UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION SALINAS DRIVE, LAHUG, CEBU CITY COLLEGE OF NURSING

A CLINICAL CASE PRESENTATION ON PULMONARY TUBERCULOSIS WITH PNEUMONIA EMERGENCY ROOM

SUBMITTED TO THE FACULTY OF THE COLLEGE OF NURSING

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF BACHELOR OF SCIENCE IN NURSING

SUBMITTED BY: MIRA, ARVIN T. BSN-IVG MARCH 14, 2008 DATE

Clients Profile Name of Patient: Mr. Miguel B. Taipen Age: 55-y.o. Sex: M Status: Married Address: Balamban, Cebu Date of Birth: January 12, 1953 Birth Place: Balamban, Cebu Ed. Background: Elementary Graduate Occupation: Self-employed

Definition of the Disease

Pulmonary Tuberculosis is a chronic, recurrent infectious disease that affects the lungs. It is a major cause of death from infectious disease worldwide in the Philippines. Pulmonary TB ranks 5th in leading causes of morbidity (1997) and mortality (1995). It is caused by mycobacterium tuberculosis, an aerobic, rod shaped acid-fast bacilli that can spread by airborne droplet nuclei produced by infected individual. These droplets are expelled in the environment by infected host, through activities such as coughing, laughing, sneezing and singing. Pneumonia on the other hand is a inflammation of the lung parenchyma. It may be either infectious or non infectious. Bacteria, viruses, fungi and other microbes can lead to infectious pneumonia. Non- infectious causes include aspiration of gastric contents and inhalation of toxic or irritating gases. Most common causative agent of communityacquired pneumonia is S. pneumoniae, S. aureus are often implicated nosocomial causes. Organism such as M.tuberculosis generally causes infections in immunocompromised people. Developmental Task

Patient is middle-aged adult (40-65 yrs.old), and by anchoring to Erick Eriksons theory of psychosocial development, he is in the generativity vs. self-absorption and stagnation stage. During this time of life, patients general characteristics are focused on sense of sense welldevelopment, concerned with physical changes, at peak in his career, exploring alternative lifestyles, reflecting on his contribution to his family and society, re-examining goals and values, questioning his achievements and successes, confidence on his abilities, and the desires to modify unsatisfactory aspects of his life. I. NURSING HISTORY

Client on Context

A case of Mr. Miguel B. Taipen, a 55-year old male, was admitted for the second time on last January 28, 2008 at Vicente Sotto Memorial Medical Center due to severe dyspnea and afternoon fever. He is a Roman Catholic and Resides at Balamban, Cebu, and arrived at the hospital per taxi. History of Present Illness

January 2008, patient manifested chest pain, afternoon fever, dizziness, headache, night sweats and dyspnea. A day prior to admission patient also experienced difficulty of expectorating the sputum and had severe dyspnea. Thus, sought admission in VSMMC. Mr. MT was admitted on January 28, 2008 @ 11:00 PM. Laboratory examinations such as Chest X-ray, hematologic exams, sputum exam, urinalysis, Mantoux test and clinical chemistry were done. Pulmonary Tuberculosis with pneumonia was the final diagnosis. Antituberculosis drugs (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol ) and antibiotics (Cephalexin and Ciprofloxacin) were prescribed. History of Past Illness

Mr. BC was active on sports such as volleyball and basketball. However, alcoholic beverages (tuba, kulafo, and tanduay) and cigarettes were also part of his active young life. More than a pack of cigarettes were consumed per day. He works as an employee in a company situated in Mandaue City. Eventually, he decided to have his own business. No food allergies reported. In 2005, Mr. BC was admitted for the first time in VSMMC due to hypertension and was confined for a week. Prior to admission severe headache, dizziness and claimed pain felt on the nape were manifested. No medications were taken. Anti-hypertensive medications were prescribed but wasnt able to maintain due to financial constraints. Non-diabetic, non-asthmatic, with no history of any sexual transmitted diseases. Mid 2007, patient experienced frequent coughing but does not sought for further consultation. He was able to manage the said symptoms by taking Roch Herbal Medicine. Environmental History

Patient lives in Balamban, Cebu from his birth until present. They privately owned the house and lot with a 30-minute walk to the health center and very accessible to basic health services. There are 2 bedrooms, 30-minute ride to church and barangay hall. The water source is BWD, and his son and daughter in-law together with their children also lives among them. The house has four windows, accessible to the market, and peace and order situation is well. The neighborhood is not congested with 100-200 meters of interval in between houses. Electricity is supplied by veco, there is an adequate space around the house for plants and ornaments, no firewall established/made, and the home is accessible to transportation.

II. Gordons Functional Health Patterns 1. Health Perception & Health Management Patient recognizes the importance of health as this is the only way to prolong life. Current condition serves as a problem to the family, because this also means financial constraints. Feels bad because he cant continue doing his usual daily activities. Patient stops smoking and drinks alcoholic beverages since 2007, because he knows for a fact that it does not do good to his health. Patient rarely visits health care professionals for check-up and doesnt perform selfexams. Immunization status was unrecalled. 2. Nutrition & Metabolic Pattern Since 1970, patient smokes more than a pack of cigarette/day and drinks alcoholic beverages, such as tanduay, kulafu, and tuba. Usual meals of the day are as follows: mais with fish or dried fish and vegetables. Patient eats 3 times a day and sometimes had snacks in between meals. He eats fatty foods occasionally. Drinks 6-8 glasses of water/day. Claimed to drink multivitamins but not regularly. As of the present, because of his hospitalization, patients metabolic pattern changes. Patient weighs only 125 lbs, 56 in height. Soft diet was recommended for the patient because he can hardly tolerate a certain food. He was advised to increase his fluid intake to 2-3L/day. Patients skin is dry and flaky. 3. Elimination Pattern Before hospitalization, patient doesnt have any urinary problem. He had his bowel movement every morning and described consistency of his stool as firm and brownish in color. He never had any bladder surgery. 4. Activity & Rest Pattern Patient was a BYAHEDOR (salesman) of broomstick. He usually sells it from house to house by walking only. Sometimes he would be required to travel to any place in the Visayas. Patient claimed walking is his means of exercise. Prior to hospitalization, patient is very weak and non-ambulatory. His current health condition has interfered his activities of daily living. He needs assistance when ambulating and performing such activities. 5. Cognition & Perception Pattern

Patient doesnt wear eyeglasses despite of his visual problem yet he can still do remember important events, places and persons. He is able to remember recent and memorable events in his life. Upon hospital admission, patient can still remember why he is being admitted in the hospital and can understand simple instructions but sometimes he finds difficulty in expressing his self or explaining things to others. 6. Sleep & Rest Pattern Patient usually sleeps at 9 PM and wakes up at 5 am. Watching T.V and listening to radio is his means of relaxation. He never experienced using sleeping aids. Prior to hospital admission, patient is having difficulty sleeping and is having nightmares sometimes. He is also disturbed by the noise in the hospital environment. 7. Self Concept Financial and emotional are top concerns of the patient at present. Hes bothered because he can no longer support his family due to his present illness. His self-esteem has lowered and he just considered his family as the source of his strength. 8. Role Relationship Pattern Patient is the breadwinner of the family, though his married children also help them financially. He has no known enemies with his peers, grasp and to his family. He described his family as the most important persons in his life. In terms of decision making, patient seeks for advise to his wife and children before making any decisions. He feels closest to his youngest child. Patient is not active in any social activities in their community. 9. Sexuality & Reproductive Pattern Patient was circumcised at the age of 13 and has 3 children. They didnt practice any family contraceptive method. He never had sexually transmitted disease and do not experience pain or discomforts when voiding. 10.Stress & Coping Pattern One of the most tragic incidents in his life, when his son died at the age of 18 and his present condition is only secondary. Despite of all the trials in life he was able to move on things one at a time and as days goes by. Currently, patients illness has affected by the stress he feels. He usually turn to his family when he feels under pressure and lean on to God. 11. Value & Belief Pattern

A Roman Catholic and verbalized that religion is important to him and his relationship with God is the most important part in his life. He and his entire family also believe in some superstitious beliefs and practiced some of them.

III. Physical Examination General Survey

Seen patient lying in bed, awake, conscious, coherent and responsive, with IVF no.2, D5 LR @ 30 gtts/min hooked at 4:00 Am. Needed assistance in ambulating and performing self-care activities.

Baseline Vital Signs - Temperature-38.5 0C/axilla - Pulse Rate- 92 bpm - Respiratory Rat- 26 cpm Blood Pressure-130/80 mm Hg.

1.Skin, Hair, Nails Skin: -dark brown complexion, senile skin turgor, dark brown pigmentation noted -rough, febrile with a temperature of 38.5 degrees Celsius, with pale palm and sole noted. Hair: -Black in color mixed with white colored hairs not evenly distributed, (-) parasite -smooth scalp, no lesions, brittled hair Nails: -round and thickened nails, yellow colored nails, long and dirty fingernails and toenails noted -capillary refill test <3 secs 2. Head, Neck & Lymph Nodes Head: -Symmetrical, centered head position proportional to the body, features appropriate size, can move side to side and up and down Neck: -Symmetrical, can control movements -thyroid in midline position

-Palpable carotid artery Lymph Nodes: palpable and tender

3. Eyes & Ears Eyes: -symmetrical, pale conjunctiva, (+) PERRLA, (+) blinking reflex, lashes are present in both eyes, pupil is round and equal, iris is uniform in color -Able to identify colored objects Ears: -small and equal in size, similar in appearance, no lesions detected - non tender auricles and mastoid tip, can hear sounds 1-2 feet away -tympanic membrane moves when patient swallows, (-) lesions/nodule 4. Mouth & Nose Mouth: -pale, dry lips and gums, no lesions on gum, missing teeth, tonsils are not inflamed, uvula is at midline Nose: -same color as the face, symmetrical in appearance, no deformities noted -air is felt through opposite nares when exhaled, sinuses non tender upon palpation, septum at midline, (-) discharges 5. Thorax & Lungs -thorax symmetrical, sternum in level with the ribs, rise and fall upon respiratory cycle, respiration rate:26cpm, - dull sounds elicited upon percussion on bony prominences -with adventitious breath sounds present, forcible respirations, with pneumonia as evidenced though the x-ray result 6. Heart -Heart rate is 92 bpm, BP is 130/80 mmHg upon assessment - Symmetrical rise and fall of the chest noted -dull sound produced upon percussion on flat bones -no pain and nodules present upon palpation -able to auscultate S1 and S2 at the PMI 7. Abdomen

-(-) rashes seen or lesions, umbilicus centrally located, sunken, symmetrical abdominal contour -bowel sounds present in four quadrants (8 bowel sounds/min), (-) bruits, non-tender, (-) masses - tympanic sound produced upon percussion in all quadrants -no pain and masses noted upon palpation 8. Genitourinary & Reproductive -grossly male -Scrotum is not enlarge, urinary meatus located at the tip of the penis, (-) discharge -no pain in urination and negative lesions 9. Musculoskeletal -Uneven base, weakness noted -Limited range of motion -Able to identify where he is being touched -Upper and lower extremities equal in length -Foot is aligned with lower leg, knees are aligned with each other -decreased muscle strength 10. Neurologic Mental Status Assessment: Dress: needs assistance, prefers to wear loose and comfortable clothing. Hygiene: unclean nails, uncombed hair Speech: can understand what people say, can communicate but cant pronounce words well. Memory: short- term memory is intact and can still remember important events in life Logic: able choose what he likes from what he doesnt like, and can express desires Cranial Nerves Assessment CN I Olfactory; identifies correct odor applied to each nostril CN II Optic; able to read 1-2 feet away from the patient CN III Oculomotor; can follow object moved from up to down, side to side; pupils constrict when illuminated CN IV Trochlear; can follow object without turning his head CN V Trigeminal; identifies light touch, dull and sharp sensations from forehead, cheeks to chin, eyelids blink bilaterally CN VI Abducens; eyes move laterally and can follow the 6 cardinal fields of gaze CN VII Facial; can perform facial movements as instructed CN VIII Acoustic; can hear spoken words and intact equilibrium/ sense of balance CN IX Glossopharyngeal; identifies correct taste; gag reflex present

CN X Vagus; Gag reflex present CN XI Spinal Accessory; can shrug shoulders against resistance CN XII Hypoglossal; can stick out tongue and move it to sides, up and down

IV. Laboratory Findings Urinalysis Color: yellow Transparency: cloudy Reaction: 6.0 Specific Gravity: 1.030 Sugar: Negative Protein: Negative Miscellaneous structures Squamous Epithelial Cells: few Round Epithelial Cells: Negative Bacteria: Positive RBC: 0-1 Pus Cells: 0-1 Cast: Negative

Chest X-ray (January 28, 2008) Findings: There is inhomogeneous density in the right lower lung. Heart is normal in size and shape. The trachea is at midline. The osseous thoracic cage showed no significant bony abnormality. Conclusion: PNEUMONIA, right lower lung

V. Summary of Significant Findings Patient has positve advent itious lung sound(crackles) upon auscultation, with mucopurulent sputum, febrile (38.5 0C/axilla), weak/decrease muscle strength, labored breathing as evidenced by elevated respiratory rate, and severe dyspnea.

VI. Anatomy & Physiology The organs of the respiratory system extend from the nose to the lungs and are divided into the upper and lower respiratory tracts. Upper respiratory tract consists of the nose and the pharynx, or throat. Lower respiratory tract includes the larynx, or voice box; the trachea, or windpipe, which splits into two main branches called bronchi; bronchioles; and the lungs, a pair of saclike, spongy organs.

Nasal Passages they filter the air to remove potentially disease-causing particles; and they moisten and warm the air to protect the structures in the respiratory system. Pharynx - lined with a protective mucous membrane and ciliated cells that remove impurities from the air; houses the tonsils. Larynx - primary role in producing sound; it prevents food and fluid from entering the air passage to cause choking; and its mucous membranes and cilia-bearing cells help filter air. The cilia in the larynx waft airborne particles up toward the pharynx to be swallowed. Trachea, bronchi & bronchioles - The base of the trachea is located a little below where the neck meets the trunk of the body. Here the trachea branches into two tubes, the left and right bronchi, which deliver air to the left and right lungs, respectively. Within the lungs, the bronchi branch into smaller tubes called bronchioles. The trachea, bronchi, and the first few bronchioles contribute to the cleansing function of the respiratory system, for they, too, are lined with mucous membranes and ciliated cells that move mucus upward to the pharynx.

Alveoli - deliver oxygen to the circulatory system and remove carbon dioxide; Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli and remove foreign substances that have not been filtered out earlier.

VII. PATHOPHYSIOLOGY Pulmonary Tuberculosis with Pneumonia HOST -55 years old -male -immunocompramised status -substance abuser l AGENT M. Tuberculosis M. Bovis M. Avium ENVIRONMENT -Living in an overcrowded, substandard housing

l l Inhalation of the AFB through airborne/droplet nuclei Infection organisms begins to multiply (may also be transmitted via lymph system and bloodstream to other parts of the body) Inflammatory response Fever, RR, will be initiated (If there is an adequate intervention) Phagocytes (neutrophils and macrophages) -------------engulf many of the bacteria(TB-specific lymphocytes lyse the bacteria and normal formation of tissue) granulomas (surrounded by macrophages) Accumulation of tissue Cough(mucopurulent, exudates in the alveoli hemoptysis, night sweats) fibrous tissue mass (initial exposure occurs 2-10 weeks (central portion is Bronchopneumonia after the exposure) Ghon tubercle) inadequate tissue oxygenation and fatigue & wt. loss necrosis and forming impaired gas exchange a cheesy mass

 calcified and form a collagenous scar

hypoxia, shock, respiratory failure, atelectasis, pleural effusion DEATH

Becomes dormant presence of reactivator (inadequate immune system, reinfection, and activation of active bacteria) Ghon tubercle ulcerates releasing the cheesy material into the bronchi bacteria becomes airborne (resulting in a further spread of the disease) the ulcerated tubercle heals & forms a scar tissue previously infected lung becomes more inflamed further development of bronchopneumonia and tubercle formation same complications of the initial infection
DEATH

X. Discharge Plan A case of Mr. Miguel B. Taipen, 55-year old male, married, residing from Balamban, Cebu, was admitted for the second time at Vicente Sotto Memorial Medical Center on last January 28, 2008 at approximately 11 pm with the chief complaints of severe dyspnea and afternoon fever. His final medical diagnosis was Pulmonary Tuberculosis with Pneumonia, was ordered for discharged on last February 5, 2008 per physicians discretion. M- instruct patient to religiously follow the medication regimen and its duration: (Refampicin, Ethambutol, Isoniazid) OD, ac (Cephalexin 500 mg, Ciprofloxacin 500 mg) TID E- encourage patient and family to keep physical environment conducive for health maintenance and development T- teach patient how to effectively cough to successfully expectorate sputum - instructed patient to cover mouth and nostrils when coughing to avoid further spread of the disease - to properly discard the sputum and wash clothes used in covering the mouth and nostrils H- to maintain good physical and oral hygiene - to religiously follow the therapeutic regimen to avoid exacerbations of the disease - instruct patient to allow ample time of rest to reduce oxygen consumption and demand - to limit physical activities to avoid fatigue O - teach and instruct patient to report immediately any unusual signs and symptoms such as severe dyspnea and high grade fever -to watch any signs of complications such as respiratory arrest D- teach patient to increase high carbohydrate and protein containing food intake to compensate the high metabolic demand during the course of disease process - to increase water intake to facilitate proper waste excretion and to liquify sputum - to include fruits and vegetables in his daily diet as a source of vitamins and minerals to facilitate rapid recovery S- encourage patient and family to attend mass every Sunday to cultivate their social and spiritual life