Group I RN-Heals 2013 Tondo Medical Center

Mark Wilson Pascual Mark Peralta Marilie Sheena Pereda Quincy Mae Pingkian Sheryl Po Suselle Poblete

Joann Rabano Bernadette Ramilo Rani Marie Jane Reodica Aguemarie Reolada Dorcelyn Reyes Sheryl Ricafort

Hyacinth Lucero

Michael Khevin Marasigan

Table of Content
I. Introduction
A. B. C. D. Background of the Study Rationale for Choosing the Case Significance of the Study Scope and Limitation of the Study

II.

Clinical Summary
A. B. C. D. E. F. G. H. I. J. K. L. General Data Chief Complaint: History of Present Illness: Past Medical History Familial History Physical Assessment Patterns of Functioning (GORDONS) Activities of Daily Living Patients Concept about Health, Illness and Hospitalization Laboratory and Diagnostic Examination Impression/Diagnosis Ecologic Model

III.

CLINICAL DISCUSSION OF THE DISEASE

A. Anatomy and Physiology B. Drug Study

IV.

NURSING PROCESS
A. Long Term Objective B. Problem List C. Nursing Care Plan

D. Discharge Planning

Case Presentation on Pulmonary Tuberculosis

I INTRODUCTION A. Background of the Study Pulmonary tuberculosis, a chronic sub-acute or acute respiratory disease commonly affecting the lungs characterized by the formation of tubercles in the tissues which tend to undergo cessation, necrosis and calcification. It is also known as poor mans disease or consumption disease. The causative agent in this disease is Mycobacterium Tuberculosis, a rod shaped bacteria. The disease is transmitted by deliberate inoculation of microorganisms by droplet. This disease is transmitted to other people through the inhalation of organisms directly into the lungs from contaminated air. The Philippines is one of the highest tuberculosis (TB) burden countries in the world with nationwide coverage of directly observed treatment, short-course (DOTS) achieved in 2003. This study reports on the National TB Control Programme (NTP) surveillance data for the period 2003 to 2011. During this period, the number of TB symptomatics examined increased by 82% with 94% completing the required three diagnostic sputum microscopy examinations. Of the 1 379 390 cases diagnosed and given TB treatment, 98.9% were pulmonary TB cases. Of these, 54.9% were new smear-positive cases, 39.3% new smear-negative cases and 4.7% were cases previously treated. From 2008 to 2011, 50 030 TB cases were reported by non-NTP providers. Annual treatment success rates were over 85% with an average of 90%; the annual cure rates had an eight-year average of 82.1%. These surveillance data represent NTP priorities the large proportion of smear-positive cases reflected the countrys priority to treat highly infectious cases to cut the chain of transmission. The performance trend suggests that the Philippines is likely to achieve Millennium Development Goals and Stop TB targets before 2015. Tuberculosis (TB) is the sixth leading cause of morbidity and mortality in the Philippines; the country is ninth out of the 22 highest TBburden countries in the world and has one of the highest burdens of multidrug-resistant TB. Directly observed treatment, short-course (DOTS)4 strategy for TB control commenced in 1997 and nationwide coverage was achieved in 2003.5 The prevalence of TB in 2007 was 2.0 per 1000 for smear-positive TB and 4.7 per 1000 for culture-positive TB. Compared with 1997, there was a 28% and 38% decline in prevalence for smearpositive and culture-positive TB, respectively. ( world health organization) This disease is can be acquired easily by person being in contact with an infected one, when you are living in a crowded area like the squatters area and when you have poor nutrition. It is commonly present in third world or developing countries like the Philippines.

B. Rationale for Choosing the Case The researchers decided to choose this case because they wanted to acquire more knowledge about Pulmonary Tuberculosis. They wanted to use the knowledge that they have acquired in promoting awareness to the people especially to the poor that they should seek for medical care in order to prevent the development and progression of PTB. The researchers also wanted to focus on preventive measures. PTB can cause Tuberculosis meningitis, a very rare and fatal disease and the researchers would not want that to happen, so they will focus more on information campaign as part of primary prevention of health. Presently our country has so many cases of PTB.

C.

Significance of the Study This study will help the nursing profession by providing information about the proper management and care for PTB patient. It will also educate the people, especially those with PTB and vulnerable individuals to seek medical care in order to prevent TBM. It will increase awareness about the importance of having a healthy lifestyle and clean environment. This study will elaborate the inter relatedness of environment, life style habits and acquiring Pulmonary Tuberculosis.

D. Scope and Limitation of the Study This study is focused on the nursing aspect of care to those patients who have Pulmonary Tuberculosis. This study will only be used in the nursing profession. The researchers only focused their attention on the medications, diagnostics, care plan, pathophysiology and discharge planning. This study is not limited to the PTB patients only, but it is for all people who are interested in PTB. We are more focused on primary prevention through health education because primary prevention is the true prevention.

II CLINICAL SUMMARY A. General Data Name: PATIENT I Age: 46 y/o Birthplace: Pulangi, Albay Sex: Female Religion: Roman Catholic Civil Status: Married Address: P. Cadorniga st Navotas city Date Admitted: December 13, 2013 Time Admitted: 2:10 am Attending Physician: Dr. Arthur Gonzales

B. Chief Complaint The patient was admitted at Tondo Medical Center last December 13, 2013 at 2:10 in the morning due to the complaint of difficulty of breathing (DOB). She was attended at the Emergency department and had taken a clinical history and physical assessment. She was transferred at the Medical Ward particularly in the pulmonary ward of the hospital for further evaluation of the condition. She was attended by Dr. Arthur Gonzales, a resident physician of the said hospital.

C.

History of Present Illness Patients condition started about 6 months prior to consultation, as onset of cough, non-productive and an intermittent fever usually in the afternoon, moderate grade temperature which are not documented. According to her it was relieved by an intake of paracetamol. One week prior to admission the patient experienced worsening of the condition, she had productive cough non-bloody with whitish secretions. There is also difficulty of breathing and vomiting. The patient cant eat properly because she has no appetite fo r food. She also experience stabbing pain on her chest according to the assessment it is 6/10 and it radiates to his back. The patient only took paracetamol for her fever. On the day of December 13, 2013 she was rushed to the hospital because of difficulty of breathing. Previously when she started experiencing these conditions, she does not seek for any medical care from the physician because according to her it is still tolerable.

D. Past Medical History The patient had upper respiratory tract infection when she was a child, she cannot remember. Previously she was not hospitalized. She does not have complete immunizations because according to her it is not available in their place during those days, She has no history of hypertension and Diabetes mellitus. Whenever she had any flu or cough, she uses herbal plants. She does not have any regular medical and dental check-ups. She does not have allergies to what ever kind of foods and medications as far as she knows. Whenever she had fever she takes Paracetamol and Bioflu. She does experience any severe accidents.

E.

Familial History

Telesporo Cia, 75 Deceased CVA

Eugenia Chavez 65 Deceased VA

Carlito, 75

Litsilda, 50

Flusofida, 48

Junior, 44

PATIENT I,
46 PTB Arsenio, 50

Josephine, 42

Gaudiocio, 40

Blencio, 38

Allan,25

Analyn, 23

Anabel, 22

Analiza, 19

Ana Marie, 15

Arnold, 10

Legends Male Female PTB Pulmonary Tuberculosis CVA Cerebro Vascular Attack VA Vehicular Accident

F.

Physical Assessment Upon Admission : GCS-15 oriented to 3 spheres-(E4M6V5) V/S: BP- 90/60 mmHg, CR: 84 bpm, RR: 36 cpm, T-38.1 C LOC: Oriented

Date: December 13, 2013 Height: 62 inches Weight: 31.5 kilograms BMI: 12.5 (Severe Malnutrition)

AREA A. SKULL 1. Size, shape and symmetry of the skull

TECHNIQUE

NORMS

FINDINGS

ANALYSIS and INTERPRETATION

Inspection Palpation

Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour Smooth, uniform consistence; absence of nodules or masses Symmetric or slightly asymmetric facial features; palpebral fissure equal in size; symmetric nasolabial No edema and hollowness

Rounded(normocephalic); smooth skull contour

Normal

2. Presence of nodules, masses, and depressions

Palpation Inspection

Has no tenderness; no masses nor nodules

Normal

3. Facial Features

Inspection Palpation

Symmetrical and palpebral fissure equal in size, nasolabial folds are symmetrical

Normal

4. Presence of edema and hollowness in the eye.

Inspection

Has Hollowness

Abnormal, Volume deficiency of fat within the orbit

(the space inside of the bony eye socket). This condition of the patient is related to his nutritional status, she is malnourished. Her BMI is 12.5.
(http://www.drmeronk.com/hollowed/under-eye-hollows.html)

C. HAIR

1. Evenness of growth, thickness, or thinness of hair

Inspection Palpation

Evenly distributed and covers the whole scalp; Maybe thick or thin Silky; resilient hair

Evenly distributed with no patches of hair loss; thick hair Silky, smooth and resilient hair Presence of lice

Normal

2. Texture and oiliness over the scalp 3. Presence of infection and infestation

Inspection Palpation Inspection Palption

Normal.

No infection and infestation

Abnormal, There is pediculosis, a type of parasitic infection. Lice may be contracted from infcetd clothes and direct contact with an infected person. The idea is that an oily substance, such as oil, smothers the lice and they may die. (Kozier,
Fundamentals of Nursing 7th ed. Page 733)

D. FACE Facial features, symmetry of facial movements Inspection Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds Symmetrical facial features while talking or elevating the eyebrow. Equal palpebral fissure, symmetrical nasolabial folds. Normal

IV. EYES A. EYEBROWS Hair distribution, alignment, skin quality and movement Inspection Symmetrical and in line with each other; maybe black, brown or blond depending on race; evenly distributed Symmetrical and aligned with each other; black; evenly distributed. Movements are symmetrical. Normal

B. EYELASHES Evenness of distribution and direction of curl C. EYELIDS Surface characteristics and position (in relation to the cornea, ability to blink, and frequency of blinking) Inspection Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open; eyelids meet completely when the eyes are closed; symmetrical Able to close the eyes and has the ability to blink. Normal Inspection Palpation Evenly distributed; turned outward Turned outward eyelashes; hair equally distributed Normal

D. CONJUNCTIVA 1. Color, texture, and the presence of lesions in the bulbar conjunctiva Inspection Palapation Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers Pale color; smooth in texture Abnormal, pale conjunctiva may be related to the low RBC level of the patient. (Fundamentals of Nursing 5th edition by Taylor, page 642)

2. Color, texture, and the presence of lesions in the palpebral conjunctiva

Inspection Palpation

Pale

Abnormal, pale conjunctiva may be related to the low RBC level of the patient. (Fundamentals of Nursing 5th edition by Taylor, page 642)

E. SCLERA Color and clarity Inspection White in color; clear; no yellowish discoloration; some capillaries maybe visible White sclera with some visible capillaries, anicteric sclera. Normal

F. CORNEA Clarity and texture Inspection No irregularities on the surface; looks smooth; clear or transparent Clear and smooth in texture Normal

G. IRIS Shape and color Inspection Anterior chamber is transparent; no noted visible materials; color depends on the persons race Dark brown in color; transparent anterior chamber Normal

H. PUPILS 1. Color, shape, and symmetry of size Inspection Color depends on the persons race; size ranges from 3-7 mm, and are equal in size; equally round Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual Pupil size is 3mm. Normal

2. Light reaction and accommodation

Inspection

Dilates when looking at far objects and constricts when looking at near objects. Constricts when there is light.

Normal

I. VISUAL ACUITY 1. Near vision Inspection Able to read newsprint Nearsightedness (Myopia) Abnormal, it is a refractive defect of the eye in which collimated light produces image focus in front of the retina when accommodation is relaxed. It is caused by an eyeball that is longer than normal, which may be a familial trait. Transient mayopia occurs due to

influenza, steroids, sever dehydration and large intake of antacids. (Black, Medical Surgical Nursing7th
edition, page 1963).

J. LACRIMAL GLAND Palpability and tenderness of the lacrimal gland Palpation No edema or tenderness over lacrimal gland No tenderness and edema noted. Normal

K. EXTRAOCULAR MUSCLES Eye alignment and coordination Inspection Both eyes coordinated, move in unison, with parallel alignment Moves in Unison Normal

L. VISUAL FIELDS Peripheral visual fields Inspection When looking straight ahead, client can see objects in the periphery Can see objects in the periphery. Normal

V. EARS A. AURICLES 1. Color, symmetry of size, and position Inspection Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees from vertical Mobile, firm, and not tender; pinna recoils after it is folded Same color as the facial skin; tip of auricle aligned at the outer canthus of the eye. Normal

2. Texture, elasticity and areas of tenderness

Palpation

Smooth in texture, flexible and elastic pinna; no tenderness

Normal

C. HEARING ACUITY TESTS 1. Clients response to normal voice tones Inspection Normal voice tones audible Can hear normal volume tones or words. Normal

VI. NOSE 1.Any deviations in shape, size, or color and flaring or discharge from the nares 2. Nasal septum (between the nasal chambers) 3. Patency of both nasal cavities Inspection Symmetric and straight; no discharge or flaring; Uniform color Nasal septum intact and in midline Air moves freely as the client breathes through the nares Not tender; no lesions Symmetric and straight; Uniform color with nasal flaring. Nasal septum intact and in midline Only left nares is patent. Right nares is with secretion. Nor tenderness nor lesions. Abnormal, Nasal flaring suggests airway obstruction. Nasal discharge shows the presence of mucus secretions in the air tract. Normal

Inspection Palpation Inspection

Abnormal, not patent right nares show the presence of mucus secretions and would suggest there is an infection in the respiratory system. Normal

4. Tenderness, masses, and displacements of bone and cartilage VII. SINUSES Identification of the sinuses and for tenderness VIII. MOUTH A. LIPS Symmetry of contour, color

Palpation

Inspection

Not tender

Not painful when palpated

Normal

Inspection

Palpation

Uniform pink color; soft, moist, smooth texture;

Pink in color, dry and

Abnormal, May suggest cellular dehydration. (Black,

and texture

symmetry of contour; ability to purse lips

cracked lips

Medical Surgical Nursing7th edition, page 208).

B. BUCCAL MUCOSA Color, moisture, texture, and the presence of lesions Inspection Uniform pink color; moist, smooth, soft, glistening, and elastic texture Pink color and dry. Abnormal, May suggests dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

C. TEETH Color, number and condition and presence of dentures Inspection 32 adult teeth; smooth, white, shiny tooth enamel; smooth, intact dentures Has 31 adult teeth. The patient has yellowish teeth. Have bad breath. Have tooth decay in the lower right second molars. Abnormal, most unpleasant odors are known to arise from proteins trapped in the mouth which are processed by oral bacteria. The most common location for mouth-related halitosis is the tongue. (http://en.wikipedia.org/wiki/Halitosis). It is also related to dental carries and frequency of tooth brushing.

D. GUMS Color and condition Inspection Pink gums; no retraction Pink gums; has no visible retractions Normal

E. TONGUE/FLOOR OF THE MOUTH 1. Color and texture of the mouth floor and frenulum. Inspection pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness Pink and moist. Tongue moves freely and no pain felt. Normal

2. Position, color and texture, movement and base of the tongue 3. Any nodules, lumps, or excoriated areas

Inspection

Central position; pink color; smooth tongue base with prominent veins Smooth with no palpable nodules, lumps, or excoriated areas

Located and positioned in the center.

Normal

Palpation

Inspection

No tenderness nor masses

Normal

F. PALATES and UVULA 1. Color, shape, texture and the presence of bony prominences Inspection Palpation Light pink, smooth, soft palate; lighter pink hard palate , more irregular texture Positioned in midline of soft palate The hard palate has a lighter color than the soft palate; has quite rough texture Normal

2. Position of the uvula and mobility (while examining the palates) G. OROPHARYNX and TONSILS 1. Color and texture

Inspection

Positioned at the center of the oropharynx

Normal

Inspection

Pink and smooth posterior wall Pink and smooth; no discharge; of normal size Present

Dry, pinkish in color.

Abnormal, May suggests dehydration. (Black, Medical Surgical Nursing7th edition, page 208). Normal

2. Size, color, and discharge of the tonsils 3. Gag reflex

Inspection

Has no discharge; pinkish

Inspection

Present

Normal

X. THORAX A. ANTERIOR THORAX 1. Breathing patterns Inspection Quiet, rhythmic, and effortless respirations Difficulty of breathing Abnormal, labored breathing is a common manifestation affecting clients with cardiac and pulmonary disorders. It is related to obstructed airway. It also related to the decreased size of the lungs due to PTB. (Black, Medical Surgical Nursing7th edition, page 1566). Abnormal. The patient is febrile with temperature of 38.1 due to the disease process. (Fundamentals of Nursing)

2. Temperature, tenderness, masses

Palpation

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

Has an intact skin; has equal warmth to touch. No masses.

3. Anterior thorax auscultation

Auscultation

Bronchovesicular and vesicular breath sounds

Has crackles sounds on the upper thorax & lower thorax

Abnormal, crackles or rales are audible when there is a sudden opening of small airways that contain fluid. It is usually heard during inspiration. (Black, Medical Surgical Nursing7th edition, page 1756).

B. POSTERIOR THORAX 1. Shape, symmetry, and comparison of anteroposterior thorax to transverse diameter 2. Spinal alignment Inspection Palpation Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric Has a anteroposterior to transverse diameter ratio of 1:2, elliptical in shape and symmetrical chest Has a vertical alignment Normal

Inspection

Spine vertically aligned

Normal

3. Temperature, tenderness, and masses

Palpation

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses Vesicular and bronchovesicular breath sounds

No masses nor tenderness; has equal warmth.

Abnormal. The patient is febrile with temperature of 38.1 due to the disease process. (Fundamentals of Nursing)

7. Posterior thorax auscultation

Auscultation

Has crackles heard on the anterior and middle part of right and left lungs. Diminished lung sound on the posterior right lung.

Abnormal, the condition is related to the decreased size of the right lung and poor inspiratory effort due to pain. (http://www.nurse411.com/Heart_Lung_Sounds.asp)

XI. CARDIOVASCULAR A. AORTIC and PULMONIC AREAS B. TRICUSPID AREA Auscultation No pulsations No pulsations felt Normal

Auscultation

No pulsations; no lift or heave Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL Aortic pulsations S1: Usually heard at all sites Usually louder at the apical area S2: Usually heard at all sites

No pulsations of lifts

Normal

C. APICAL AREA

Auscultation

Has full pulsation

Normal

D. EPIGASTRIC AREA E. CARDIOVASCULAR AREAS AUSCULTATION

Auscultation Auscultation

Has pulsation Has full and rapid pulsation. 84 bpm/minute. Sounds on the aortic and pulmonic areas; has a lub sound on the apex and dub sounds on the tricuspid

Normal Normal

Normal

Usually louder at the base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate (60 to 90 beats/min) Diastole: silent interval; slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults XII. CAROTID ARTERIES 1. Carotid artery palpation Palpation Symmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from sitting to supine position; elastic arterial wall

area. Blood pressure is 90/70 mm Hg. Normal

Has weak pulsation. Symmetrical pulse.

Abnormal, decreased amount of blood volume passing the artery. (Black, Medical Surgical Nursing7th edition, page 1574).

XIV. AXILLAE 1. Axillary, subclavicular, and supraclavicular lymph nodes Inspection No tenderness, masses, or nodules Have no masses and nodules. Presence of a foul Abnormal, The appocrine glands located in the axillae produces sweat. The secretion of these glands

smelling odor.

is odorless, but when decomposed or acted upon by bacteria in the skin, it takes on a musky, unpleasant odor. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 699)

XV. ABDOMEN 1. Skin integrity Inspection Unblemished skin; uniform color Flat, rounded(convex), or scaphoid(concave) No evidence of enlargement of liver or spleen Symmetric contour Uniform color and has no blemishes Has a concave abdomen. Normal

2. Abdominal contour

Inspection

Normal

3. Enlargement of liver or spleen

Inspection

No enlargement of the spleen and liver seen

Normal

4.Symmetry of contour

Inspection

Has a symmetrical abdominal contour Abdominal movements noted when inhaling.

Normal

5. Abdominal movements associated with respirations, peristalsis or aortic pulsations

Inspection

Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin persons at epigastric area No visible vascular pattern

Normal

6. Vascular pattern XVI. MUSCULOSKELETAL SYSTEM

Inspection

Has no blood vessels visible

Normal

A. MUSCLES

1. Muscle size and comparison on the other side

Inspection

Proportionate to the body; even in both sides

Proportionate to the body; even in both sides

Normal

2. Fasciculation and tremors in the muscles 3. Muscle tonicity

Inspection

No fasciculation and tremors Even and firm muscle tone

Has no fasciculation and tremors Weak muscle tone

Normal

Palpation

Abnormal, possibly related to the amount of food that patient is eating due to loss of appetite.
(http://en.wikipedia.org/wiki/Muscle_weakness)

4. Muscle strength

Palpation

Has equal muscular strength on both sides

Weak muscle strength

Abnormal, possibly related to the amount of food that patient is eating due to loss of appetite.
(http://en.wikipedia.org/wiki/Muscle_weakness)

C. JOINTS 1. Joint swelling Inspection No swelling, no warmth, no redness, no pain, no crepitus No swelling, no warmth, no redness, no pain. No swelling, no warmth, no redness, no pain, no crepitus No edema, no pain when moved. Warmth to touch. Normal

EXTREMETIES

Inspection, Palpation

Abnormal, patient is febrile with temperature of 38.1 due to disease process. (Fundamentals of Nursing)

Neurologic Assessment:

Category Mental Status Level of Consciousness Orientation Language test Recall

Normal Findings

Actual Findings

Analysis and interpretation

Alert Oriented Coherent Able to remember

Alert Oriented to person, time and place. Coherent Able to state what happened to her in the past.

Normal Normal Normal Normal

Cranial Nerves CN 1 Olfactory CN 11 Optic Able to smell and recognize stimuli 20x20 vision, able to read, 3-5 mm [pupil size] Able to identify the scent of the alcohol Pupil size is 3 mm, able to read, myopia or nearsightedness. Normal

Abnormal, it is a refractive defect of the eye in which collimated light produces image focus in front of the retina when accommodation is relaxed. It is caused by an eyeball that is longer than normal, which may be a familial trait. Transient mayopia occurs due to influenza, steroids, sever dehydration and large intake of antacids. (Black, Medical Surgical Nursing7th
edition, page 1963).

CN III, IV, VI Occulomotor Trochlear Abducens

(+) Extraoccular Movement (EOM); Lateral Upward and downward; pupils reactive to light.

Pupils react to light. There is constriction and consensual accommodation. Able to move the eyes in any direction in unison.

Normal

CN V Trigeminal

Able to feel and clearly identify stimulus, with bilateral facial sensation. With active corneal reflex. (+) Corneal reflex , Facial asymmetry

Able to feel my finger on her face while covering her eyes.

Normal

(+) Facial symmetry Normal CN VII Facial

Can hear clearly and can walk. CN VIII Vestibulocochlear Able to hear clearly, can maintain balance Present gag reflex, able to swallow and able to idebtify the taste of the food. Normal

CN IX, X Glossopharyngeal Vagus

(+) gag reflex, uvula at the center, soft palate rises

Normal

CN XI Accessory (Spinal)

Able to shrug shoulders against resistance and able to turn the head side and against resistance. Able to move tongue from side to side

Can shrug shoulders against resistance and can turn the head fro right to right.

Normal

Able to protrude the tongue and move it side to side. Normal

CN XII Hypoglossal

Muscle Strength

MNT Grading System:

Left Arm

(+5) Active motion against full resistance

+4 active motion against some resistance.

Abnormal, possibly related to the amount of food that patient is eating. Possible exhaustion experienced by the patient when she coughs. (http://en.wikipedia.org/wiki/Muscle_weakness) Abnormal

Right Arm

(+5) Active motion against full resistance (+5) Active motion against full resistance (+5) Active motion against full resistance

+4 active motion against some resistance. Abnormal +4 active motion against some resistance. +4 active motion against some resistance.

Left Leg Right Leg

Abnormal

G. Patterns of Functioning The researchers utilized the Gordons typology in assessing the pattern of functioning of our patient in her life. How does she manages and takes care of herself based on Eleven Patterns. Functional Health Pattern Prior to Hospitalization Health perception- Health Management The patient doesnt have complete immunization because according to her it is not available during those days and having immunization during those years are expensive and they cannot afford it. She was never been hospitalized. No known allergies to any foods and drugs. She can eat fish, oyster and others. Does not experience any accidents. When she had a disease, she used herbal medicines like guava leaves, oregano, lagundi, etc. For her, being healthy is important. A person is healthy when she is strong, she can do what she wants and does not experience any diseases. She does not have any regular medical and dental check-ups. Norms and Standards Measure for personal cleanliness and grooming, called personal hygiene, promote physical and psychological well-being. Various studies have confirmed that improved personal hygiene practices reduce illness rates. (Larson, 2002; Larson and Aiello, 2001). Personal hygiene practices vary widely among people. The time of the day one bathes and how often one shampoo or changes the bed linens, and sleeping garments are relatively unimportant. What is important is that personal care be carried out conveniently and frequently enough to promote personal hygiene. Illness, hospitalization and institutionalization generally require modifications in hygiene practices. In these situations, the nurse helps the patient to continue some hygiene practices, and can teach the patient and family members, when necessary, regarding hygiene. Nurses assist the patient with basic hygiene must respect individual patient preferences, providing only the care that patients cannot or should not provide for themselves.

When she is experiencing something wrong in her body, she does not tell it promptly because according to her it is tolerable. She does not have a regular exercise, instead she cleans the house and washes the clothes of her family. The patient is malnourished. She takes a bath once a day and brushes her teeth once a day. She does use lotion, shampoo and soap. She washes her hands regularly but not always using soap. When she feels discomfort in her body she also goes to the manghihilot because it is available on their area and it is more approachable. She often forgot to cover her mouth and nose when someone sneezes and coughs in front of her. A person has a disease when she eats little amount of food, when she is weak. Health for her is important for proper functioning. Whenever she is sick, she gets money from her children especially to the eldest, which is working abroad. She wears slippers while inside their house. She feels that her hygienic practices are adequate, and she feels clean and neat. The patient is non-smoker and she does not drink any alcoholic beverages. She denies the use any illicit drugs.

(Fundamentals of Nursing 5th edition by Taylor, page 1005). Malnutrition is the lack of sufficient nutrients to maintain healthy bodily functions and is typically associated with extreme poverty in economically developing countries. Most commonly, malnourished people either do not have enough calories in their diet, or are eating a diet that lacks protein, vitamins, or trace minerals. Medical problems arising from malnutrition are commonly referred to as deficiency diseases. Deficiency in micronutrients such as Vitamin A reduces the capacity of the body to resist diseases. Deficiency in iron, iodine and vitamin A is widely prevalent and represent a major public health challenge. An array of afflictions ranging from stunted growth, reduced intelligence and various cognitive abilities, reduced sociability, reduced leadership and assertiveness, reduced activity and energy, reduced muscle growth and strength, and poorer health overall are directly implicated to nutrient deficiencies. (http://en.wikipedia.org/wiki/Malnourishment) The main purpose of washing hands is to cleanse the hands of pathogens (including bacteria or viruses) and chemicals which can cause personal harm or disease, particularly diarrhea and pneumonia. To maintain good hygiene, hands should always be washed after using the toilet, changing a diaper, tending to someone who is sick, or handling raw meat, fish, or poultry, or any other situation leading to potential contamination. Hands should also be washed before eating, handling or cooking food. Conventionally, the use of soap and warm running water and the washing of all surfaces thoroughly, including under fingernails is seen as necessary. Alcohol rub sanitizers kill bacteria, multi-drug resistant bacteria (MRSA and VRE), tuberculosis, and viruses (including HIV, herpes, RSV, rhinovirus, vaccinia, influenza, and hepatitis) and fungus. (http://en.wikipedia.org/wiki/Hand_washing) Herbalists treat many conditions such as asthma, eczema, premenstrual syndrome, rheumatoid arthritis, migraine, menopausal symptoms, chronic fatigue, and irritable bowel syndrome, among others. Herbal preparations are best taken under the guidance of a trained professional. Be sure to consult with your doctor or an herbalist before self-treating. Some common herbs and their uses are discussed below. Please see our monographs on individual herbs for detailed descriptions of uses as well as risks, side effects, and potential interactions.
(http://www.umm.edu/altmed/articles/herbal-medicine-000351.htm)

Nutritional Metabolic Pattern She loves to eat pork, fish and vegetables. She is not choosy when it comes to any cook and kind of food. She eats 3x a day She consumes less food serving size due to loss of appetite brought by

Nutrition is a basic human need that changes throughout the life cycle and along the wellness-illness continuum. (Fundamentals of Nursing 5th edition by Taylor, page 1135) An adequate food intake consists of balance essentials nutrients: water, carbohydrates, fats, proteins, vitamins and minerals. Habits about eating are

disease process. She does not eat any junk foods. She drinks 5 glasses of water a day. For her, the amount of food she consumes is adequate. She takes food supplement but it is not frequent. During snack time, she usually eats banana because it is affordable and readily available in their place. When her cough started, she is not eating the appropriate amount of food. According to her husband, she usually eats 4 spoons of rice with viand only. It is due to her cough and loss of appetite. During her hospitalization, she is on diet as tolerated with aspiration precaution. She eats food given by the hospital. She is taking vitamin B6 and other medications.

affected by many factors like financial and health conditions. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1171,1175) The middle aged adult should continue to eat a healthy diet, following the recommended portions of the 5 food groups, with special attention to protein, calcium and limiting consumption to cholesterol. Two to three liters of fluid should be included in the diet. Pre menopausal women need to ingest sufficient calcium and vitamin d to prevent osteoporosis. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1180,1181) An adult individual needs to balance energy intake with his or her level of physical activity to avoid storing excess body fat. Dietary practices and food choices are related to wellness and affect health, fitness, weight management, and the prevention of chronic diseases such as osteoporosis, cardiovascular diseases, cancer, and diabetes. For adults (ages eighteen to forty-five or fifty), weight management is a key factor in achieving health and wellness. In order to remain healthy, adults must be aware of changes in their energy needs, based on their level of physical activity, and balance their energy intake accordingly. (http://www.faqs.org/nutrition/A-Ap/AdultNutrition.html) Inadequate nutrition is associated with marked weight loss, generalized muscle weakness, altered functional ability, increased susceptibility to infection, impaired pulmonary function and prolonged length of hospitalization. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1190). Elimination can be affected by a persons developmental stage, daily patterns, the amount and quality of fluid or food intake, the level of activity, lifestyle, emotional states, pathologic processes, medication, and procedures such as diagnostic test and surgery. Most people have individual pattern of elimination including frequency, timing considerations, position and place. For most people defecation is a private affair experienced easily only in the comfort of ones own bathroom. Defecation may be difficult in shared hospital room with only a curtain for privacy. (Fundamentals of Nursing 5th edition by Taylor, page 1341) The frequency of defecation is highly individualized, varying from several times per day to two to three times per week. Sufficient bulk in the diet is necessary to provide fecal volume. Bland diets and low-fiber diets are lacking in the bulk and therefore create insufficient residue of waste products to stimulate the reflex for defecation. Low-residue foods such as rice, eggs and lean meats move more slowly through the intestinal tract. (Kozier et.al, Fundamentals of Nursing 7th ed. Page

Elimination She defecates twice a week and sometimes she feels pain and difficulty. According to her the characteristic of her stool is hard, dry and colored dark brown. She feels pain at her abdomen on the hypogastric and umbilical area. She urinates 7x a day and does not feel any pain and difficulty. Previously her defecation pattern is daily, but when her condition exacerbated, it is also affected.

1228). Activity stimulates peristalsis, thus facilitating the movement of chime along the colon. (Fundamentals of Nursing 5th edition by Taylor, page 1229). A persons urinary habits depend on social culture, personal habits and physical abilities. Urine collects in the bladder contains between 250 to 450 ml of urine. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1256). The excretory function of the kidney diminishes with age but usually not significant below normal levels unless disease intervenes. With age, the number of functioning nephrons decreases to some degree, impairing the kidneys filtering abilities. The amount of flood intake affects the urinary frequency of an individual. Foods high in sodium or fluids high in sodium ca cause fluid retention because water are retained to maintain the normal concentration of the electrolyte. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1258-1259). Activity and Exercise She does not have any work, she is a plain house wife, who is in-charge of her children. Her usual activity is cleaning the house, cooking and washing the clothes of her children. She loves to listen to radio programs usually in the afternoon. She likes to converse with her friends and neighborhood. When she cleans, it is usually for 1 hour because she gets easily tired. Her youngest child helps her in the household chores. When after all the chores are done she will rest and watch television. She does not involve her self in any vigorous activities. However, she is aware that her activity is not enough, and she recognizes the importance of having regular exercise. The human body was designed for motion, and regular exercise is necessary for its healthy functioning. Individuals who choose inactive lifestyles or who are forced into inactivity by illness or injury placed themselves at high risk for serious health problems. (Fundamentals of Nursing 5th edition by Taylor, page 1116) Vigorous physical activity is not always needed to achieve positive result. (Fundamentals of Nursing 5th edition by Taylor, page 1117) Lack of exercise, inactivity, or immobility related to illness, or injury place a person at high risk for serious health problems. Immobility can affect the major body systems. Like the benefits, a person receives from exercise, complications resulting from immobility differ occurrence and severity based on the patients age and overall health status. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1118). The wonderful tool of exercise can help teens become fit and healthy. Performing some form of physical activity daily will significantly boost your basal metabolic ratethe number of calories your body burns in order to keep you alive. By having a high metabolism, you burn calories 24 hours a dayeven while you sleep! You can literally turn your body into a fat-burning machine! This has many benefits: With a strong metabolism comes a strong immune system. When you burn fat, the toxins are released into the bloodstream, and are quickly carried out of the body through sweat. This inoculates you against the probability of developing cancerous and diseased cells. Therefore, hard exercise that makes you sweatis very good for you. Exercise also helps to regulate the amount of insulin released into the bloodstream. Insulin is commonly referred to as the fat-making hormone. Its job

is to metabolize blood sugar into energy. But too much insulin in the bloodstream keeps your body from burning stored fat. Years of an overworked pancreas the organ that produces insulincan lead to onset (type 2) diabetes. However, if you useburnmore calories than you consume, you significantly reduce the chances of developing this disease. Exercise can also help control other problems, such as: Sleep apnea, moodiness, stress, decreased energy, cardiovascular disease, high cholesterol and others. There are too many benefits to list here. But be assured that this tool can help you become a fit, stronger, disease-free, and overall healthier person. The main goal of aerobic exercise is to keep the heart elevated for an extended period of time for the purpose of strengthening the heart and lungs. The most common aerobic exercise is walking. Running is the quickest way to lose weight, because it burns many calories. It also tones your calves and thighs. However, to avoid extreme muscle aches or injuries, do not begin a running routine until you have performed two to three months of aerobic walking. (http://www.thercg.org/youth/articles/0201-tioe.html)

Cognitive-perceptual The patient is an elementary graduate. She stops studying because of financial problem She can read and write properly. She is aware to different people or happening around her. She can talk properly. During the interview her voice is weak. According to her she is sensitive to the feelings of the people around her. There are no any blockages of communication noted. She is not always reading any books like pocket books. She can express her feelings appropriately. She does not have any difficulty when it comes to communication. Sleep and Rest The patient regularly sleeps at 8:00pm. The patient sleeps a total of 5 hrs. every night. She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough. She usually sits because according to her she can breath more easily.

Cognition is greatly affected by education. Those who study and develop their skills have better cognitive performances because they have been provided with different information and chances to develop their self. Perception is affected by the sensory diseases. Presence of any sensory abnormalities affects or halters perception that would affect proper communication. (Black, Medical Surgical Nursing7th edition, page 1880). Cognition involves a persons intelligence, perceptual ability and ability to process information. It represents a progression of mental abilities from illogical to logical thinking, from simple to complex problem solving and from concrete to abstract ideas. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 359).

For no known reason, 8 hours of sleep a night has been the accepted standard for adults despite obvious variations seen in the general population. It is important however that a person follows a pattern of rest that maintains well-being. Many factors affect a persons ability to rest. Illnesses and various life situations that causes physiological stress tends to disturb sleep. Sleep quality is also influenced by certain drugs Some decreases REM sleep (barbiturates ,amphetamines and

She takes a nap in the morning from 8 am to 11 am. She feels that her sleep and rest is inadequate. She sleeps together with her husband. They have a separate room from their children. Sleeping is important to her.

antidepressants) and some are seen to cause sleep problems (steroids, caffeine and asthma medications) (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1169-117). The National Sleep Foundation in the United States maintains that eight to nine hours of sleep for adult humans is optimal and that sufficient sleep benefits alertness, memory and problem solving, and overall health, as well as reducing the risk of accidents.[8] A widely publicized 2003 study[9] performed at the University of Pennsylvania School of Medicine demonstrated that cognitive performance declines with fewer than eight hours of sleep. It has also been shown that sleep deprivation affects the immune system and metabolism. In a study by Zager et al in 2007,[21] rats were deprived of sleep for 24 hours. When compared with a control group, the sleep-deprived rats' blood tests indicated a 20% decrease in white blood cell count, a significant change in the immune system. Scientists have shown numerous ways in which sleep is related to memory. In a study conducted by Turner, Drummond, Salamat, and Brown[28] working memory was shown to be affected by sleep deprivation. Working memory is important because it keeps information active for further processing and supports higher-level cognitive functions such as decision making, reasoning, and episodic memory. Turner et al. allowed 18 women and 22 men to sleep only 26 minutes per night over a 4-day period. Subjects were given initial cognitive tests while well rested and then tested again twice a day during the 4 days of sleep deprivation. On the final test the average working memory span of the sleep deprived group had dropped by 38% in comparison to the control group. (http://en.wikipedia.org/wiki/Sleep) Self concept is ones mental image of oneself. A positive self concept is essential to a persons mental and physical health. Individuals with a positive self concept are better able to develop and maintain interpersonal relationship and resist psychological and physical illness. Self concept involves all of these self perceptions, that is, appearance, values and beliefs that influences behaviors and that are referred to when using the words I or me. Body image is ho the person perceives the size, appearance and functioning of the body. If a persons body image closely resembles ones ideal body, the individual is more likely to think positively about the physical and non-physical concept of self. Self concept is also affected by role-strains. People undergoing role-strains are frustrated because they feel or made to feel inadequate or unsuited to a role. Illness and trauma can also affect the self-concept. People responds to different stressors such as illness and alterations in function related to aging in a variety of

Self-perception According to her there is something wrong in her health and body. As a mother, she sometimes feels sad because she cannot do the previous things like going with her husband in the farm. According to her husband she is a good mother and a good wife. Her strength is her family, when there are any circumstances that involving any family member she is concerned and make some moves. She is simple.

Role-relationship She was the fourth child in her family. She is married and they have 6 children. She is performing the trypical responsibilities of a plain house wife. Her children have a good relationship to her. She is being cared by her children who are very supportive to her. Her husband is a good husband he is a provider who does everything for the family to have food. She has a harmonious relationship with her brothers and sisters. Whenever there are any problems, they are helping each other. She can form a healthy relationship with others. She is the person who chooses her friends. She is a very quite person. She does not have any enemies.

Sexuality-reproductive She is engage in sexual activity to her husband only. Presently she is still active in her sex life. She still have regular menstruation. She is aware that she will have cessation of her menstruation. She dresses appropriately, based on her gender. She is also able to express her feminine attitudes.

ways: acceptance, denial, withdrawal and depression are common. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 957-962). Relationship to another person is a developed manner in which there is the sharing of self, showing care and putting trust. A healthy relationship affects an individuals emotional development, it will facilitate the channeling of the ideas, feeling of joy an others. An interpersonal relationship is a relatively long-term association between two or more people. This association may be based on emotions like love and liking, regular business interactions, or some other type of social commitment. Interpersonal relationships take place in a great variety of contexts, such as family, friends, marriage, acquaintances, work, clubs, neighborhoods, and churches. They may be regulated by law, custom, or mutual agreement, and are the basis of social groups and society as a whole. A relationship is normally viewed as a connection between two individuals, such as a romantic or intimate relationship, or a parentchild relationship. All relationships involve some level of interdependence. People in a relationship tend to influence each other, share their thoughts and feelings, and engage in activities together. Because of this interdependence, anything that changes or impacts one member of the relationship will have some level of impact on the other member. Psychologists have suggested that all humans have a basic, motivational drive to form and maintain caring interpersonal relationships. According to attachment theory, relationships can be viewed in terms of attachment styles that develop during early childhood. These patterns are believed to influence interactions throughout adulthood by shaping the roles people adopt in relationships. (http://en.wikipedia.org/wiki/Intimate_relationship) Sexuality is defined not only by a persons genetalia but also by attitudes and feelings. It can also be defined as learned behaviors in how a person reacts to his or her own sexuality and by how one behaves in relationships with others. (Fundamentals of Nursing 5th edition by Taylor, page 931) Sexuality is a crucial part of a persons identity. Sex is central to who we are, to our emotional well-being and to the quality of our lives. The world health organization defined sexual health as the integration of the somatic, emotional, intellectual and social aspect of sexual beings in ways that are positively enriching and that enhances personality, communication and love. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 973). During the middle adulthood both men and women experience decreased hormone production causing the climacteric, usually called menopausal in women. These events often affect the individuals self-concept, body image and sexual

Coping-stress Whenever she has problem, she asks guidance from our Lord She watches television as her stress management. She always listen to radio programs when she feels lonely. When she gets mad, she just keep quiet. When she experiences coughing and difficulty of breathing she just relaxes and breathes deeply. Her husband or children taps her back when she coughs. Value-belief She is a Roman Catholic She attends mass occasionally. She always ask the guidance of our Lord Whenever there are Christian events, like Holy week, she participates in the activities like fasting. She believes in ghosts, and elementals. She seldom reads the bible. Does not always pray the rosary. She respects and obeys her husband. For her education is very important to her children, so she and her husband is doing all the efforts to send their children to school.

identity. Women through the menopausal period experiences hot flushes, vasomotor instability, sleep disturbances, vaginal dryness, genital tract atrophy, mood changes and skin, hair changes. The incidence of osteoporosis and cardiovascular lipid changes also increases. The climacteric in the males is no as dramatic in the females; changes are more gradual. Sexual response love and play involve peoples emotional, psychologic, physical and spiritual make up, which plays a significant role in the satisfaction. Sexual desires fluctuates within each person and varies from person to person. If people suppresses or block out conscous sexual desires, they may not experience any physiological respose. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 975,980). Coping mechanisms which are behaviors used to decrease stress and anxiety. Many coping behaviors are learned, based on ones family past experiences, and sociocultural influences and expectations. (Fundamentals of Nursing 5th edition by Taylor, page 855)

Spiritual well-being is the condition that exists when the universal spiritual needs for meaning and purpose, love and belonging, and forgiveness are met. O Briens conceptual model of spiritual well-being in illness identified three empirical referents of spiritual well-being: personal faith, religious practice and spiritual contentment. Spiritual beliefs are of special importance to nurses because of the many ways they can influence a patients level of health and self-care behaviors. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 975,979). Spiritual well-being is manifested by a generally feeling of being alive, purposeful and fulfilled. People nurture or enhance their spirituality in many ways. Some focus on development of the inner self or world; others focus on the expression of their spiritual energy with others or outer world. Relating to ones inner self or soul may be achieved through conducting an inner dialogue with a higher power or with ones self through prayer or medications. The expression of a persons spiritual energy to others is manifested in loving relationship with and service to others, joy and laughter and participation in religious services and associated fellow gatherings and activities and by expression of compassion, empathy, forgiveness and hope. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 996).

H. Activities of Daily Living

1.

ASPECT Nutrition

2.

Elimination

PRIOR TO HOSPITALIZATION Patient loves to eat meat, fish and vegetables. She eats anything that is being served to her. She does not eat junk foods. She is not taking food supplements like vitamins frequently. She eats 4 spoons of rice with viand because according to her it is due to her cough and loss of appetite. She eats thrice a day. Patient voids 7 times a day, and defecate twice a week. She doesnt experience any pain and difficulty in terms of urination. Previously her defecation pattern is daily, but when her condition exacerbated, it is also affected.

DURING HOSPITALIZATION The patient is on diet as tolerated with aspiration precaution. She eats dry, thickened food on a small frequent feeding. She is advised to chew food properly.

INTERPRETATION and ANALYSIS The patient can eat any food she wants as long as it is dry, thickened, and frothy. It should be in a small frequent feeding, as to avoid aspiration.

The patient does not defecate or urinated during the conduct of the interview.

The patient does not defecate for more than a week due to decreased gastric motility related to decrease physical activity. For most people defecation is a private affair experienced easily only in the comfort of ones own bathroom. Defecation may be difficult in shared hospital room with only a curtain for privacy. (Fundamentals of Nursing 5th edition by Taylor, page 975 & 979) The patient performs deep breathing exercise as instructed by the nurse.

3.

Exercise

Cleaning their house is the only activity she considered as her exercise. She does not have routine exercise. However, she is aware that her activity is not enough, and she recognizes the importance of having regular exercise. She loves to listen to radio programs usually in the afternoon. When after all the chores are done she will rest and watch television.

Deep breathing and coughing exercises are advised and performed. The patient has decreasing function as the disease progresses.

4.

Hygiene

5.

Substance Use

Patient takes a bath every day, brushes her teeth once a day. She wears slippers while inside their house. She feels that her hygienic practices are adequate, and she feels clean and neat. There is body odor noted. Patient is a non-smoker and denies use of illicit drugs. She does not drink alcohol.

The patient is advised to use disposable mask; isolate/dispose used tissues properly; frequent hand washing; cover mouth and nose when sneezing and coughing. The patient doesnt use any prohibited substances like alcohol, cigarettes and illicit drugs. Patient stated she can sleep at: Day shift: 9am-10am 3pm-5pm Night shift: 9pm-11:30pm 1am-5am Patient verbalized that she had adequate sleep and rest during confinement than at home. Not applicable

Avoid transmission of microorganisms among patients and hospital worker. (Fundamentals of Nursing) The patient does not use any addictive substances. Illicit drugs are strictly prohibited in the hospital premises, even cigarette smoking and alcohol drinking. Many factors affect a persons ability to rest, illness and various life situations that causes physiological stress tends to disturb sleep quality is also influence by certain drugs that are seen to cause sleep problems such as: Steroids Caffeine Asthma medications (kozier et. Al, Fundamentals of Nursing 7TH edition page 1169) Not applicable

6.

Sleep and Rest

Sleeping is important to her. She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough. She takes a nap during breaktime, from 12 noon to 1 pm. She sleeps together with her husband. The patient regularly sleeps at 8:00pm and wakes up at 1:00 am. She feels that her sleep and rest is inadequate because of her conditions. She dresses appropriately, based on her gender. She still has regular menstruation. She is engage in sexual activity to her husband only. Presently she is still active in her sex life

7.

Sexual Activity

I.

Patients Concept about Health, Illness and Hospitalization ILLNESS For the patient, an individual is weak and eats little amount of food. HOSPITALIZATION The patient looks at hospitalization as the last recourse when one has an illness. For the patient, it is the place where an individual is being treated from severe cases. - Placement of an individual in a hospital for observation, diagnostic test, or treatment for some

HEALTH The patient believes that being healthy is being strong, does not experience any sickness and energetic. - Health is defined as a state of complete physical, mental and social well-being and not merely the

-Is a disease, sickness or the condition of being in a poor

absence of disease or infirmity. WHO definition

health, either physically or mentally. (Blackwells Nursing Dictionary)

diseases. (Blackwells Nursing Dictionary)

J.

Laboratory and Diagnostic Examination Blood examinations

DATE Dec. 13, 2013

PROCEDURE Hemoglobin Hematocrit RBC count WBC Neutrophils Lymphocytes

NORMS 120-160g/L 0.38-0.40 g/L 4.2-5.4x 1012 per liter 5-10x109/L 81.3% 10.2%

RESULT 110 g/L 0.33 g/L 4.8 x 10 15.2 x 10 84.1% 8.6 %

Basophils Monocytes Eosinophils Platelets Fasting Blood Sugar Creatinine Na K Sputum AFB SPUTUM COLLECTION 1st collection

0.1% 7.5% 0.9% 150-450x109/L 70-110 mg/dl 44.2-106.08 umol/L 135-145mmol/L 3.6-5.5mmol/L

0.1 % 6.3 % 0.9 % 234 x 10 96 mg/dl 98.8 umol/L 136mmol/L 4.1mmol/L

INTERPRETATION and ANALYSIS LOW Due to malnutrition; anemia LOW Due to malnutrition, slight dehydration NORMAL HIGH Leukocytosis indicates infection HIGH Acute bacterial infection LOW Low lymphocyte concentration associated with increase rate of infection NORMAL LOW Depleted in overwhelming bacterial infection NORMAL NORMAL NORMAL Normal NORMAL NORMAL

Dec. 20,2013 POSITIVE

2nd collection

POSITIVE

Positive for Mycobacterium tuberculosis in the active stage of the disease. Urinalysis Specimen Color Appearance Specific gravity pH protein glucose ketones bilirubin blood bacteria Electro Cardiogram normal findings Chest X-ray The patient had undergone chest x-ray upon admission. The film shows presence of infiltrates or clouds. The right is smaller than the left lung, particularly the lower lobe of the right lung. K. Impression/Diagnosis Dr. Gonzales, the patients attending physician, who diagnosed the disease as Pulmonary tuberculosis. This diagnosis is supported by the pathognomonic signs that manifested by the patient. These include intermittent fever in the afternoon, difficulty of breathing, coughing, weight loss and chest pain. This diagnosis is supported by the following diagnostic exam such as sputum AFB and chest x-ray. free catch yellow cloudy 1.038 7.0 negative negative negative 1+ negative few

L.

Course in the Ward The patient was accompanied by her husband and her children. While waiting for the doctor, she was placed in a wheel chair.

DATE

MEDICAL PROCEDURES/ORDERS

NURSING ASSESSMENT and FUNCTION

September 19, 2013

- History taking - Physical assessment - Neurological Assessment - Chest-x-ray - IVF of PNSS 1 liter to run for 12 hours. - Medications Acetylcysteine dissolved in glassof water TID B complex 2 ampules TIV stat Cefuroxime 500 mg/Cap Theophylline 1 cap TID Salbutamol + ipratropium neb, 1 neb every 6 hours - Diet as Tolerated with aspiration precaution.

Upon admission: -GCS E4 V5 M6 - Vital signs BP- 90/60 mmHg, CR: 84 bpm, RR: 36 cpm, T-38.1 C - IV insertion done at the right arm, infusing well. -Due meds given - X-ray result obtained. - History taking - Physical assessment done - Neurologic assessment done -crackles noted upon auscultation. 2:40 AM -Received from ER to Medicine ward. - Placed in pulmonary ward - Patient was oriented. - Kept rested -Advised relatives to use mask and hand washing regularly. - On DAT with aspiration precaution

M. Ecologic Model Hypothesis The patient developed PTB thru the inhalation of mycobacterium tuberculosis due to being exposed to an environment, specifically in their community, where in some people around her have Pulmonary Tuberculosis. Not always covering her nose and doing proper hand washing are the practices that have predisposes the patient to develop the disease. She had come in close contact with people who had PTB. Agent Host 46 yrs old Female Filipino, Roman Catholic Tuberculosis is a common and deadly infectious disease caused by mycobacterium mainly Mycobacterium tuberculosis. Mycobacterium tuberculosis. A rod-shaped organism. The disease is directly transmitted through inhalation of organisms directly into the lungs.

Highest educational attainment: Elementary graduate. Living together with her family in Navotas city Have incomplete vaccination. Practices hand washing but improper without soap. Takes a bath once a day and brushes teeth once. Does not always cover her nose and mouth in situations needed to. Does not have a regular medical check up. Exposed to a person who is carrier of M. Tuberculosis.

Environment The patient resides in a crowded community where in cases with Tuberculosis is present. The present environment where she resides is not polluted. TB is an airborne infection. People who are most commonly infected are those who have repeated close contact with an infected person.

The researchers used the epidemiologic web causation model, in which this model focuses to the complex multi factorial causes of a disease.

Financial insufficiency.

Does not have a regular medical check up.

Does not regularly take vitamins and minerals

Does not always cover her nose and mouth when exposed to a person who coughs or sneezes.

Educational attainment.

Inadequate of knowledge about health management. .

HOST Infected of Tuberculosis Meningitis.

Weakened immune system

Lack of immunizations

Degener ation of healthy cells.. Taking a bath once a day and brushing teeth only once.

Airborne transmission Does not practice proper hand washing.

Exposure to a carrier of M. tuberculosis.

Mayco Bacterium Tuberculosis Analysis PTB is caused by mycobacterium tuberculosis. This bacterium enters the host thru the nose and mouth. It first affects the alveoli of the lungs then this bacterium spreads thru the bloodstream. This bacterium migrates to other parts of the body.

Hand washing has been the most effective means of preventing transfer. It is the true prevention. Not covering the nose and mouth when someone sneezes or coughs causes the bacteria in their sputum to travel through the air. The so called airborne transmission will now take place affecting the individual. Living in an unhealthy place predisposes the individual to develop certain diseases especially those within the respiratory system. (Brunner and Suddarths Textbook of Medical- Surgical Nursing 11th ed by Smeltzer et al p. 643)

Conclusion and recommendation The researchers therefore conclude that PTB can be prevented if we always clean the environment, practicing proper hand washing, personal hygiene and use of personal protective equipments are the things that are very important. Personal discipline is a crucial factor. As nurses, they are focused on promoting wellness through health education especially to that of the poor. III, CLINICAL DISCUSSION OF THE DISEASE A. Anatomy and Physiology Respiration is the process by which living organisms take in oxygen and release carbon dioxide. The human respiratory system, working in conjunction with the circulatory system, supplies oxygen to the body's cells, removing carbon dioxide in the process. The exchange of these gases occurs across cell membranes both in the lungs (external respiration) and in the body tissues (internal respiration). Breathing, or pulmonary ventilation, describes the process of inhaling and exhaling air. The human respiratory system consists of the respiratory tract and the lungs. Respiratory tract The respiratory tract cleans, warms, and moistens air during its trip to the lungs. The tract can be divided into an upper and a lower part. The upper part consists of the nose, nasal cavity, pharynx (throat), and larynx (voice box). The lower part consists of the trachea (windpipe), bronchi, and bronchial tree. The nose has openings to the outside that allow air to enter. Hairs inside the nose trap dirt and keep it out of the respiratory tract. The external nose leads to a large cavity within the skull, the nasal cavity. This cavity is lined with mucous membrane and fine hairs called cilia. Mucus moistens the incoming air and traps dust. The cilia move pieces of the mucus with its trapped particles to the throat, where it is spit out or swallowed. Stomach acids destroy bacteria in swallowed mucus. Blood vessels in the nose and nasal cavity release heat and warm the entering air.

Air leaves the nasal cavity and enters the pharynx. From there it passes into the larynx, which is supported by a framework of cartilage (tough, white connective tissue). The larynx is covered by the epiglottis, a flap of elastic cartilage that moves up and down like a trap door. The epiglottis stays open during breathing, but closes during swallowing. This valve mechanism keeps solid particles (food) and liquids out of the trachea. If something other than air enters the trachea, it is expelled through automatic coughing. Alveoli: Tiny air-filled sacs in the lungs where the exchange of oxygen and carbon dioxide occurs between the lungs and the bloodstream. Bronchi: Two main branches of the trachea leading into the lungs. Bronchial tree: Branching, air-conducting subdivisions of the bronchi in the lungs. Diaphragm: Dome-shaped sheet of muscle located below the lungs separating the thoracic and abdominal cavities that contracts and expands to force air in and out of the lungs. Epiglottis: Flap of elastic cartilage covering the larynx that allows air to pass through the trachea while keeping solid particles and liquids out. Pleura: Membranous sac that envelops each lung and lines the thoracic cavity. Air enters the trachea in the neck. Mucous membrane lines the trachea and C-shaped cartilage rings reinforce its walls. Elastic fibers in the trachea walls allow the airways to expand and contract during breathing, while the cartilage rings prevent them from collapsing. The trachea divides behind the sternum (breastbone) to form a left and right branch, called bronchi (pronounced BRONG-key), each entering a lung. The lungs The lungs are two cone-shaped organs located in the chest or thoracic cavity. The heart separates them. The right lung is somewhat larger than the left. A sac, called the pleura, surrounds and protects the lungs. One layer of the pleura attaches to the wall of the thoracic cavity and the other layer encloses the lungs. A fluid between the two membrane layers reduces friction and allows smooth movement of the lungs during breathing. The lungs are divided into lobes, each one of which receives its own bronchial branch. Inside the lungs, the bronchi subdivide repeatedly into smaller airways. Eventually they form tiny branches called terminal bronchioles. Terminal bronchioles have a diameter of about 0.02 inch (0.5 millimeter). This branching network within the lungs is called the bronchial tree. The terminal bronchioles enter cup-shaped air sacs called alveoli (pronounced al-VEE-o-leye). The average person has a total of about 700 million gas-filled alveoli in the lungs. These provide an enormous surface area for gas exchange. A network of capillaries (tiny blood vessels) surrounds each alveoli. As blood passes through these vessels and air fills the alveoli, the exchange of gases takes place: oxygen passes from the alveoli into the capillaries while carbon dioxide passes from the capillaries into the alveoli. This processexternal respirationcauses the blood to leave the lungs laden with oxygen and cleared of carbon dioxide. When this blood reaches the cells of the body, internal respiration takes place. The oxygen diffuses or passes into the tissue fluid, and then into the cells. At the same time, carbon dioxide in the cells diffuses into the tissue fluid and then into the capillaries. The carbon dioxide-filled blood then returns to the lungs for another cycle.

Breathing Breathing exchanges gases between the outside air and the alveoli of the lungs. Lung expansion is brought about by two important muscles, the diaphragm (pronounced DIE-a-fram) and the intercostal muscles. The diaphragm is a dome-shaped sheet of muscle located below the lungs that separates the thoracic and abdominal cavities. The intercostal muscles are located between the ribs. Nerves from the brain send impulses to the diaphragm and intercostal muscles, stimulating them to contract or relax. When the diaphragm contracts, it moves down. The dome is flattened, and the size of the chest cavity is increased. When the intercostal muscles contract, the ribs move up and outward, which also increases the size of the chest cavity. By contracting, the diaphragm and intercostal muscles reduce the pressure inside the lungs relative to the pressure of the outside air. As a consequence, air rushes into the lungs during inhalation. During exhalation, the reverse occurs. The diaphragm relaxes and its dome curves up into the chest cavity, while the intercostal muscles relax and bring the ribs down and inward. The diminished size of the chest cavity increases the pressure in the lungs, thereby forcing air out. A healthy adult breathes in and out about 12 times per minute, but this rate changes with exercise and other factors. Total lung capacity is about 12.5 pints (6 liters). Under normal circumstances, humans inhale and exhale about one pint (475 milliliters) of air in each cycle. Only about three-quarters of this air reaches the alveoli. The rest of the air remains in the respiratory tract. Regardless of the volume of air breathed in and out, the lungs always retain about 2.5 pints (1200 milliliters) of air. This residual air keeps the alveoli and bronchioles partially filled at all times.

B. Drug Study

GENERIC / BRAND NAME Theophylline

ACTION

CLASSIFICATION

INDICATION

CONTRAINDICATION

SIDE EFFECTS

NURSING INTERVENTION

-The main mechanism of action of theophylline is that of adenosine receptor antagonism. - Theophylline is a nonspecific adenosine antagonist, antagonizing A1, A2, and A3 receptors almost equally, which explains many of its cardiac effects and some of its antiasthmatic effects.

- Mild stimulant -Bronchodilator

- For chronic obstructive diseases of the airway. -COPD

- Hypersensitivity - Pregnant.

-Stomach stomach -pain -Diarrhea -Headache - Restlessness - Insomnia - Irritability

- Monitor patients heart rate. - Assess for CNS effects. - Teach the patient to avoid smoking. - Educate the importance of taking the right amount in the right time of medications. - Assess for any hypersensitivity.

Salbutamol

- A short-acting 2adrenergic receptor agonist used for the relief of bronchospasm in conditions such as asthma and chronic obstructive pulmonary disease.

- Bronchodialtor

-Relief and prevention of bronchospasm in patients with reversible obstructive airway disease -Inhalation: Treatment of acute attacks of bronchospasm -Prevention of exercise-induced bronchospasm.

-Contraindicated with hypersensitivity to albuterol. -Use cautiously with diabetes mellitus (large IV doses can aggravate diabetes and ketoacidosis).

-Dizziness, drowsiness, fatigue, headache. - vomiting, change in taste

- Assess for any hypersensitivity to albuterol. - Be cautious when driving. -Eat food is a small frequent way. - Maintain betaadrenergic blocker on stand by.

Vitamin B

- Support and increase the rate of

- Water soluble Vitamin

- Encourage patient to take the vitamin regularly.

metabolism. - Maintain healthy skin and muscle tone - Enhance immune and nervous system function. - Promote cell growth and division including that of the red blood cells that help prevent anemia. Cefuroxime - Inhibits bacterial cell wall synthesis by binding to one or more of the penicillinbinding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. -Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested. -Is any agent which dissolves thick mucus usually used to help relieve respiratory difficulties. - Antibacterial - Treatment of infections caused by staphylococci and other microorganisms like klebsiella. - Treatment of susceptible infections of the lower respiratory tract - Hypersensitivity to cefuroxime and other cephalosphorine. - GI bleeding - Headache - Nausea - Dizziness - Vomiting - Increased BUN and Creatinine

- Encourage them to go to the doctor before drinking any vitamins.

- Observe for signs and symptoms of anaphylaxis during first dose; with prolonged therapy, monitor renal, hepatic, and hematologic function. - Educate the importance of taking the right amount in the right time of medications. - Assess for any hypersensitivity.

Acetylcysteine

Mucolytic

-Acute & chronic respiratory tract affections w/ abundant mucus secretions. -

-Contraindicated with asthmatic patients and patients with history of peptic ulceration.

-Urticaria, bronchospasm, nausea, vomiting. Aerosol treatment: Rhinitis, stomatitis.

-Should be taken with food -The sachet should be dissolve into a glass of cold or warm water, and drink

(hydrolyzing glycosaminoglycans: tending to break down/lower the viscosity of mucincontaining body secretions/component s).

Used in the treatment of wet cough.

immediately. -Do not dissolve other medicines together with acetylcysteine, since both acetylcysteine and the other drug effect could be influenced or cancelled. - Assess for any allergies. Severe hypersensitivity to isoniazid or in clients with previous isoniazid associated hepatic injury or side effects. Active liver disease. Peripheral neuropathy, nausea & vomiting, heartburn, dizziness, optic neuritis, hepatitis - store in dark, tightly closed containers - administer with pyridoxine, 10-50 mg/day, in malnourished, alcoholic, or diabetic clients to prevent symptoms of peripheral neuropathy. When used for tuberculosis, continue therapy for 6-9 months.

Isoniazid

The most effective tuberculostatic agent. Probably interferes with lipid and nucleic acid metabolism of growing bacteria, resulting in alteration of the bacterial wall. Is tuberculostatic. Suppresses RNA synthesis by binding to the beta subunit of DNA-dependent RNA polymerase. This prevents attachment of the enzyme to DNA and blockade of RNA transcription. Both bacteriostatic and bactericidal; most active against rapidly replicating organisms.

Antitubercular drug

Tuberculosis caused by human, bovine, and BCG strains of Mycobacterium tuberculosis

Rifampin

Antitubercular drug

All types of tuberculosis. Must be used in conjunction with at least one other tuberculostatic drug, but is the drug of choice for retreatment.

Hypersensitivity; not recommended for intermittent therapy.

Diarrhea, nausea & vomiting, headache, drowsiness, anorexia, sore mouth/tongue, flushing

IV Fluid Treatment / Infusion Classification Indication Contraindication Nursing Responsibilities *Do not connect flexible plastic containers of intravenous solutions in series, i.e., do not piggyback connections. Such use could result in air embolism due to residual air being drawn from one container before administration of the fluid from a secondary container is completed. *CHF *Freshwater drowning *Diabetic ketoacidosis(DKA) *Pressurizing intravenous solutions contained in flexible plastic containers to increase flow rates can result in air embolism if the residual air in the container is not fully evacuated prior to administration. *Use of a vented intravenous administration set with the vent in the open position could result in air embolism. Vented intravenous administration sets with the vent in the open position should not be used with flexible plastic contain.

*Hypovolemia *Heat-related emergencies Plain NSS Isotonic

IV NURSING PROCESS A. Long Term Objective After two month of intensive treatment the patient will not experience the signs and symptoms of PTB. The complications brought about by PTB will be prevented through proper participation to the different medical and nursing interventions. B. Problem List

CUES Subjective Cues: - Patient verbalized, Matagal na akong

NURSING PROBLEM Difficulty of breathing

RANK 1

JUSTIFICATION Airway must be given the first attention as based on the rule of ABC which is Airway, Breathing and Circulation. In

inuubo.Nahihirapan na akong huminga. Objective Cues: - Presence of adventitious breath sound (Crackles) upon auscultation. -The patient is coughing with phlegm. - Oriented - GCS E4V5M6 - BP- 90/60 mmHg, CR: 84 bpm, RR: 36 cpm, T38.1 C - Difficulty vocalizing - Has hallow eyes. - Bluish nail beds. -use of axillary muscles when breathing Subjective: -The husband of the client verbalized, Naku hindi na nawala ang lagnat ng asawa ko, pabalik-balik na lang Objective: -Flushed skin; warm to touch -Increase body temperature higher than normal range -Increased respiration RR= 36cpm -The patient is sweating -T: 38.1C Subjective: - The patient is only eating 4 spoons of rice with viand. - The relative verbalized Hindi siya nakakakain ng maayus dahil sa kanyang ubo. Objective: - The patient weight is 31.5 kilograms. - Poor muscle tone. - Appears weak. Imbalanced Nutrition: Less than Body Requirements related to loss of appetite secondary to deceased process. 3 Hyperthermia related to infection as evidenced by increased WBC 2

addition, difficulty of breathing can cause anxiety to the client that is why, immediate attention must be done. Addressing the problem to proper health care provider will give patent airway to the client. Oxygenation is a vital need for every cell, if there are any problems related to it can easily affect the functioning of the individual. Retained secretions can cause blockage of airway which will further cause difficulty of breathing (Fundamentals of Nursing 7th ed by Kozier et al. p. 1299)

This demands immediate treatment/care and subsequent medical attention, as they can result in delirium and convulsions. This is an actual problem that needs to addressed. Lack of action in this health care problem may cause dehydration which may later cause a bigger threat to the health of the client.

This condition needs to be addressed immediately for the client to be able to gain enough strength in performing her usual activities. The body obtains energy in the form of calories from carbohydrates, protein and fat. The body uses energy for voluntary activities such as walking and in involuntary activities such as breathing. (Fundamentals of Nursing 7th ed by Kozier et al.)

- Minimal subcutaneous fat. - can eat half serving of hospital food only Subjective: - The husband verbalizes that her wife is easily getting tired. Her maximum work is one hour only, and then she would go to rest. - Her usual activities is cleaning the house, cooking and washing the clothes. Their children help her wife.

Activity intolerance related to inadequate oxygen supply as evidenced by easy fatigability.

This nursing diagnosis is not life threatening and doesnt need immediate attention, however, it can affect the bodys normal functioning Individuals who have inactive lifestyles or who are faced with inactivity because of illness or injury are at risk for many problems that can affect major body systems. Clients experience a significant decrease in the muscular strength and agility whenever they do not maintain a moderate amount of physical activity. (Fundamentals of Nursing 7th ed by Kozier et al. p. 1068). This condition doesnt need immediate attention but needs to be addressed for sleep is a basic human need. A lack of rest for long periods can cause illness or worsening of existing illness. (Fundamentals of Nursing, 6 th ed by Potter and Perry p. 1206)

Subjective: - The patient regularly sleeps at 8:00pm and wakes up at 1:00 pm. - She usually sits because according to her she can breath more easily. - She takes a nap in the morning from 8 am to 11 am. - She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough. C. ASSESSMENT Nursing Care Plan NURSING DIAGNOSIS Ineffective breathing pattern related to difficulty of breathing as evidenced by increased RR and presence of crackles on both lung fields.

Sleep Deprivation related to prolonged physical discomfort (dyspnea) as evidenced by inability to concentrate

BACKGROUND KNOWLDEGE Intermediate Cause: - Retained secretions in the respiratory tract. Intermediate Cause: - Inflammatory response

GOAL and OBJECTIVES Short term Goal: Objectives: Within 15-30 mins of nursing intervention the patient will be able to experience

NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective Cues: - Patient verbalized, Matagal na akong inuubo. Nahihirapan akong huminga. Objective Cues: - Presence of

Objective 1: Independent-Facilitative: 1. Obtain vital signs of the patient.

- Health status is regulated through homeostatic mechanisms. A change in V/S might indicate health change. (Taylor et.al, FON 5th ed. Page 523)

A. After 15-30 mins of nursing interventions the patient was able to experience relief from difficulty of

adventitious breath sound (Crackles) upon auscultation. - presence of productive cough - nasal flaring - RR = 36cpm - use of accessory muscles in breathing - bluish nail beds

Root Cause: - Bacterial infection of the respiratory system. Health Implication: This condition can cause Acute Respiratory Distress Syndrome (ARDS) which results from the combination of infection and inflammatory response. The lungs become quickly filled with fluid and become very stiff. This stiffness, combined with difficulties extracting oxygen due to the alveolar fluid creates a need for ventilation. Septic shock is one potential complication. (Black, Medical Surgical Nursing 7th ed. Page 1896)

effective breathing pattern as evidenced by RR within normal range. Long term goal: Within 4-8 hours of nursing intervention the patient will be able to maintain normal breathing pattern as evidenced by RR in normal range, absence of nasal flaring and use of accessory muscle.

2. Observe for respiratory rate and rhythm; presence of nasal flaring; and use of accessory muscles when breathing like the diaphragm and coastal muscles. 3. Perform the Blanch Test.

-Nasal flaring and use of accessory muscles indicates increased effort is required for breathing.

- Blanch test reflects the adequacy of o2 circulation in the periphery. 4. Auscultate the lungs to note any lung sounds. -Crackles are intermittent sounds that occur when air moves through airway that contain fluids. (Taylor et.al, FON 5th ed. Page 1386) -Tapping the chest can loosen the secretions. (Taylor et.al, FON 5th ed. Page 1251) -Suction removes secretions through the use of a strong pressure.

Objective 2: Independent- Facilitative: 1. Perform Chest physiotherapy.

Dependent-Facilitative: 1. Suction secretion as needed.

breathing as evidenced by RR 26cpm. Goal partially met. B. After 4-8 hours of nursing intervention patient was able to maintain normal breathing pattern as evidenced by RR ranging from 18-20 cpm, absence of nasal flaring and use of accessory muscles in breathing. Goal successfully met.

2. Increase the amount of oral fluid intake as ordered by the doctor.

- Current data indicates that fluid restriction may actually reduce blood volume and decrease cerebral circulation. The lack of volume causes the blood to be thick and sluggish and may decrease the mobilization of nutrition and toxins out of

Dependent-Supplemental: 1. Administer bronchodilators as ordered.

Objective 3: Independent-Facilitative: 1. Elevate the head of the bed. 2. Position the head in the midline of the body.

the circulation. Patient should be maintained in a euvolemic state rather than a fluid-restricted state. (Black, MSN 7th ed. Page 2201) - They act on the respiratory tract, it opens narrowed airways. (Black, MSN 7th ed. Page 1652) - For maximal lung expansion that will improve oxygen delivery. -Position changes allow free movement of the diaphragm and expansion of the chest wall. (Taylor et.al, FON 5th ed. Page 1396)

Asessment

Nursing Diagnosis

Background Knowledge

Goal And Objectives

Nursing Interventions

Rationale

Evaluation

EFFECTIVENESS Subjective: -The husband of the client verbalized, Naku hindi na nawala ang lagnat ng asawa ko, pabalik-balik na lang Hyperthermia related to inflammatory response as evidenced by warm to touch skin and temperature of 38.1 C Etiology Immediate Cause: Inflammatory response of the body against microorganisms. After 30- 40 minutes of nursing interventions, the client will be able to lessen temperature from 38 C to less than 37.7 C

1. After 5 minute of nursing intervention, the family of the client able to assess for the causative/ contributing factor/s that may alter the condition of the

INDEPENDENT Objective: -Flushed skin; warm to touch -Increase body temperature higher than normal range -Increased respiration , RR= 36 cpm -The patient is sweating -T: 38.1C Intermediate Cause: Infection of M. Tuberculosis Root Cause: Weakened immune system. 1. After 5 minute of nursing intervention, the family of the client will be able to assess for the causative/ contributing factor/s and be able to participate in one intervention. Identify underlying cause (in our case it is due to inflammatory response cause by the disease process) To know for the right treatment to be given.

patient. 2. After 15 minutes of nursing intervention the family of the client able to evaluate effects of hyperthermia and able to participate in some of the intervention that they may render to reduce bodys temperature of the patient.

Health Implication: Fevers of 104 F (40 C) or higher demand immediate home treatment and subsequent medical attention, as they can result in delirium and convulsions,

2. After 15 minutes of nursing interventions, the family of the client will be able to evaluate effects of hyperthermia and be able to participate in at least 3 out of 4 interventions.

INDEPENDENT Monitor patients vital signs. Give particular attention to the temperature. Temperature of 102F106F (38.9C- 41.1C) suggests acute infectious disease process. Fever pattern may aid in diagnosis; eg 24 hour period suggest septic episode, septic endocarditis or Tuberculosis (TB). Chills often precede temperature spikes. [Nursing Care Plans Edition 6, page 667. Copyright 2002 by Marilyn E. Doenges, RN, BSN, MA, CS] To note for further care to be given. Oliguria and/or renal

3. After 15 minutes of nursing intervention the family of the client able to attain wellness after some of the dependent and independent nursing intervention that Efficiency: After 40 minutes of nursing intervention the patients temperature decreased from 38.1C to 37.4C.

Assess for presence of posturing or seizures. Monitor/ record all sources

of fluid loss such as urine.

failure may be occurring due to hypotension, dehydration. [NANDA] Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat or sweat gland dysfunction. [NANDA] Used to reduce fever by its central action on the hypothalamus; fever should be controlled in patients who are neutropenic or asplenis. However, fever may be beneficial in limiting growth of organisms and enhancing autodestruction of infected cells. [Nursing Care Plans Edition 6, page 667. Copyright 2002 by Marilyn E. Doenges, RN, BSN, MA, CS]

Appropriateness: -All of the following intervention helps in decreasing patients body temperature, maintaining it in normal range and monitoring in progress of the condition. Acceptability: The family and the patient has willfully accepted and be able to participate in the interventions done to the patient.

Note presence/ absence of sweating as body attempts to increase heat loss by evaporation, conduction and diffusion. DEPENDENT Administer antipyretics as orederd; paracetamol 500 mg/tab 1 tab q4 prn T>37.8 C

3. After 15 minutes of nursing interventions, the family of the client will be able to assist with measures to reduce body temperature and

INDEPENDENT Provide tepid sponge baths; avoid use of alcohol. May help reduce fever. Note: use of ice water/ alcohol may cause chills,

participate in at least 3 out of 4 interventions.

actually elevating temperature. In addition, alcohol is very drying to skin. [Nursing Care Plans Edition 6, page 667. Copyright 2002 by Marilyn E. Doenges, RN, BSN, MA, CS]

DEPENDENT Administer replacement fluids and electrolytes.

To support circulating volume and tissue perfusion. [NANDA] To meet increased metabolic demands. [NANDA]

4. After 2 minutes of nursing intervention, the family of the client will be able to promote wellness and give 2 out of 2 interventions.

Provide high-calorie diet, tube feedings or parenteral nutrition.

INDEPENDENT Discuss importance of adequate fluid intake. Review signs and symptoms of hyperthermia (eg. Flushed skin, increased body temperature, increased respiratory/heart rate).

To prevent dehydration. [NANDA]

Indicates need for prompt intervention.

D. Discharge Planning Medications Continue Taking the Anti-TB drugs. The intensive phase is for 2 months and the maintenance phase is for 4 months. Medicines are readily available at TB- DOTS since the patient was enrolled for the TB-DOTS program.

Exercise/Economic Factor

Practice deep breathing exercise and coughing exercises. Resume previous activities. Prevent extraneous work. Have a regular physical exercise like brisk walking for 30 minutes daily. For financial insufficiency, there are government drug stores available. The patient may continue her work in the factory. Follow faithfully the regimen for tuberculosis, especially the medications. Have a regular sputum test and chest x-ray , as ordered by the doctor to monitor progress of the decease. The client should practice hand washing regularly. Always cover the mouth and the nose when exposed to person who coughs or sneezes. She should not spit anywhere, instead spit in a single container to prevent transfer of M. Tuberculosis. Always have a regular check up at your nearest health center, at least once a week to monitor the progress of the treatment. The client should report immediately to the physician if there is difficulty of breathing, there is productive cough more than 5 days and there is chest pain and experiencing fatigue. The diet should be high caloric. Always drink a lot of water. Also eat fruits and vegetables. Dont skip meals. If there are any food supplements available, consult it with the doctor. Eat vitamin c rich food to strengthen immune systems. Always pray for the guidance of the Lord. Spiritual health affects the wellness of an individual greatly. Strengthen relationship with Lord by showing love and respect to the people around you. May continue/resume sexual activity.

Treatment

Health Teaching

Out-patient Follow-up

Diet

Spiritual/Sexual Activities