogram with diagram.

ABDOMINAL TUBERCULOSIS WITH PERFORATION PERITONITIS

PERFORATION PERITONITIS
Perforation Peritonitis is inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera due to infections from certain organisms followed by gastrointestinal perforation. Perforation is said to occur once a pathology which extends through the full thickness of the hollow viscus leading to peritoneal contamination with intraluminal contents. Perforation can occur anywhere in the gastrointestinal tract starting from oesophagus to the rectum. CAUSES: Usually, it is a result of bacterial infection; the organisms come from diseases of the GI tract or, in women, from the internal reproductive organs. Peritonitis can also result from external sources such as injury or trauma (eg, gunshot wound, stab wound) or an inflammation that extends from an organ outside the peritoneal area, such as the kidney.

The most common bacteria implicated are Escherichia coli, Klebsiella, Proteus, and Pseudomonas. Other common causes of peritonitis are appendicitis, perforated ulcer, diverticulitis, and bowel perforation. Peritonitis may also be associated with abdominal surgical procedures and peritoneal dialysis.

Perforation peritonitis is one of the most common surgical conditions encountered in surgical practice and is a common cause of morbidity and mortality and warrants early surgical intervention. Adequate resuscitation along with baseline investigations and broad spectrum antibiotics are imperative in all cases. Further management depends upon the cause of peritonitis.

In regards to my patient
According to study I have done in my case, perforation peritonitis resulted due to abdominal tuberculosis which leaded to bowel perforation resulting in peritonitis. It is further discussed below.

ABDOMINAL TUBERCULOSIS
(INTESTINAL TUBERCULOSIS in MY CASE) Abdominal tuberculosis is a most common type of extra-pulmonary tuberculosis, comprising of tuberculosis of gastrointestinal tract, peritoneum, omentum, mysentery and its lymph nodes and other abdominal organs such as liver, spleen and pancreas. The extrapulmonary tuberculosis involves 11-16% of all patients of tuberculosis out of which 3 to 4% belong to abdominal tuberculosis. The gastrointestinal tract is involved in more than 60% of cases of abdominal tuberculosis. Extra pulmonary tuberculosis is common amongst HIV-infected patients. Abdominal tuberculosis can mimic a variety of other abdominal conditions/diseases and only a high degree of suspicion can help in the diagnosis otherwise it is likely to be missed or delayed resulting in high morbidity and mortality. ETIOLOGY Abdominal tuberculosis can occur primarily or it can be secondary to a tubercular focus elsewhere in the body. Gastrointestinal tuberculosis occurring due to ingestion of milk or food infected with Mycobacterium bovis can result in primary intestinal tuberculosis, but it is nowadays rare. Secondarily, Infection by Mycobacterium tuberculosis causing abdominal tuberculosis is acquired in following ways: 1. Dissemination of primary pulmonary tuberculosis in childhood.

2. Swallowing of infected sputum in active pulmonary tuberculosis. 3. Hematogenous dissemination from a focus of active pulmonary tuberculosis or military tuberculosis. 4. Mycobacteria can spread from infected adjacent organs like fallopian tubes. 5. Intestinal infection can occur by lymphatic spread from infected mesenteric lymph nodes. 6. Mycobacteria can also get disseminated through bile from tubercular granulomas of the liver.

ETIOLOGY in my patient
It could not be confirmed what was the real cause of abdominal tuberculosis but it is highly possible that it was due to swallowing of infected sputum as he was in an active stage of pulmonary tuberculosis. According to my analysis, the pulmonary tuberculosis might have resulted from the transmission of organisms through his mother (who had incompletely treated Pulmonary Tuberculosis that lead to death) during his childhood. Sites of Involvement in Abdominal Tuberculosis 1. Gastrointestinal tract 2. Peritoneum, e.g. ascites 3. Lymph nodes 4. Solid organs, e.g. liver, spleen and pancreas The most common site is the terminal ileum and ileocaecal region due to increased physiological stasis, increased fluid and electrolyte absorption, minimal digestive activity, and an abundance of lymphoid tissue (Peyers patches) at this site. The other sites, in order of frequency, include the colon and jejunum. Peritoneal involvement occurs in 4-10% patients of extrapulmonary tuberculosis (EPTB).Tubercular peritonitis follows either the direct spread of tuberculosis from ruptured lymph nodes and intra-abdominal organs or hematogenous seeding. Peritoneal involvement may be in the form of peritoneal adhesions or exudative fluid in the peritoneal cavity (ascites). Rarely, tuberculosis may involve other areas such as the perianal region, appendix, duodenum, stomach, and oesophagus. The nodal involvement due to tuberculosis is commonly mesenteric or retroperitoneal. The abdominal solid organs (liver, spleen, and pancreas) may also be affected with tuberculosis, but rarely.

PATHOPHYISIOLOGY
Precipitating factor Previous contact with the case of TB (mother) Predisposing factor: -malnutrition associated with decrease in immunity activates inactivated organisms. Low Nutrition = low immunity= high tubercle bacillus

Pulmonary tuberculosis

Primary infection due to ingestion of milk or food infected with Mycobacterium bovis.

Secondary infection due to Swallowing of infected sputum in active pulmonary tuberculosis

Ileum; ielocecal area and lymph nodes involved (80-90%) Rarely tuberculosis may also involve Stomach, duodenum and esophagus.

Mycobacterium cannot continue to grow in the acidic extracellular environment, and thus most infections are controlled, but TB can persist within the tubercles for extended periods.

Although many activated macrophages surround the tubercles, many other macrophages are inactivated or poorly activated. TB uses these macrophages to replicate causing the tubercle to grow and invade the intestinal wall/abdominal structure.

Cell-mediated immune response terminates the unimpeded growth of M. tuberculosis within 2 to 3 weeks after the initial infection.

(CD4) helper T cells activate the macrophages to kill the intracellular bacteria with resultant epithelioid granuloma formation. Tuberculous granulomas of variable size are initially formed in the submucosa or the Peyers patches. Caseating granulomas in histopathological examination indicates infection of Mycobacterium tuberculosis.

Tuberculin test become positive around this time.

CD8 suppressor T cells lyse the macrophages infected with the mycobacteria, resulting in the formation of caseating granulomas.

Under immunosuprresed conditions

Secondary lesions occurs. The caseous centres of the tubercles liquefy .this liquid is very crucial for the growth of TB, and therefore multiplies rapidly (extracellularly)

These later becomes a large antigen load causing the walls of intestine become necrotic and rupture.

Perforation (formation of a hole in an organ), fecal materials exits to peritoneal cavity causing formation of abscess. Infection spreads throughout the abdomen (peritoneal cavity)

Bacteria invasion of peritoneal cavity causing inflammation of the membrane that lines the abdomen peritoneum (peritonitis)

Septic shocks: 1. Decrease bloodpressure 2. Decrease blood volume

-Prescribed antibiotics and /or surgical repair. -Treatment of Tuberculosis with ATT.

Coma

Fluid volume replacement

Death

Recovery

SIGN AND SYMPTOMS

In order of frequency, abdominal tuberculosis manifests as tubercular lymphadenitis, peritonitis and hepato-splenic or pancreatic tuberculosis. The disease may present at any age but commonly seen in young adults. In children, peritoneal and nodal form of tuberculosis is more common than intestinal tuberculosis. The modes of presentation may vary from asymptomatic disease (an incidental finding on laparotomy) to acute, acute on chronic or chronic symptomatic disease. The clinical manifestations depend on the site and type of involvement. The symptomatology mainly includes (i) Constitutional symptoms in about one-third of patients fever malaise anemia night sweats loss of weight weakness. (ii) Local symptoms and signs referable to the site involved. Type Ulcerative Clinical presentations Chronic diarrhea, malabsorption, intestinal perforation (occasional). Rectal bleeding is rare but reported occasionally in colonic tuberculosis Intestinal obstruction or an abdominal (ileocaecal) lump Recurrent subacute intestinal obstruction (e.g. vomiting, constipation, distention, colicky pain). There may be associated gurgling sounds or feeling of moving ball of wind in the abdomen and visible distended intestinal loops with visible peristalsis.These symptoms get relieved with passage of flatus / stool. Sometimes, acute intestinal obstruction may develop. Stricture or fistula-in-ano Peptic ulcer with or without gastric outlet obstruction or perforation Hepatosplenomegaly usually a part and parcel of disseminated tuberculosis is accompanied with fever, night sweats and decreased or loss of appetite Microscopic involvement shows granulomatous hepatitis. Abdominal distention and ascites, sometimes there may be a soft cystic lump due to loculated ascites As a mass or lump of matted lymph nodes in the central abdomen or as vague abdominal pain. There is associated fever, night sweats and malaise.

2 3

Hypertrophic Stricturous / constrictive

4 5 6

Anorectal Gastroduodenal Liver and spleen

7 8

Peritoneum Lymph node

A physical examination of abdomen may show signs of ascites, lump in the abdomen or visible peristalsis with dilated loops of gut. However, abdominal examination may be unrewarding in a large number of cases. Because of varied clinical manifestations, one or the other form of abdominal tuberculosis may mimic any one of the followings: Malignant neoplasms, e.g. lymphoma, carcinoma Inflammatory bowel disease Cirrhosis of the liver especially peritoneal tuberculosis Ileocaecal mass may mimic appendicular lump or malignancy caecum or other conditions.

A high degree of suspicion combined with proper use of diagnostic modalities will help in the timely diagnosis of the disease

Symptoms after peritonitis:

Symptoms depend on the location and extent of the inflammation. The early clinical manifestations of peritonitis frequently are the symptoms of the disorder causing the condition. At first, a diffuse type of pain is felt. The pain tends to become constant, localized, and more intense near the site of the inflammation. Movement usually aggravates it. The affected area of the abdomen becomes extremely tender and distended, and the muscles become rigid. Rebound tenderness and paralytic ileus may be present. Usually, nausea and vomiting occur and peristalsis is diminished. The temperature and pulse rate increase, and there is almost always an elevation of the leukocyte count.

Sign and symptoms in my patient.

As my patient had abdominal tuberculosis, the sign and symptoms he developed one and half months were: Low grade fever Weakness Weight loss Blood in stool ,sometimes

Later on few days before admission with peritonitis he had: Abdominal distention No passage of stool or flatus for 3 days. Severe pain on abdomen, increasing on movement. Rigidity of abdominal muscle due to pain Vomiting Anorexia

DIAGNOSIS AND INVETIGATIONS

1. History taking 2. Physical examination 3. INVESTIGATIONS Blood examination may show varying degree of anemia, leucopenia and raised ESR Serum biochemistry: Serum albumin level may be low. Serum transaminases are normal. Mantoux test: This gives supportive evidence to the diagnosis of abdominal tuberculosis in 55 to 70% patients if positive, however, a negative tuberculin test may also be observed in one-third of patients. Negative mantoux test in patients of tuberculosis could be due either to (a) immunosuppression or malnutrition producing energy or (b) recent overwhelming tuberculosis or military tuberculosis or (c) rarely circulating mononuclear adherent cells suppressing the sensitized Tlymphocytes in peripheral blood or (d) suppression of PPD-reactive Tlymphocytes. 4. Imaging Techniques: Plain X-ray abdomen and chest: It may show presence of multiple air fluid levels and dilated loops of gut in case there is sub acute or acute intestinal obstruction. Calcification in the abdominal lymph nodes also indicates tuberculosis. 5. Barium Studies: It has been documented that barium studies are useful in 75% patients with suspected intestinal tuberculosis. Barium meal follow through is the best diagnostic test for intestinal lesions. The bowel lesions highly suggestive of tuberculosis include multiple strictures, distended caecum or terminal ileum. 6. Ultrasound: The USG of abdomen may show a mass of matted loops of small bowel with thickened walls, rolled up or diseased omentum, and loculated ascites. Peritoneal thickening and nodularity are the other ultrasonographic findings of peritoneal tuberculosis. Tubercular lymphadenitis usually involves mesenteric, peri-pancreatic, periportal and para-aortic groups of lymph nodes. These lymph nodes are seen as conglomerate mass and/or as scattered enlarged nodes with hypoechoic center because of necrosis (Fig.). This necrosis within lymph nodes may also be seen in metastatic lymphadenopathy. However, caseation with calcification is highly suggestive of tubercular lymphadenitis rather than malignant. The nodes maytransiently increase in size once the treatment is started and then gradually diminish in size.

Fig.: Abdominal ultrasonography showing enlarged mesenteric lymph nodes (Note the hypoechoic centers due to caseation.

7.

Computed Tomography (CT): Abdominal CT scan is better than ultrasound detecting high density ascites, lymphadenopathy with caseation ,bowel wall thickening and irregularsoft tissue densities in the omental area. Abdominal lymphadenopathy is the commonest manifestation of tuberculosis on CT. Loculated fluid collections in the presence of omental infiltration, peritoneal enhancement, transperitoneal reaction, i.e. septal, and mesenteric (macronodules >5 mm in diameter) or bowel involvement are important features of abdominal tuberculosis on CT. The other CT findings reported to be highly suggestive of abdominal tuberculosis are irregular soft tissue densities in omental area, low density masses and a disorganized appearance of soft tissue densities, fluid and bowel forming an ill-defined mass.

Fig. : Tubercular peritonitis. Contrast enhanced CT (CECT) abdomen showing peritoneal reaction with ascites and mesenteric streaking. 8. Endoscopy: Terminal ileoscopy is the easiest and direct method of establishing the diagnosis of ileocolic tuberculosis. The findings on endoscopy of ileum include submucosal granulomas in all cases from which biopsy may be taken for confirmation of the diagnosis. 9. Laparoscopy: Laparoscopy examination is an effective method of diagnosing tubercular peritonitis because (i) it directly visualizes the inflamed thickened peritoneum studded with whitish-yellow miliary tubercles and (ii) biopsy of the peritoneum confirms the diagnosis. Laparoscopy facilitates an accurate diagnosis in 80-90% of patients. Laparoscopic biopsy specimens may reveal AFB in 75% patients and caseating granulomas in 85-90% patients. The finding of adhesions or fibrotic strands within turbid ascites is virtually diagnostic of tuberculosis. The liver, spleen and omentum can also be examined on laparoscopy, are also studded with tubercles in hepatosplenic tuberculosis. Laparoscopy through open exposure of the peritoneum may be employed in patients with fibroadhesive peritoneal tuberculosis so as to avoid chances of perforation.

Flow chart 1: Algorithmic approach to diagnosis of abdominal tuberculosis

For Peritonitis:
The leukocyte count is elevated. The hemoglobin and hematocrit levels may be low if blood loss has occurred. Serum electrolyte studies may reveal altered levels of potassium, sodium, and chloride. An abdominal x-ray is obtained, and findings may show air and fluid levels as well as distended bowel loops. A CT scan of the abdomen may show abscess formation. Peritoneal aspiration and culture and sensitivity studies of the aspirated fluid may reveal infection and identify the causative organisms.

Diagnosis and assessment done in my patient:

1. History taking revealed that his mother was a PTB patient who had refused treatment and passed away. Information received also suggested that the patient did not have healthy life style as he did not give much care for his nutritional requirements.

2. Physical examination: done before surgery also had findings of distended abdomen, and other signs and symptoms related to peritonitis which has been discussed above. 3. Blood examination: 4. Chest x-ray 5. Ultrasound 6. Laparosopy and histopathological examination of specimen collected.

LABORATORY EXAMS

TEST
Hb (hemoglobin) WBC(white bloodcount)

Date

RESULT

2070/02/25 13.4% 8.3% 2070/02/25 26,800 mm3 2070/02/27 21,300 mm3

NORMAL VALUES 13-18% (4,000 11,000)/ mm3

SIGNIFICANCE RATIONALES
Iron containing Oxygen transport in the blood WBC fights infection. Increase in WBC signifies bacterial infection Within normal range Indicates presence of infection

Platelets

Important factor for 2070/02/25 6,41,000mm3 (150,0003 3 blood to clot 2070/02/27 1,88,000mm 450,000)/mm

Neutrophils

2070/02/25 2070/02/27 Lymphocytes 2070/02/25 2070/02/27 Monocytes 2070/02/25 Eosinophils Sugar Sugar pp

63% 79% 32% 20% 04%

40%-75% 20%-45% 2%-10% 1%-6% 70-140mg/dl

Lymphocytes B and T are the natural cell killers Indicates infection

2070/02/25 01% 2070/02/25 2070/02/26 2070/02/27 2070/02/30 2070/03/01 2070/02/25 2070/02/26 2070/02/27 2070/02/30 2070/03/01 90mg/dl 98mg/dl 53mg/dl 63mg/dl 69mg/dl 30mg/dl 27mg/dl 26mg/dl 22mg/dl 19mg/dl

Urea

10-50mg/dl

Creatinine

2070/02/25 0.8mg/dl 2070/02/26 0.7mg/dl

0.6-1mg/dl

Sodium

2070/02/27 2070/02/30 2070/03/01 2070/02/25 2070/02/26 2070/02/27 2070/02/30 2070/03/01 2070/03/02 2070/03/04 2070/03/06

0.8mg/dl 0.6mg.dl 0.8mg/dl 125meq/l 135meq/l 137meq/l 138meq/l 129meq/l 125meq/l 132meq/l 135meq/l

135145mEq/l

Potassium

Amylase Billirubin total Billirubin conjugated SGOT

2070/02/25 2070/02/26 2070/02/27 2070/02/30 2070/03/01 2070/03/02 2070/03/04 2070/03/06 2070/02/25 2070/02/25 2070/02/26 2070/02/27 2070/02/25 2070/02/26 2070/02/27 2070/02/25 2070/02/26 2070/02/27 2070/02/25 2070/02/26 2070/02/25 2070/02/26 2070/02/27 2070/02/27

5.2meq/l 3.8meq/l 3.3meq/l 2.6meq/l 1.7meq/l 2.3meq/l 3.0meq/l 4meq/l 18 0.9 0.7 1.6 0.3 0.2 0.7 20 34 104 49 19 23 356 104 198 3.6 1.5

3.5-5.2mEq/l

<100 0.4-1.0mg/dl 0.10.4 mg/dl 5-42 IU/l

Usually elevated when pancreatitis is cause.

SGPT

5.0-35 IU/l

Alkaline phosphate Total Protein Total Albumin

97- 279 IU/l

4.5- 8.0 gm/dl May be decreased 2.5- 5.5 gm/dl because of fluid

shifts, lack of food intake, and nothing by mouth (NPO) status.

Calcium PT

2070/02/27 6.5 2070/02/25 14.9 sec

Control 12

sec INR HIV I and II HBsAg Anti HCV antibodies 2070/02/25 2070/02/25 2070/02/25 2070/02/25 1.30 Negative Negative Negative Negative Negative Negative

URINE ROUTINE EXAMINATION Colour Deep yellow Appearance- s. turbid Sugar- Negative Albumin- + Crystal- nil RBCs- plenty/phf Pus cells- 1-3/phf Epithelial cells -1 2/phf ULTRASOUND OF ABDOMEN /PELVIS- REPORT DATE: 2070/02/25 IMPRESSION: Bowel loops appear to be loaded with fecal matter. No intra bowel free fluid is noted No area of hyper peristalsis noted No lymphadenopathy noted Large bowel noted to be loaded with feaces with no areas of hyperperistalis. Intestinal onstruction (? subacute type)

SPUTUM EXAMINATION Date: 2070/02/21 A(B/M/S) B(B/M/S) C(B/M/S) AFB found AFB found AFB found 3+ 9 AFB 1+

TREATMENT
(MEDICAL MANAGEMENT)
The treatment of abdominal tuberculosis is on the same lines as for pulmonary tuberculosis. Conventional antitubercular therapy for at least 6 months including initial 2 months of HREZ (e.g. isoniazid, rifampicin, ethambutol and pyrazinamide) followed by 4 month HR is recommended in all patients with abdominal tuberculosis. However, previously, the antitubercular therapy was extended upto 8 to 12 months, but recently, a 6 month short course chemotherapy regimen has been found as effective as standard 12 months regimen. However, many physicians still extend the duration of treatment to 12 to 18 months. Corticosteroids have been employed to decrease fibrosis during healing so as to prevent development of obstruction but now-a-days, not preferred as they may delay healing and predispose to perforation or further obstruction. Studies have now shown that even obstructing intestinal lesions can be successfully treated with antitubercular drugs without the need for surgery and complete resolution radiological abnormalities may occur. The goals for treatment of TB are to cure the individual and to minimize transmission to other persons. It is essential that treatment be tailored and supervision be based on each clients clinical and social circumstances. DOT may be the most effective way to maximize the completion of therapy. Administer anti-infective agents, as indicated, for example: Primary drugs: isoniazid (INH, Liniazid), rifampin (RIF, Rifadin, Rimactane), pyrazinamide (PZA, Tebrazid), and ethambutol (Etbi, Myambutol): These four drugs should not be given in divided doses; all four drugs should be given together. Evidence shows this promotes the therapys effectiveness (CDC, 2005). INH is usually drug of choice for those exposed and who are at risk for developing TB. Extended therapy for up to 24 months is indicated for reactivation cases, extrapulmonary reactivated TB, or in the presence of other medical problems, such as diabetes mellitus or silicosis. Rufabutin (Mucobutin): Therapeutic agent for atypical mycobacterium. May be used in client with advanced HIV disease with TB Second-line drugs, such as ethionamide (Trecator-SC), paraaminosalicylate (PAS), cycloserine (Seromycin), amikacin (Amikin), and levofloxacin (Levoquin): These second-line drugs may be required when infection is resistant to or intolerant of primary drugs or may be used concurrently with primary antitubercular drugs. Note: MDR-TB requires minimum of 18 to 24 months therapy with at least three drugs in the regimen known to be effective against the specific infective organism and that client has not previously taken. Treatment is often extended to 24 months in clients with severe symptoms or HIV infection. Monitor laboratory studies, such as the following: Sputum smear results: Client who has three consecutive negative sputum smears over a 3- to 5-month period is adhering to drug regimen and who is asymptomatic will be classified as a nontransmitter. Liver function studies, such as aspartate aminotransferase (AST), alinine aminotransferase (ALT): The most common serious adverse effect of drug therapy particularly RIF, but possibly others as wellis drug-induced hepatitis.

SURGICAL MANAGEMENT
Surgical treatment is done to manage the complications such as obstruction, perforation (free or with access or fistula) and massive hemorrhage not responding to conservative therapy. Strictures are managed by strict uroplasty or resection of the involved segment of the bowel. The perforation is managed by resection and anastomosis rather than by simple closure so as to avoid fistula formation. Bypass surgery such as enteroenterostomy, ileotransverse colostomy is not recommended for obstructive lesions as they may cause formation of blind loops leading to obstruction, fistulation, malabsorption etc.

MANAGEMENT AFTER PERIOTISNIS:

MEDICAL MANAGEMENT
Fluid, colloid, and electrolyte replacement is the major focus of medical management. The administration of several liters of an isotonic solution is prescribed. Hypovolemia occurs because massive amounts of fluid and electrolytes move from the intestinal lumen into the peritoneal cavity and deplete the fluid in the vascular space. Analgesics are prescribed for pain. Antiemetics are administered as prescribed for nausea and vomiting. Intestinal intubation and suction assist in relieving abdominal distention and in promoting intestinal function. Fluid in the abdominal cavity can cause pressure that restricts expansion of the lungs and causes respiratory distress. Oxygen therapy by nasal cannula or mask can promote adequate oxygenation, but airway intubation and ventilator assistance occasionally are required. Massive antibiotic therapy is usually initiated early in the treatment of peritonitis. Large doses of a broad-spectrum antibiotic are administered intravenously until the specific organism causing the infection is identified and the appropriate antibiotic therapy can be initiated. SURGICAL MANAGEMENT Surgical objectives include removing the infected material and correcting the cause. Surgical treatment is directed toward excision (ie, appendix), resection with or without anastomosis (ie, intestine), repair (ie, perforation), and drainage (ie, abscess). With extensive sepsis, a fecal diversion may need to be created. MANAGEMENT FOR MY PATIENT (Both intestinal tuberculosis and perforation peritonitis) As my patient came with perforation peritonitis, emergency operation was the first treatment protocol. Then, medical management and Nursing management were carried out accordingly.

OPERATIVE PROCEDURE NOTE

Date: 2070/02/25 Exploratory Laparotomy with anstomosis with proximal ileostomy done for multiple perforation viscera. OT RECORD: Provisional diagnosis: Peritonitis due to hollow viscous perforation Post-op diagnosis: Multiple lleal perforation PROCEDURE: Exploratory laparotomy with resection of perforated ileal part, anastomosis of ileum , repair of perforation with proximal loop, ileostomy and tension wire suturing. Anaesthesia: general anesthesia Surgeon: Dr Ghanashyam Anesthesia: Dr. Hem Assistant surgeon: Dr. Ranjan, Dr. Udita FINDINGS: Multiple perforation at ileum 2 perforation at 60 cm proximal to Ielocecal Junction(IC Junction) 1 perforation at 75cms proximal to IC junction 1 perforation at 120 cm proximal to IC junction Tubercles at bowel, proximal bowel edematous and dilated enlarged , mesenteric lymph nodes, some are caseating. About 150 ml of dirty contaminated fluid in peritoneal cavity.

REAPAIR: Resection of terminal ileum, 60 cms proximal to IC junction including 2 perforation sites done and anstomosis done in 2 layers. Primary repair of perforation at 75 cm proximal t o IC junction done, loop ileostomy made out of perforation at 120 cms proximal to IC junction. Peritoneal wash done , haemostasis maintained Tension wire suturing done Abdomen closed in wires.

Resected ielal part with perforation site sent for Histopathological examination. Mesenteric Lymph Node sent for Histopathological examination.

HISTOPATHOLOGICAL EXAMINATION REPORT:

Specimen: Resected ielal part with perforation Gross: 490- two tubular structure . one measures 3.3x4.5 cm with perforation measuring 3.0x0.2 cm and another tunbular tissue measures 2.7x 1.0cm , P/E-5B Microscopy : 490- sections from the submitted tissue show ulceration of mucosa and infiltration by chronic inflammatory cells in stoma. There is caseous necrosis along with well formed granuloma consisting of lymphocytes, plasma cells, epithelloid cells and multineucleated giant cells. Fibrosis, vascular congestion are also noted in section examined. 491- sections from lymph node show caseous necrosis and multiple well formed granulomas consisting of epithelloid cells, langhans type cells. Impression: 490- consistent with variable villous abnormality showing specific diagnostic changes; Tubercular ileits 491- Tubercular lymphadenitis

FECAL DIVERSION PROCEDURE

Ileostomy (perfomed in my case during surgery) Ileostomy Performed when the entire colon, rectum, and anus must be removed, in which case the ileostomy is permanent; or, a temporary ileostomy can be done to provide complete bowel rest in conditions, such as with chronic colitis and in some trauma cases.

Most frequently performed for complications of inflammatory bowel diseaseCrohns disease and ulcerative colitisincluding intestinal perforation or intestinal stricture causing obstruction, abscess, or massive hemorrhage (Clark, 2005; Boehmke, 2006) May also be done because of intestinal trauma, polyps, cancer, or complications from cancer (Clark, 2005).

Etiology: dependent on underlying pathology requiring procedure

NURSING MANAGEMENT:
Nursing management was carried out following the Nursing theory and Nursing Process along with it.

APPLICATION OF NURSING THEORY

Nursing Theory is a conceptualization of some aspects of nursing communicated for the purpose of describing, explaining, predicting or prescribing nursing care .In other words, a Nursing Theroy is a set of concepts , definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project purposive systematic view of phenomena by designing specific inter-realtionships among concepts for the purposes of describing, explaining, predicting, and/or prescribing. There are numbers of Nursing theories and one of those theory is the Problem Solving Theory by Faye Glenn Abdellah, which I have applied for my case study patient during my nursing care. According to Abdellah, Nursing is based on an art and science that molds the attitudes, intellectual competencies and technical skills of individual nurse into the desire and ability to help people, sick or well, cope with their health needs. Applying her theory I have tried to provide my patient with complete patient centered care and at the same time enhance my knowledge on problem solving methods. Nursinng may be carried out under general or specific medical direction. As per Abdellah, nursing as a comprehensive service includes: 1. Recognizing the nursing problems of t he patient 2. Deciding the appropriate course of action to take in terms of rel evant nursing principles 3. Providing continuous care of the individuals total needs 4. Providing continuous care to relieve pain and discom fort and provide immediate security for the individual 5. Adjusting the total nursing care plan to meet the patients individual needs 6. Helping the individual to become more self directing in attaining or maintaining a healthy state of mind & body 7. Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations 8. Helping the individual to adjust to his limitations and emotional problems

9. Working with allied health professions in planning for optimum health on local, state, national and international levels 10. Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet the health needs of people. PHILOSOPHICAL UNDERPINNINGS OF THE THEORY Abdellahs patient-centred approach to nursing was developed inductively from her practice and is considered a human needs theory. The theory was created to assist with nursing education and is most applicable to the education of nurses. Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings. Abdellah and colleagues developed a list of 21 nursing problems. They also identified 10steps to identify the clients problems. 11 nursing skills to be used in developing a treatment typology10 steps to identify the clients problems. 1. Learn to know the patient 2. Sort out relevant and significant data 3. Make generalizations about available data in relation to similar nursing problems presented by other patients 4. Identify the therapeutic plan 5. Test generalizations with the patient and make additional generalizations 6. Validate the patients conclusions about his nursing problems 7. Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior 8. Explore the patients and familys reaction to the therapeutic plan and involve them in the plan 9. Identify how the nurses feels about the patients nursing problems 10. Discuss and develop a comprehensive nursing care plan 11 nursing skills 1. Observation of health status 2. Skills of communication 3. Application of knowledge 4. Teaching of patients and families 5. Planning and organization of work 6. Use of resource materials 7. Use of personnel resources 8. Problem-solving 9. Direction of work of others 10. Therapeutic use of the self 11. Nursing procedure Abdellahs 21 nursing problem 1. To maintain good hygiene and physical comfort.

2. To promote optimal activity: exercise, rest, and sleep 3. To promote safety through prevention of accident, injury, or other trauma and through the prevention of the spread of infection. 4. To maintain good body mechanics and prevent and correct deformity. 5. To facilitate the maintenance of a supply of oxygen to all body cells. 6. To facilitate the maintenance of nutrition of all body cells. 7. To facilitate the maintenance of elimination. 8. To facilitate the maintenance of fluid and electrolyte balance. 9. To recognize the physiological responses of the body to disease conditions pathological, physiological, and compensatory. 10. To facilitate the maintenance of regulatory mechanisms and functions. 11. To facilitate the maintenance of sensory function. 12. To identify and accept positive and negative expressions, feelings, and reactions. 13. To identify and accept interrelatedness of emotions and organic illness. 14. To facilitate the maintenance of effective verbal and nonverbal communication. 15. To promote the development of productive interpersonal relationships. 16. To facilitate progress toward achievement of personal spiritual goals . 17. To create and/or maintain a therapeutic environment. 18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs. 19. To accept the optimum possible goals in the light of limitations, physical, and emotional. 20. To use community resources as an aid in resolving problems arising from illness. 21. To understand the role of social problems as influencing factors in the cause of illness

NURSING PROCESS: 1. ASSESSMENT:

Subjective data ` ACTIVITY/REST Generalized weakness and fatigue. Shortness of breath with exertion. Difficulty sleeping. EGO INTEGRITY Feelings of helplessness and hopelessness. FOOD/FLUID Loss of appetite Nausea, vomiting Indigestion Weight loss PAIN/DISCOMFORT Abdominal pain on movement, on incision area. Facial expression of pain. SOCIAL INTERACTION Feelings of isolation and rejection because of communicable disease. TEACHING/LEARNING Assistance need with dietary concerns Information need on management of ostomy. Teaching need on disease(Tubeculosis) ELIMINATION Occasional diarrhea Objective data Anxiety, apprehension, Irritability Presence of dark circles under the eye.

Poor skin turgor. Muscle wasting and loss of subcutaneous fat.

poor perforamance of ostomy care

Fecal Diversion, presence of ileostomy.

Nursing Problems: Actual problems

Verbalization of change in body image Not touching or looking at stoma, refusal to participate in care Reports of pain and restlessness. Disruption of skin and tissuepresence of incision and sutures, drains Verbalizations of interrupted sleep, not feeling well-rested Changes in behaviorirritability and lethargy statement of misconception, misinformation Inaccurate performance of ostomy care Unfamiliarity with information resources Expressing or exhibiting feelings of being overwhelmed

Potential problems.
Tissue destruction, extension of infection due to Tuberculosis. Environmental exposure related to active stage of TB. Insufficient knowledge to avoid exposure to pathogens. Improper fitting or care of appliance/skin. Excessive losses through normal routesemesis or diarrhea. Prolonged anorexia, altered intake Restriction of bulk and residue-containing foods

PLANNING Nursing Priorities:

1. Relieve from pain 2. Prevent complications, septicemia. 3. Prevent spread of infection. 4. Maintain skin integrity. 5. Support behaviors and tasks to maintain health. 6. Achieve and maintain adequate ventilation and oxygenation. 7. Attainment of adequate fluid balance. 8. Achievement of optimal nutritional status. 9. Promote rest and relaxation. 10. Promote effective coping strategies. 11. Assist client and family in psychosocial adjustment. 12. Support independence in self-care. 13. Provide information about procedure, prognosis, treatment needs, potential complications, and community resources

Nursing Care Plan

DRUG STUDY
Drug used in my patient:
2070/02/25 to 2070/03/06 Inj Gentamycin Inj Pantaprazole Inj Tramadol Inj Ondem Inj Pethidine Inj Phenargan 2070/02/26 to 2070/03/06 Inj Metron Inj Cipro 2070/03/01 to 2070/03/06 Inj. Normal saline IV pint Inj. Dextrose 5% I pint Inj. KCl 60meq/24hr increased to 120meq/24hr since 2070/03/02 2070/02/24 and continued till date ATT (Anti Tubercular Treatment) Isoniazid Rifampin Pyranzinamide Ethambutol 500mg 200mg I/V I/V TDS BD 160mg 40 mg 50mg 4mg 50mg 25mg I/V I/V I/V I/V I/M I/M OD OD TDS SOS SOS SOS

GENTAMYCIN Parenteral, intrathecal: Alcomicin (CAN), Pediatric: Gentamicin Sulfate Topical dermatologic cream, ointment: Garamycin Ophthalmic: Garamycin, Gentak, Genoptic Drug class: Aminoglycoside Therapeutic actions: Bactericidal: Inhibits protein synthesis in susceptible strains of gramnegative bacteria; appears to disrupt functional integrity of bacterial cell membrane, causing cell death. Indications: Parenteral: Serious infections caused by susceptible strains of Pseudomonas aeruginosa, roteus species, Escherichia coli, Klebsiella- Enterobacter-Serratia species, Citrobacter, Staphylococcus species. Serious infections when causative organisms are not known (often in conjunction with a penicillin or cephalosporin) Unlabeled use: With clindamycin as alternative regimen in PID Contraindications and cautions Contraindicated with allergy to any amino glycosides.Use cautiously with renal or hepatic disease; sulfite sensitivity; preexisting hearing loss; active infection with herpes, vaccinia, varicella, fungal infections, mycobacterial infections (ophthalmic preparations); myasthenia gravis; parkinsonism; infant botulism; burn patients; lactation, pregnancy. Dosages: Dosage should be based on estimated lean body mass. Parenteral: Adults: 3 mg/kg/day in three equal doses every 8 hr IM or IV. Up to 5 mg/kg/day in three to four equal doses in severe infections, usually for 710 days. For IV use, a loading dose of 12 mg/kg may be infused over 3060 min. PID: 2 mg/kg IV followed by 1.5 mg/kg tid plus clindamycin 600 mg IV qid. Continue for at least 4 days and at least 48 hr after patient improves, then continue clindamycin 450 mg orally qid for 1014 days total therapy. Surgical prophylaxis regimens: Several complex, multidrug prophylaxis regimens are available for preoperative use; consult manufacturers instructions. Adverse effects CNS: Ototoxicitytinnitus, dizziness, vertigo, deafness (partially reversible to irreversible), vestibular paralysis, confusion, disorientation, depression, lethargy, nystagmus, visual disturbances, headache, numbness, tingling, tremor, paresthesias, muscle twitching, seizures, muscular weakness, neuromuscular blockade CV: Palpitations, hypotension, hypertension

GI: Hepatic toxicity, nausea, vomiting, anorexia, weight loss, stomatitis, increased salivation GU: Nephrotoxicity Hematologic: Leukemoid reaction, agranulocytosis, granulocytosis, leukopenia, leukocytosis, thrombocytopenia, eosinophelia, pancytopenia, anemia, hemolytic anemia, increased or decreased reticulocyte count, electrolyte disturbances Hypersensitivity: Purpura, rash, urticaria, exfoliative dermatitis, itching Local: Pain, irritation, arachnoiditis at IM injection sites Other: Fever, apnea, splenomegaly, joint pain, superinfections

Nursing considerations Assessment History: Allergy to any aminoglycosides; renal or hepatic disease; preexisting hearing loss; active infection with herpes, vaccinia, varicella, fungal infections, mycobacterial infections (ophthalmic preparations); myasthenia gravis; parkinsonism; infant botulism; lactation, pregnancy Physical: Site of infection; skin color, lesions; orientation, reflexes, eighth cranial nerve function; P, BP; R, adventitious sounds; bowel sounds, liver evaluation; urinalysis, BUN, serum creatinine, serum electrolytes, LFTs, CBC. Interventions Monitor serum concentrations when feasible to avoid potentially toxic levels. Peak levels should not exceed 12 mcg/mL (68 mcg/mL is usually adequate for most infections). Trough levels should not exceed 2 mcg/mL. Give by IM route if at all possible; give by deep IM injection. Culture infected area before therapy. Use 2 mg/mL intrathecal preparation without preservatives, for intrathecal use. Avoid long-term therapies because of increased risk of toxicities. Reduction in dose may be clinically indicated. Patients with edema or ascites may have lower peak concentrations due to expanded extracellular fluid volume. Cleanse area before application of dermatologic preparations. Ensure adequate hydration of patient before and during therapy. Monitor hearing with long-term therapy; ototoxicity can occur. Monitor renal function tests, CBC, and serum drug levels during long-term therapy. Consult with prescriber to adjust dosage as needed.

PANTOP Generic Name: pantoprazole Functional Class: Antiulcer, Proton-pump inhibitor/Antisecretory compound Chemical Class: Benzimidazole Mechanism of action: Suppresses gastric secretion by inhibiting hydrogen/potassium ATpase enzyme system in gastric parietal cell, characterized by gastric acid pump inhibitor, since it blocks final step of acid production Uses: Gastroesophgeal reflux disease, severe erosive esophagitis, pathologic hypersecretory conditions, heartburn, and treatment of active duodenal ulcer with or without anti-infective for H. Pylori. Indications: Oral: Short-term (8 wk or less) and longterm treatment of GERD Maintenance healing of erosive esophagitis Long-term treatment of pathological hypersecretory conditions IV: Short-term (710 days) treatment of GERD in patients unable to continue oral therapy Dosages Adults: 40 mg PO daily for maintenance healing of erosive esophagitis for 8 wk or less. The 8wk course may be repeated if healing has not occurred; give continually for hypersecretory disorders; 40 mg/day IV for 710 days. Up to 240 mg/day PO or IV has been used for severe hypersecretory syndromes. Side Effects: headache, dizziness, chest pain, angina, tachycardia, palpitation, tinnitus, diarrhea, abdominal pain, vomiting, nausea, constipation, rash, back pain, cough Contraindications: Hypersensitivity Precautions: Pregnancy, breast feeding, children Adverse effects CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalities Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophy Respiratory: URI symptoms, cough, epistaxis, pneumonia Other: Cancer in preclinical studies, back pain, fever, vitamin B12 deficiency, loss of bone density, bone fractures. Nursing considerations: Assess: GI system: bowel sounds q8h, abdominal for pain, swelling, anorexia Hepatic studies: AST,ALT, alk phos during treatment Administer: Do not break, crush, or chew del rel tab After breakfast daily

Evaluate: Therapeutic response: absence of epigastric pain, swelling, fullness Teach patient/ family: To report severe diarrhea, product may have to be discontinued. That diabetic patient should know hypoglycemia may occur. To avoid hazardous activities, dizziness may occur. To avoid alcohol, salicylates, NSAIDs; may cause GI irritation. To wear sunscreen, protective clothing to prevent burns. TRAMADOL Drug name: Tramadol Functional class: central analgesic Action: not completely understood, binds to opioid receptors, inhibits reuptake of norepinephrine, serotonin; does not cause histamine release or affect heart rate. Uses: Relief of moderate to moderately severe pain Relief of moderate to severe chronic pain in adults who need around-the-clock treatment for extended periods (ER tablets) Unlabeled uses: Premature ejaculation; restless leg syndrome Contraindications and cautions Contraindicated with allergy to tramadol or opioids or acute intoxication with alcohol, opioids, or psychoactive drugs. Use cautiously with pregnancy, lactation; seizures; concomitant use of CNS depressants, MAOIs, SSRIs, TCAs; renal impairment; hepatic impairment. Dosage and routes: Patients who require rapid analgesic effect: 50100 mg PO every 46 hr; do not exceed400 mg/day. Patients with moderate to moderately severe chronic pain: Initiate at 25 mg/day in the morning, and titrate in 25-mg increments every 3 days to reach 100 mg/day. Then, increase in 50-mg increments every 3 days to reach 200 mg/day. After titration, 50100 mg every 46 hr; do not exceed 400 mg/day. Alternatively, 100-mg ER tablet once daily, titrated by 100-mg increments every 5 days; do not exceed 300 mg/day. For orally disintegrating tablets, do not exceed 200 mg/ day. Available forms: tabs50 mg, Inj. 50mg/ml Side effects/ adverse reactions: CNS: dizziness, CNS stimulation, somnolence, headache, anxiety, confusion, euphoria, seizure, hallucinations.

GI: nausea, constipation, vomiting, dry mouth, diarrhea, abdominal pain, anorexia, flatulence, GI bleeding. CV: vasodilation, orthostatic hypotension, tachycardia, hypertension, abnormal ECG. INTEG: pruritus, rash, urticaria, vesicles. GU: urinary retention/frequency, menopausal symptoms, dysuria, menstrual disorder. Interactions: decreased level of tramadol: carbamazepine. inhibition of norepinephrine and serotonin reuptake: MAO inhibitors, use together with caution. Lab test interference: increases creatinine, liver enzymes, decrease Hgb. Contraindications: Hypersensitivity, acute intoxication with any CNS depressents. Precautions: Seizure disorder, pregnancy(C), lactation, children, elderly, renal or hepatic disease, respiratory depression, head trauma, increased intracranial pressure, acute abdominal condition, drug abuse. Pharmacokinetics: rapidly and almost completely absorbed, steady state 2 days, may cross blood-brain barrier, extensively metabolized, 30% excreted in the urine as unchanged drug. NURSING CONSIDERATION: Assess: Pain: location, type, character, give before pain becomes extreme. I/O ratio: check for decreasing output; may indicate urinary retention. Need for drug. For constipation: increase fluids, bulk in diet. CNS changes: dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction. Allergic reactions: rash, urticaria. Administer: with antiemetic for nausea, vomiting. When pain is beginning to return; determine dosage interval by patient response. Perform/provide: Storage in cool environment, protected from sunlight. Assistance with ambulation. Safety measures: side rails, night light, call bell within easy reach. Evaluate: Therapeutic response, decrease in pain. Teach patient/ family: To report any symptoms of CNS changes, allergic reactions that drowsiness, dizziness and confusion may occur, to call for assistance. To make position changes slowly, orthostatic hypotension may occur. To avoid OTC medications and alcohol unless approved by prescriber.

ONDANSETRON HYDROCHLORIDE Zofran, Zofran ODT, Zuplenz Drug class: Antiemetic Therapeutic actions Blocks specific receptor sites (5-HT3), which are associated with nausea and vomiting in the chemoreceptor trigger zone, centrally and at specific sites peripherally. It is not known whether its antiemetic actions are from actions at the central, peripheral, or combined sites.

Indications Parenteral and oral: Prevention of nausea and vomiting associated with emetogenic cancer chemotherapy in patients older than6 month. Prevention of postoperative nausea and vomiting to prevent further episodes or, when postoperative nausea and vomiting must be avoided (oral), prophylactically (parenteral) in patients older than 1 mo Prevention of nausea and vomiting associated with radiotherapy Unlabeled uses: Treatment of nausea and vomiting associated with acetaminophen poisoning, prostacyclin therapy Contraindications and cautions Contraindicated with allergy to ondansetron. Use cautiously with pregnancy, lactation, hepatic impairment. Dosages Adults Parenteral :Prevention of chemotherapy-inducednausea and vomiting: Three 0.15 mg/kg doses IV: First dose is given over 15 min,beginning 30 min before chemotherapy; subsequent doses are given at 4 and 8 hr, or a single 32-mg dose is infused over 15 min beginning 30 min before the start of the chemotherapy. Adverse effects CNS: Headache, dizziness, drowsiness, shivers, malaise, fatigue, weakness, myalgia CV: Chest pain, hypotension Dermatologic: Pruritus GI: Abdominal pain, constipation, liver impairment, diarrhea GU: Urinary retention Local: Pain at injection site Interactions Drug-food Increased extent of absorption if taken orally with food Nursing considerations Assessment History: Allergy to ondansetron, pregnancy, lactation, nausea and vomiting Physical: Skin color and texture; orientation, reflexes, bilateral grip strength, affect; P, BP; abdominal examination; urinary output; ECG Interventions Ensure that the timing of drug doses corresponds to that of the chemotherapy or radiation. Administer oral drug for 12 days following completion of chemotherapy or radiation. For Zofran ODT, peel foil backing of one blister and remove tablet gently. Do not push tablet through the foil backing. Immediately place tablet on tongue , where it will dissolve in seconds, and have patient swallow it with saliva.

MEPERIDINE HYDROCHLORIDE (PETHIDINE) Demerol Drug class: Opioid agonist analgesic Therapeutic actions: Acts as agonist at specific opioid receptors inthe CNS to produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same as those mediating the effects of endogenous opioids (enkephalins, endorphins). Indications Oral, parenteral: Relief of moderate to severe acute pain Parenteral: Preoperative medication, support of anesthesia, and obstetric analgesic. Contraindications and cautions Contraindicated with hypersensitivity to opioids, diarrhea caused by poisoning (before toxins are eliminated), bronchial asthma, COPD, cor pulmonale, respiratory depression, anoxia, kyphoscoliosis, acute alcoholism, increased intracranial pressure, pregnancy, seizure disorder, renal impairment. Contraindicated in premature infants. Use cautiously with acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, Addisons disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis, labor or delivery (opioids given to the mother can cause respiratory depression of neonate; premature infants are especially at risk), renal or hepatic impairment, lactation. Dosages Adults Relief of pain: Individualize dosage; 50 150 mg IM, subcutaneously, or PO every 3 4 hr as needed. Diluted solution may be given by slow IV injection. IM route is preferred for repeated injections. Preoperative medication: 50100 mg IM or subcutaneously, 3090 min before beginning anesthesia. Support of anesthesia: Dilute to 10 mg/ml and give repeated doses by slow IV injection, or dilute to 1 mg/mL and infuse continuously. Individualize dosage. Obstetric analgesia: When contractions become regular, 50100 mg IM or subcutaneously; repeat every 13 hr. Adverse effects CNS: Light-headedness, dizziness, sedation,euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, drowsiness, lethargy, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, seizures, miosis, visual disturbances, suppression of cough reflex CV: Facial flushing, peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, chest wall rigidity, hypertension, hypotension, orthostatic hypotension, syncope Dermatologic: Pruritus, urticaria, laryngospasm, bronchospasm, edema

GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm, increased colonic motility in patients with chronic ulcerative colitis GU: Ureteral spasm, spasm of vesical sphincters, urine retention or hesitancy, oliguria, antidiuretic effect, reduced libido or potency Local: Tissue irritation and induration (subcutaneous injection) Major hazards: Respiratory depression, apnea, circulatory depression respiratory arrest, shock, cardiac arrest Other: Sweating, physical tolerance and dependence, psychological dependence. Nursing Interventions Administer to lactating women 46 hr before the next feeding to minimize the amount in milk. Reduce dosage of meperidine by 25%50% in patients receiving phenothiazines or other tranquilizers. Give each dose of the oral syrup in half glass of water. If taken undiluted, it may exert a slight local anesthetic effect on mucous membranes. Reassure patient that addiction is unlikely; most patients who receive opiates for medical reasons do not develop dependence syndromes.

PROMETHAZINE HYDROCHLORIDE
Phenadoz, Phenergan, Promethegan Drug classes Antiemetic, Antihistamine, Antimotion-sickness drug, Dopaminergic blocker, Phenothiazine, Sedative-hypnotic. Therapeutic actions Selectively blocks histamine-1 receptors, diminishing the effects of histamine on cells of the upper respiratory tract and eyes and decreasing the sneezing, mucus production, itching, and tearing that accompany allergic reactions in sensitized people exposed to antigens; blocks cholinergic receptors in the vomiting center that are believed to mediate the nausea and vomiting caused by gastric irritation, by input from the vestibular apparatus (motion sickness, nausea associated with vestibular neuritis), and by input from the chemoreceptor trigger zone (drug- and radiation-induced emesis); depresses the RAS, including the parts of the brain involved with wakefulness. Indications Symptomatic relief of perennial and seasonal allergic rhinitis, vasomotor rhinitis, allergic conjunctivitis; mild, uncomplicated urticaria and angioedema; amelioration of allergic reactions to blood or plasma; dermatographism, adjunctive therapy (with epinephrine and other measures) in anaphylactic reactions Treatment and prevention of motion sickness; prevention and control of nausea and vomiting associated with anesthesia and surgery

Preoperative, postoperative, or obstetric sedation Adjunct to analgesics to control postoperative pain

Contraindications : Contraindicated with hypersensitivity to antihistamines or phenothiazines, coma or severe CNS depression, bone marrow depression, vomiting of unknown cause, concomitant therapy with MAOIs, lactation (lactation may be inhibited) Dosages Adults Allergy: Average dose is 25 mg PO or by rectal suppository, preferably at bedtime. If needed, 12.5 mg PO before meals and at bedtime; 25 mg IM or IV for serious reactions. May repeat within 2 hr if needed. Motion sickness: 25 mg PO bid. Initial dose should be scheduled 3060 min before travel; repeat in 812 hr if needed. Thereafter, give 25 mg on arising and before evening meal. Nausea and vomiting: 25 mg PO; repeat doses of 12.525 mg as needed, every 4 6 hr. Give rectally or parenterally if oral dosage is not tolerated. 12.525 mg IM or IV, not to be repeated more frequently than every 46 hr. Sedation: 2550 mg PO, IM, or IV. Preoperative use: 50 mg PO the night before, or 50 mg with an appropriately reduced dose of meperidine and the required amount of belladonna alkaloid. Postoperative sedation and adjunctive use with analgesics: 2550 mg PO, IM, or IV Adverse effects: Same as Pethidine Nursing Interventions Do not give to children younger than 2 yr because of risk of fatal respiratory depression; use lowest effective dose and caution in children 2 yr and older. Give IM injections deep into muscle. Do not administer subcutaneously; tissue necrosis may occur. Do not administer intra-arterially; arteriospasm and gangrene of the limb may result. Do not administer subcutaneously into an artery or under the skin; drug may leach into tissue and cause serious injury. If IV route is used, limit drug concentration and rate of administration and ensure open IV line.

METRONIDAZOLE (me troe nida zole) Apo-Metronidazole (CAN), Flagyl, Flagyl 375, Flagyl ER, MetroGel, MetroGel-Vaginal, NidaGel (CAN), Noritate, Protostat, Vandazole Drug classes Amebicide, Antibacterial , Antibiotic, Antiprotozoal

Therapeutic actions Bactericidal: Inhibits DNA synthesis in specif-ic (obligate) anaerobes, causing cell death; antiprotozoal-trichomonacidal, amebicidal Biochemical mechanism of action is not known. Indications Acute infection with susceptible anaerobic bacteria Acute intestinal amebiasis Amebic liver abscess Trichomoniasis (acute and partners of pa-tients with acute infection) Bacterial vaginosis Preoperative, intraoperative, postoperative prophylaxis for patients undergoing colo-rectal surgery Topical application: Treatment of inflam-matory papules, pustules, and erythema of rosacea Unlabeled uses: Prophylaxis for patients undergoing gynecologic, abdominal sur-gery; hepatic encephalopathy; Crohns dis-ease; antibiotic-associated pseudomem-branous colitis; treatment of Gardnerella vaginalis, giardiasis (use recommended by the CDC); infected decubitus ulcers; perioral dermatitis Contraindications and cautions Contraindicated with hypersensitivity to metronidazole; pregnancy (do not use for trichomoniasis in first trimester). Use cautiously with CNS diseases, hepatic disease, candidiasis (moniliasis), blood dyscrasias, lactation Dosages Adults: IV Anaerobic bacterial infection: 15 mg/kg IV infused over 1 hr; then 7.5 mg/kg infused over 1 hr every 6 hr for 710 days, not to exceed 4 g/day. Prophylaxis: 15 mg/kg infused IV over 3060 min and completed about 1 hr be-fore surgery. Then 7.5 mg/kg infused over 3060 min at 6- to 12-hr intervals after initial dose during the day of surgery only. Adverse effects CNS: Headache, dizziness, ataxia,vertigo, incoordination, insomnia, seizures, peripheral neuropathy, fatigue GI: Unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, cramps GU: Dysuria, incontinence, darkening of the urine Local: Thrombophlebitis (IV); redness, burning, dryness, and skin irritation (topical) Other: Severe, disulfiram-like interaction with alcohol, candidiasis (superinfection) Interactions Decreased effectiveness with barbiturates Disulfiram-like reaction (flush-ing, tachycardia, nausea, vomiting) with alcohol Psychosis if taken with disulfiram

Increased bleeding tendencies with oral anticoagulants Nursing considerations Assessment History: CNS or hepatic disease, candidiasis (moniliasis), blood dyscrasias, preg-nancy, lactation Physical: Reflexes, affect; skin lesions, color (with topical application); abdominal examination, liver palpation; urinalysis, CBC, LFTs Interventions Administer oral doses with food. Apply topically (MetroGel) after cleansing the area. Advise patient that cosmetics may be used over the area after application. Reduce dosage in hepatic disease

CIPROFLOXACIN Drug classes: Antibacterial, Fluoroquinolone Therapeutic actions Bactericidal; interferes with DNA replication in susceptible bacteria preventing cell reproduction. Indications For the treatment of infections caused by susceptible gram-negative bacteria, including Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, Enterobacter cloa-cae, Proteus vulgaris, Proteus rettgeri, Morganella morganii, Pseudomonas aeruginosa, Citrobacter freundii, Staphy-lococcus aureus, Staphylococcus epider-midis, group D streptococci, Serratia marcescens Treatment of uncomplicated UTIs caused by E. coli, K. pneumoniaeas a one-time dose in patients at low risk of nausea, diarrhea (Proquin XR) Otic: Treatment of acute otitis externa Treatment of chronic bacterial prostatitis IV: Treatment of nosocomial pneumonia caused by Haemophilus influenzae, K. pneumoniae Oral: Typhoid fever Oral: STDs caused by Neisseria gonorrheae Prevention of anthrax following exposure to anthrax bacilla (prophylactic use in regions suspected of using germ warfare) Acute sinusitis: Caused by H. influenzae, Streptococcus pneumoniae,or Moraxella catarrhalis Lower respiratory tract infections: Caused by E. coli, Klebsiella, Enterobacter species, P. mirabilis, P. aeruginosa, H. influenzae, Haemophilus parainfluenzae, S. pneumoniae Unlabeled use: Cystic fibrosis in patients who have pulmonary exacerbations, gastroen-teritis in children, mycobacterial infection, travelers diarrhea

Contraindications and cautions Contraindicated with allergy to ciprofloxacin, norfloxacin or other fluoroquinolones, pregnancy, lactation. Use cautiously with renal impairment, seizures, tendinitis or tendon rupture asso-ciated with fluoroquinolone use. Dosages Adults Uncomplicated UTIs: 250 mg PO every 12 hr for 3 days or 500 mg PO daily (ER tablets) for 3 days. Proquin XR500 mg PO once a day for 3 days. Mild to moderate UTIs:250 mg every 12 hr PO for 714 days or 200 mg IV every 12 hr for 7 14 days. Complicated UTIs:500 mg every 12 hr PO for 714 days or 400 mg IV every 12 hr or 1,000 mg (ER tablets) PO daily every 714 days. Chronic bacterial prostatitis:500 mg PO every 12 hr for 28 days or 400 mg IV every 12 hr for 28 days. Infectious diarrhea:500 mg every 12 hr PO for 57 days.. Respiratory infections:500750 mg PO every 12 hr or 400 mg IV every 812 hr for 714 days. Adverse effects CNS: Headache,dizziness, insomnia, fatigue, somnolence, depression, blurred vision, hallucinations, ataxia, nightmares CV: Arrhythmias, hypotension, angina EENT: Dry eye, eye pain, keratopathy GI: Nausea,vomiting, dry mouth, diarrhea,abdominal pain GU: Renal failure Hematologic: Elevated BUN, AST, ALT, serum creatinine and alkaline phosphatase; decreased WBC count, neutrophil count, Hct Other: Fever, rash Nursing considerations Interventions Arrange for culture and sensitivity tests be-fore beginning therapy. Continue therapy for 2 days after signs and symptoms of infection are gone. Be aware that Proquin XRis not inter-changeable with other forms. Ensure that patient swallows ER tablets whole; do not cut, crush, or chew. Ensure that patient is well hydrated. Give antacids at least 2 hr after dosing. Monitor clinical response; if no improvement is seen or a relapse occurs, repeat culture and sensitivity. Encourage patient to complete full course of therapy.

ISONIAZID (isonicotinic acid hydrazide, INH) (eye soe nyea zid) Isotamine (CAN), Nydrazid Drug class: Antituberculotic Therapeutic actions: Bactericidal: Interferes with lipid and nucleic acid biosynthesis in actively growing tubercle bacilli. Indications TB, all forms in which organisms are susceptible Prophylaxis in specific patients who are tuberculin reactors or household members of recently diagnosed tuberculars or who are considered to be high risk (patients with HIV, IV drug users, recent converters [5 mm or more increase on skin test within 2 yr in patients younger than 35 yr or 15 mm or more increase in patients older than 35 yr] and children younger than 4 yr with 10 mm or more induration on purified protein derivative tuberculin skin test) Unlabeled use of 300400 mg/day, increased over 2 wk to 20 mg/kg/day, for improvement of severe tremor in patients with MS Contraindications and cautions Contraindicated with allergy to isoniazid, isoniazid-associated hepatic injury or other severe adverse reactions to isoniazid, acute hepatic disease. Use cautiously with renal impairment, lactation, pregnancy Dosages Adults Treatment of active TB:5 mg/kg/day (up to 300 mg) PO in a single dose, with other effective drugs or 15 mg/kg (up to 900 mg) PO two or three times per week. First-line treatment is considered to be 300 mg INH plus 600 mg rifampin, each given in a single daily oral dose. Consult manufacturers guidelines for other possible combinations. Prophylaxis for TB: 300 mg/day PO in a single dose. Concomitant administration of 1050 mg/ day of pyridoxine is recommended for those who are malnourished or predisposed to neuropathy (alcoholics, diabetics) Adverse effects CNS: Peripheral neuropathy,seizures, tox-ic encephalopathy, optic neuritis and atrophy, memory impairment, toxic psychosis GI: Nausea, vomiting, epigastric distress, bilirubinemia, bilirubinuria, elevated AST, ALT levels, jaundice, hepatitis Hematologic: Agranulocytosis, hemolytic or aplastic anemia, thrombocytopenia, eosinophilia, pyridoxine deficiency, pel-lagra, hyperglycemia, metabolic acidosis, hypocalcemia, hypophosphatemia due to altered vitamin D metabolism Hypersensitivity: Fever, skin eruptions, lymphadenopathy, vasculitis Local: Local irritation at IM injection site Other: Gynecomastia, rheumatic syndrome, SLE syndrome

Interactions Increased incidence of isoniazid-related hepatitis with alcohol and possibly if taken in high doses with rifampin Increased serum levels of phenytoin In-creased effectiveness and risk of toxicity of carbamazepine Risk of high output renal fail-ure in fast INH acetylators with enflurane Increased risk of hepatotoxicity with aceta-minophen, rifampin Drug-food Risk of sympathetic-type re-actions with tyramine-containing foods and exaggerated response (headache, palpitations, sweating, hypotension, flushing, diarrhea, itch-ing) to histamine containing food (fish [skip-jack, tuna] sauerkraut juice, yeast extracts) Nursing considerations Assessment History: Allergy to isoniazid, isoniazid-associated adverse reactions; acute hepatic disease; renal impairment; lactation, pregnancy Physical: Skin color, lesions; T; orientation, reflexes, peripheral sensitivity, bilateral grip strength; ophthalmologic examina-tion; R, adventitious sounds; liver evaluation; CBC, LFTs, renal function tests, blood glu-cose Interventions Give on an empty stomach, 1 hr before or 2 hr after meals; may be given with food if GI upset occurs. Give in a single daily dose. Reserve parenteral dose for patients unable to take oral medications. Decrease foods containing tyramine or histamine in patients diet. Consult with physician and arrange for daily pyridoxine in diabetic, alcoholic, or mal nourished patients; also for patients who develop peripheral neuritis, and those with HIV. URIFAMPIN (rifam pin) Rifadin, Rimactane, Rofact (CAN) Drug classes: Antibiotic, Antituberculotic (first-line) Therapeutic actions Inhibits DNA dependent RNA polymerase activity in susceptible bacterial cells. Indications Treatment of pulmonary TB in conjunction with at least one other effective antituber-culotic Neisseria meningitidiscarriers, for asymp-tomatic carriers to eliminate meningococ-ci from nasopharynx; not for treatment of meningitis Unlabeled uses: Infections caused by Staphy-lococcus aureus and Staphylococcus epi-dermis, usually in combination therapy gram-negative bacteremia in infancy; Le-gionella (Legionella pneumophila) not re-sponsive to erythromycin; leprosy (in com-bination with dapsone); prophylaxis of meningitis caused by Haemophilus in-fluenza Contraindications and cautions

 Contraindicated with allergy to any ri-famycin, acute hepatic disease, lactation. Use cautiously with pregnancy (teratogenic effects have been reported in preclinical stud-ies; safest antituberculous regimen for use in pregnancy is considered to be rifampin, isoniazid, and ethambutol). Dosages Adults Pulmonary TB: 10 mg/kg/day; not to ex-ceed 600 mg in a single daily dose PO or IV(used in conjunction with other antituber-culotics). Continue therapy until bacterial conversion and maximal improvement occur. Meningococcal carriers:600 mg PO or IV once daily for 4 consecutive days or 600 mg every 12 hr for 2 days. Adverse effects CNS: Headache, drowsiness, fatigue, dizzi-ness,inability to concentrate, mental con-fusion, generalized numbness, ataxia, mus-cle weakness, visual disturbances, exudative conjunctivitis Dermatologic: Rash,pruritus, urticaria, pemphigoid reaction, flushing, reddish-orange discoloration of body fluidstears, saliva, urine, sweat, sputum GI: Heartburn, epigastric distress,anorex-ia, nausea, vomiting, gas, cramps, diarrhea, pseudomembranous colitis, pancreatitis, el-evations of liver enzymes,hepatitis GU: Hemoglobinuria, hematuria, renal in-sufficiency, acute renal failure,men-strual disturbances Hematologic: Eosinophilia, thrombocy-topenia, transient leukopenia,hemolytic anemia, decreased Hgb, hemolysis Other: Pain in extremities, osteomalacia, myopathy, fever, flulike symptoms Nursing considerations: Interventions Administer on an empty stomach, 1 hr be-fore or 2 hr after meals. Administer in a single daily dose. Consult pharmacist for rifampin suspension for patients unable to swallow capsules. Prepare patient for the reddish-orange col-oring of body fluids (urine, sweat, sputum, tears, feces, saliva); soft contact lenses may be permanently stained; advise patients not to wear them during therapy.

PYRAZINAMIDE (peer a zina myde) Tebrazid (CAN) Drug class: Antituberculotic Therapeutic actions Bacteriostatic or bacteriocidal against My-cobacterium tuberculosis;mechanism of ac-tion is unknown. Indications

 Initial treatment of active TB in adults and children when combined with other antituberculotics Treatment of active TB after treatment fail-ure with primary drugs Treatment of drug-resistant TB as part of an individualized regimen Contraindications and cautions Contraindicated with allergy to pyrazinamide, acute hepatic disease, lactation, acute gout. Use cautiously with diabetes mellitus, acute intermittent porphyria, pregnancy Dosages Adults and pediatric patients: 1530 mg/kg/day PO, given once a day; donot exceed 2 g/day. Always use with up to four other antituberculotics; administer for the first 2 mo of a 6-mo treatment program. 5070 mg/ kg PO twice weekly may increase compliance and is being studied as an alternative dosing schedule. Patients with HIV infection may re-quire a longer course of therapy. Adverse effects Dermatologic: Rashes, photosensitivity GI: Hepatotoxicity, nausea, vomiting, diarrhea, anorexia Hematologic: Sideroblastic anemia, thrombocytopenia, adverse effects on clot-ting mechanism or vascular integrity Other: Active gout Nursing considerations Interventions Administer only in conjunction with other antituberculotics. Administer once a day. Arrange for follow-up of LFTs (AST, ALT) pri-or to and every 24 wk during therapy.

ETHAMBUTOL HYDROCHLORIDE (e thambyoo tole) Etibi (CAN), Myambutol Drug class: Antituberculotic (second line) Therapeutic actions Inhibits the synthesis of metabolites in grow-ing mycobacterium cells, impairing cell metabolism, arresting cell multiplication, and causing cell death. Indications Treatment of pulmonary TB in conjunction with at least one other antituberculotic Contraindications and cautions Contraindicated with allergy to ethambutol; optic neuritis.

 Use cautiously with impaired renal function, lactation, pregnancy (use other antituberculotics), visual problems (cataracts, dia-betic retinopathy). Dosages Ethambutol is not administered alone; use in conjunction with other antituberculotics. Adults Initial treatment: 15 mg/kg/day PO as a single daily oral dose. Continue therapy until bacteriologic conversion has become per-manent and maximal clinical improvement has occurred. Retreatment:25 mg/kg/day as a single daily oral dose. After 60 days, reduce dose to 15 mg/kg/day as a single daily dose. Adverse effects CNS: Optic neuritis(loss of visual acuity, changes in color perception), fever, malaise, headache, dizziness, mental confusion, dis-orientation, hallucinations, peripheral neu-ritis GI: Anorexia, nausea, vomiting,GI up-set, abdominal pain, transient liver impair-ment Hypersensitivity: Allergic reactions dermatitis, pruritus, anaphylactoid reaction Other: Toxic epidermal necrolysis, thrombocytopenia,joint pain, acute gout Interactions Decreased absorption with aluminum salts Nursing considerations Interventions Administer with food if GI upset occurs. Administer in a single daily dose; must be used in combination with other antituber-culotics. Arrange for follow-up of LFTs, renal func-tion tests, CBC, ophthalmologic examina-tions

POTASSIUM CHLORIDE (Inj KCL)

Drug class: Electrolyte Therapeutic actions: Principal intracellular cation of most body tissues, participates in a number of physiologic processesmaintaining intracellular tonicity; transmission of nerve impulses; contraction of cardiac, skeletal, and smooth muscle; maintenance of normal renal function; also plays a role in carbohydrate metabolism and various enzymatic reactions. Indications Prevention and correction of potassium deficiency; when associated with alkalosis, use potassium chloride; when associated with acidosis, use potassium acetate, bicarbonate, citrate, or gluconate. IV: Treatment of cardiac arrhythmias due to cardiac glycosides Contraindications and cautions Contraindicated with allergy to tartrazine, aspirin (tartrazine is found in some preparations

marketed as Kaon-Cl, Klor-Con); therapy with potassium-sparing diuretics or aldosteroneinhibiting agents; severe renal impairment with oliguria, anuria, azotemia; untreated Addisons disease; hyperkalemia; adynamia episodica hereditaria; acute dehydration; heat cramps; GI disorders that delay passage in the GI tract. Dosages Individualize dosage based on patient response using serial ECG and electrolyte determinations in severe cases. Adults : Oral Prevention of hypokalemia: 1624 mEq/ day PO. Treatment of potassium depletion: 40 100 mEq/day PO. IV : Do not administer undiluted. Dilute in dextrose solution to 4080 mEq/L. Adverse effects Dermatologic: Rash GI: Nausea, vomiting, diarrhea, abdominal discomfort, GI obstruction, GI bleeding, GI ulceration or perforation Hematologic: Hyperkalemiaincreased serum potassium, ECG changes (peaking of T waves, loss of P waves, depression of ST segment, prolongation of QTc interval) Local: Tissue sloughing, local necrosis, local phlebitis, and venospasm with injection. Nursing Intervention: Arrange for serial serum potassium levels before and during therapy. Administer liquid form to any patient with delayed GI emptying. Administer oral drug after meals or with food and a full glass of water to decrease GI upset. Caution patient not to chew or crush tablets; have patient swallow tablet whole. Mix or dissolve oral liquids, soluble powders, and effervescent tablets completely in 38 oz of cold water, juice, or other suitable beverage, and have patient drink it slowly Arrange for further dilution or dose reduction if GI effects are severe. Agitate prepared IV solution to prevent layering of potassium; do not add potassiumto an IV bag in the hanging position. Monitor IV injection sites regularly for necrosis tissue sloughing, and phlebitis. Monitor cardiac rhythm carefully during IV administration. Caution patient that expended wax matrix capsules will be found in the stool. Caution patient not to use salt substitutes NORMAL SALINE (NS or N/S) It is the commonly-used phrase for a solution of 0.90% w/v of NaCl, about 300 mOsm/L or 9.0 g per liter. Less commonly, this solution is referred to as physiological saline or isotonic saline, neither of which is technically accurate. NS is used frequently in intravenous drips (IVs) for patients who cannot take fluids orally and have developed or are in danger of developing dehydration or hypovolemia. NS is typically the first fluid used when hypovolemia is severe enough to threaten the adequacy of blood circulation, and has long been believed to be the

safest fluid to give quickly in large volumes. However, it is now known that rapid infusion of NS can cause metabolic acidosis. Usage For medical uses, saline is often used to flush wounds and skin abrasions. Normal saline will not burn or sting when applied. Saline is also used in I.V. therapy, intraveno supplying extra water to rehydrate patients or supplying the daily water and salt needs ("maintenance" needs) of a patient who is unable to take them by mouth. Because infusing a solution of low osmolality can cause problems, intravenous solutions with reduced saline concentrations typically have dextrose (glucose) added to maintain a safe osmolality while providing less sodium chloride. As the molecular weight (MW) of dextrose is greater, this has the same osmolality as normal saline despite having less sodium. The amount of normal saline infused depends largely on the needs of the patient (e.g. ongoing diarrhea or heart failure) but is typically between 1.5 and 3 litres a day for an adult. Saline is also often used for nasal washes to relieve some of the symptoms of the common cold. The solution exerts a softening and loosening influence on the mucus to make it easier to wash out and clear the nasal passages for both babies and adults.

5% DEXTROSE INJECTION
It is a solution is sterile and nonpyrogenic. It is a parenteral solution containing dextrose in water for injection intended for intravenous administration. Each 100 mL of 5% Dextrose Injection, USP, contains dextrose, hydrous 5 g in water for injection. The caloric value is 170 kcal/L. The osmolarity is 252 mOsmol/L (calc.), which is slightly hypotonic. The solution pH is 4.3 (3.2 to 6.5). This solution contains no bacteriostat, antimicrobial agent or added buffer and is intended only as a single-dose injection. When smaller doses are required the unused portion should be discarded. 5% Dextrose Injection, USP is a parenteral fluid and nutrient replenisher. Indications and usage Intravenous solutions containing dextrose are indicated for parenteral replenishment of fluid and minimal carbohydrate calories as required by the clinical condition of the patient. Contraindications 5% Dextrose Injection, USP without electrolytes should not be administered simultaneously with blood through the same infusion set because of the possibility that pseudoagglutination of red cells may occur. Precautions Clinical evaluation and periodic laboratory determinations are necessary to monitor changes in fluid balance, electrolyte concentrations and acid-base balance during prolonged parenteral therapy or whenever the condition of the patient warrants such evaluation. Solutions containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus. Do not administer unless solution is clear and container is undamaged. Discard unused portion Adverse reactions

Reactions which may occur because of the solution or the technique of administration include febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation and hypervolemia. If an adverse reaction does occur, discontinue the infusion, evaluate the patient, institute appropriate therapeutic countermeasures and save the remainder of the fluid for examination if deemed necessary Dosage and administration The dose is dependent upon the age, weight and clinical condition of the patient. As reported in the literature, the dosage and constant infusion rate of intravenous dextrose must be selected with caution in pediatric patients, particularly neonates and low birth weight infants, because of the increased risk of hyperglycemia/hypoglycemia. Drug Interactions Additives may be incompatible. Consult with pharmacist, if available. When introducing additives, use aseptic technique, mix thoroughly and do not store. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

DAILY PROGRESS NOTE:

Date: 2070/03/03 Day: Monday Time 6 am 6pm Blood pressure 100/80 mm of Hg 110/70 mm of Hg Temperature 97 oF 99.2 oF Pulse 90/min 89/min Respiration. 24/min 26/min

Intake 2750 ml output 2200 ml Over 24 hours

Patients General condition seems weak. Patient is awake and well oriented but looks tierd and lethargic. It is the 8th post operative day (patient undergone Exploratory Laparotomy with resection and anstomosis). Pateint has fecal diversion after the surgery i.e. ileostomy present. Central Line present for Parenteral medication and nutrition. Abdominal incision present post surgery.patient also has 1st degree bedsore on sacral region. Chest Bi-lateral equal air entry, soft and tender Per abdomen.No wound soakage but gaps between two sutures present on distal portion. Dressing done. CVP was 9mm of H20 , CVP care done.. Patients blood Potassium value was 3.0 meq/l so and had been on very lowered side for a long time so Inj KCL 120meq/l over 24 hours in IV pint of NS being administered. Patient had complain of slight pain so nursing care was provided along with medical management. Deep breathing excersise was taught. Patient is in active stage of Tuberculosis under ATT for 9 days now. Health teaching about risk of infection, risk of tuberculosis transmission to others was given.

Date: 2070/03/04 Day: Tuesday Time 6 am 6pm Blood pressure 100/70 mm of Hg 110/70 mm of Hg Temperature 97.8 oF 98.8 oF Pulse 89/min 82/min Respiration. 20/min 22/min

Intake 2800 ml output 2400 ml Over 24 hours

Patient is wide awake and well oriented to time, place and person. However looks irritated and restless. Chest Bi-lateral equal air entry, soft and tender Per abdomen. No wound soakage. CVP line in-situ, Dressing done on abdominal wound and CVP site. Bedsore dressing done and left open and is healing. Colostomy bag changed and colostomy care provided with teaching given to visitor. Lab values of blood sodium = 125 meq/l and potassium= 3.0 meq/l. Health teaching about nutrition and fluid management provided. Patient instructed to change position frequently at least every 2 hours. ATT, antibiotic and other medications carried out. Date: 2070/03/05 Day: Wednesday Time 6 am 6pm Blood pressure 100/80 mm of Hg 90/70 mm of Hg Temperature 97.4 oF 98.4 oF Pulse 88/min 120/min Respiration. 20/min 28/min

Intake 4900 ml output 3930 ml Over 24 hours Pateint is well oriented and awake. Patient seems fresh and has become open to conversation. Appetite has been increased and patient is eating soft diet. Chest and abdomen examination done and are normal.CVP care and wound dressing done. Bedsore Dressing done. Ileosomy bag had leakage so bag changed and care done with assistance provided to visitor. Patient complained that he had disturbed sleep due to leakage of ielostomy bag at night. Necessary interventions carried out. (refer careplan). Besore seems to be healing with no need for dressing. Date: 2070/03/06 Day: Thursday Time 6 am 6pm Intake output Blood pressure 100/70 mm of Hg 110/70 mm of Hg 4100ml 3900 ml Temperature 97.8 oF 98.0 oF Pulse 90/min 86/min Respiration. 20/min 22/min

Patient General condition seems fair. He is awake and oriented. Abdomen tender and soft and bowel sound present. Chest clear. Abdominal wound seems to be healing but still the gap netween stures has not joined completely. Lab values of Blood sodium was= 134 meq/l and Potassium was 4meq/l.

Antibiotic and I/V fluids has been stopped and Inj KCl supplement has been stopped too. Patinet now has Tab Tramadol, Tab Pantop , Syrp Potklor and ATT as medication. Patient is eating well. Patient complained of back pain so patient was assisted to change position , sit upright with support and oil massage done by visitor.

Date: 2070/03/07 Day: Friday Time 6 am 6pm Intake output Blood pressure 100/70 mm of Hg 90/70 mm of Hg 4200ml 3900 ml Temperature 97.8 oF 98.0 oF Pulse 86min 82/min Respiration. 18/min 20/min

Patient General condition seems fair. Vital s have been stable. Patient has normal finding on chest and abdomen examination. Pateint seems well rested and cheerful. He has been eating well and increased movements during the day. Colostomy care, back care, Wound dressing provided. Patient in tolerating normal diet. No specific complain. Discharged has been planned but patient party does not seem ready . Counselling done and Information and health teaching provided regarding nutrition, continuity of care, medication, tuberculosis treatment, follow up visits, colostomy care and so on.

Date:, 2070/03/010 Day: Monday Patient seems well. Looks fresh and cheerful. Patient seemed to be coping well with the situation.Discharge has been planned for today. Patient party looked more convinced. Queries were raised about further care at home. Information provided including home adjustments for dressing continuation and colostomy care. Patient party consulted a known health personnel, for homevisit who could carry out dressing and other needed care once a day. Patient father informed that necessary adjustment to room setting has been done at home. Patient was discharged around 1pm today with follow up visit scheduled for Thursdaya they live in a walking distance from Bir Hospital.

DIVERSIONAL THERAPY USED IN MY PATIENT TO MINIMIZE STRESS:

Diversional Therapy is a client centered practice that recognizes that leisure and recreational experiences are the right of all individuals. Diversional Therapists promote the involvement in leisure, recreation and play by reducing barriers to their client's participation and providing opportunities where the individual may choose to participate. Ideally these recreational activities promote self-esteem and personal fulfillment, through an emphasis on holistic care; providing physical, psychological, social, intellectual and spiritual/cultural support. It is not just about passing the time, about being entertainers or babysitters. Stress threshold depends on individual. Different people have different experiences, some has lower grade and some has higher grade. Divertional therapy is used in parallel with medicines for the treatment of sick person because during illness a person has more concern about his body and illness. This concern may cause severe depression and emotional upsets. I used following divertional therapy to minimize stress of my patient:

Stress management strategy:

1. Talk therapy: I made conversation with my patient and his family timely through which I found out his views and expectation towards the disease condition, hospital surroundings, policies, hospital staffs and rules and regulations. I also explained her about treatment methods. I was always patient and open to their queries. Through the talk therapy, I was able to minimize stress and divert patients mind. 2. Autogenic training: It is the method of replacing pain and unpleasant event or situation with pleasant ones through self readiness and action. I taught my patient about the method and provided him sufficient rest and adequate sleep as it helps to reduce pain and induce sleep which can minimize the stress easily. 3. Imaginary: It is the imagination and concentration to take mental vacation. I encouraged my patient to prevent the stressful thought from his mind. I encouraged him to imagine pleasant sceneries and peaceful environment which helped to divert mind and reduce stressful situation.

4. Distraction: This is the method of diverting mind in another pleasant situation. I suggested him to distract his mind by listening to music, singing or watching Television program at home after discharge, and allow friends visits.(keeping in mind the risk of infections)

5. Deep breathing and relaxation: During the time of mild pain, I advised him to take deep breath and relax the body.

Result of diversional therapy: I found myself succeed to meet the goal towards minimizing the patient stress as evidenced by patient verbalization of feelings and anxiety and demonstration of behavior modification.

HEALTH TEACHING PROVIDED TO MY PATIENT DURING HOSPITALIZATION:

Health teaching during hospitalization play important role for the timely recovery of patient. Health education is important in preventing disease; promoting health and to cure disease without any complication. I have provided following teaching to the patient and his family. The objectives of health education: To promote health by using locally available resources. To prevent illness and infection. To recover from illness and achieve normal health. To prevent complications. To maintain and fulfill the nutritional status of the patient. To provide good family environment.

Health education provided to achieve above objectives: Nutrition: Providing healthy and well balanced diet is most for the quick recovery of the patient. As food is the good source of energy, it helps to cope with the disease and live healthy.

Personal hygiene: Maintain personal hygiene of client regarding bed bath, oral care, nail care, changing clean clothes, food hygiene and perineal hygiene to prevent infection. Encourage the visitors to keep the patient with proper bladder care and ostomy care. Bladder and Bowel Care: Encourage the patient to drink about 2 to 3 liters water per day. Encourage the patient to take diet according to the disease condition for example high protein diet for timely healing and tissue repair, carbohydrate for energy and limiting fibers due to risk of high effluent in ostomy. Respiratory care: Encourage the patient to take deep breath and exhale to avoid pooling of secretions and prevent pulmonary complications like cough, hypostatic pneumonia but at the same time take precautions so as to prevent tubercular infections to caregivers. Rest and sleep: Encourage the patient to take adequate rest and sleep well because rest and sleep reduces fatigue and need for oxygen consumption and provided with ideas and knowledge to enhance un-interrupted sleep. Reporting: Encourage the patient and his visitors to report any unusual signs and symptoms that may indicate complications like fever, redness/blister/injury in the skin, cough, problem in urination etc. Medicines: Provide health teaching to the visitors not to take self medications. If they see any unusual symptoms, report promptly. Encourage the visitors to ask questions if they have any queries regarding the medicines. About Tuberculosis: Provide family and patient with health teaching about the care of tuberculosis patient and the nearest care givers to prevent cross infections, complications, or reactivations. About Ileostomy care: Provide teaching about the ostomy care and assured that re demonstration was acceptable.

DISCHARGE TEACHING:
Health teaching during discharge and hospitalization are important for preventing complications, promoting health and restoring the sound health, maintaining normal and actual living style. Objectives of discharge teaching plan: To promote and maintain health and prevent from illness in home after discharge. To consider primary health care concept in health teaching. To provide holistic care to the patient. To provide need based health education.

I provided teaching on the following topics:Medicines: Anti Tuberculosis Treatment: I explained medication dosage, frequency of administration, expected action and the reason for long treatment period emphasizing on necessity of continuous drug treatment and following of DOT regimen. Reviewed potential side effects of Tuberculosis treatment such as dry mouth, gastrointestinal (GI) upset, constipation, visual disturbances, headache, and orthostatic hypertension may occur as side effects but it is important that ant tuberculosis drugs not be discontinued because of nuisance side effects. Problem solving could be done; as taking medication with food and changing the hour of dosing, may reduce discomfort associated with therapy. However, severe reactions must be reported to physician. Reviewed that TB is transmitted primarily by inhalation of airborne organisms, but may also spread through stools or urine if infection is present in these systems; also reviewed hazards of reactivation as providing knowledge may reduce risk of transmission or reactivation. Take your medicine as directed: I informed my patients to keep a list of the medicines including TB medications and other vitamins, painkillers, and include the amounts, when and why you take them. Carry your medicine list with you in case of an emergency.

Nutrition: I emphasized the importance of maintaining high-protein and carbohydrate diet and adequate fluid intake. Discussed need for periodic evaluation and administration of supplemental vitamins and minerals, as appropriate during follow up visits. Stressed importance of chewing food well, adequate intake of fluids with and following meals, only moderate use of high-fiber foods, and avoidance of cellulose. Reviewed foods that are, or may be, a source of flatus, such as carbonated drinks, beer, beans, cabbage, onions, fish, and highly seasoned foods; or odor, such as onions, cabbage, eggs, fish, and beans. Patient party to identify foods associated with diarrhea, such as green beans, broccoli, and highly seasoned foods. Recommend foods used to manage constipation, such as bran, celery, and raw fruits, and discuss importance of increased fluid intake.

Self-care: Rest as needed Drink liquids as directed Take part in ileostomy care and personal hygiene. Eat nutritious small frequent meals rather than three large meals. Encouraged for follow-up visits with the health care Seek care immediately when: Dizzy or feel confused.

 Arm or leg feels warm, tender, and painful. It may look swollen and red. Suddenly feel lightheaded and short of breath. Pulling below skin Blood in cough. Often leaking ileostomy bag or doenot fit well as before. Skin around stoma is buldging out. Any sore on skin around. Persistent diarrhea Identification of problems: Identify symptoms of electrolyte depletion, such as anorexia, abdominal muscle cramps, feelings of faintness or cold in arms and legs, general fatigue or weakness, bloating, and decreased sensations in extremities as it may indicate loss of colon function. Identify signs and symptoms requiring medical evaluation, such as recurrent abdominal pain or distention, vomiting, fever, chills, or presence of purulent drainage, swelling, and erythema of surgical incision.

WHAT I LEARNED FROM MY CASE STUDY:

1. About the disease: I studied about the disease condition, causes, sign and symptoms, treatment, management through the different resources like library, net, researches, literature, etc. Also I received information from staffs, doctors and other medical staffs. 2. About the patient. I got a chance to know about the history of patient, his personal habits, ways of living, thinking and its influences on health and illness. 3. About the environment, family and age factor. I also got information about my patient's family background, socio-cultural and education background, concept about health and illness, nutrition, economic status, traditional beliefs and attitude towards disease. I could presume that how this age groups (adolescent) are more prone to diseases nowadays by studying about patients lifestyle. I found out that avoidance of nutrition, health care by this age group could be related to advancement of technologies like children are now addicted on playing video games, online games, going to cybe , spending more and more time with friend in comparison to older days where children were busy playing physical games with peer groups and stayed under parents supervision most of the time. There may also be problems of choosing a wrong path like drug addiction, alcoholism, smoking, crimes or simply leading to malnutrition, avoidance of education e.t.c as parents are more and busier in earning money for their daily living and spending less time with their children. Though, this could be just a personal assumption of mine, which cannot be concluded through a single

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7.

case study, nevertheless, I received more inspiration and encouragement to look into the depths of situations that may lead to deterioration of ones health About nursing care: I applied holistic approach while providing nursing care to the patient. I also applied Abdellahs theory while caring my patient by using nursing process. I gained lot of knowledge about the care plan while planning and implementing the nursing care. About the documentation: Documentation is also an important skill which I developed by the case study. I could learn this skill by my observation, activities, findings and conclusion. I developed this skill so that I formulate the case study systematically and deeply. About stress and management: I got the chance to solve my patient's emotional worries, tensions by providing different techniques of reducing stress, divertional therapy and psychotherapy. I also provided him emotional and psychological support which was really helpful to reduce stress. About the hospital policy: During my case study I involved in every sector of activities like reporting, recording, admission, discharge procedures. So I could understand the rules and policy about Bir hospital, which is very useful.

SUMMARY OF MY CASE STUDY

During my 8 weeks hospital major practicum of NAMS Bir Hospital Nursing Campus BN1st year curriculum, I chose the case of Abdominal tuberculosis with perforation peritonitis for my case study, patient name Yubraj Patamagar, 17 years of female admitted in Male surgical ward. He is from Ashon. He was admitted to ward with the complain of abdominal pain and distension , and inability to pass stool , and after necessary investigations, he was diagnosed with Perfotaion Peritonitis due to Intestinal Tuberculosis. I provided holistic nursing care to the patient according to his need by considering the physical, mental, socio-cultural, spiritual and economic aspect. I provided nursing care based on Abdellahs Problem Solving Theory. During hospitalization I also provided necessary health education regarding health promotion, maintenance, prevention from infection,post surgey care, nutrition and discharge teaching that he needed to cope with his disease condition. During interaction with my patient, he and his family members were very co-operative with me so there was no difficulty providing care and collecting information. The immense help of patient and his family inspired me to study the case thoroughly and become able to provide better care.

CONCLUSION
Case study is one of the most important aspect of Nursing practice in the hospital setting.It provides us an opportunity for l comprehensive study of one selected case in comparision with book and helps to provide holistic nursing care to the patient according to developmental milestone. Abdominal Tuberculosis and Peritonitis can be important experiences for all learning personnel for getting clear and up to date knowledge about disease condition. This will not only help us to promote safe and healthy living in the family and the community but also it will help to reduce morbidity and mortality rates. Such detailed case study gives knowledge about what are problems, its causes, sign and symptoms and nursing consideration. Case study also helps us to do research. During hospitalization, I provided my patient with holistic nursing care in every aspects like physical, emotional, economical and socio-cultural ways. I also gained knowledge about nursing theory and its application in real situation. So, the case study not only gives the cognitive domain but also provide us the opportunity to develop psychomotor domain, which is very important in nursing field. So, the patient is main source of converting knowledge in practice. I also got opportunity to know about my patient, family, socio-cultural, economic status, religious background which helped me in providing care effectively. I could also find out some socio-cultural factors affecting the health of adolescent age group In this way, this case study provided me a good opportunity to gain deep knowledge on Abdomial Tuberculosis and Peritonitis, so I am completely satisfied with my case study.

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