I.

NURSING HISTORY
A. General Data
Name: XXX
Address: XXX
Date of Birth: May 5, 1920 Age: 85 y/o Place of Birth: Catarluha, Samar
Nationality: Filipino Religion: Catholic Civil Status: Widow
Date of Admission: December 4, 2005 Time: 8:05 pm
Hospital Unit: Medical Ward Room No. 440B
Attending Physician: XXX
B. Reason for Seeking Health Care
The pt was admitted due to difficulty of breathing.
C. History of Present Illness
Before the pt was admitted, a few months ago, she experienced non-
productive cough with whitish phlegm. There was no fever. Difficulty of breathing
and chest pain noted. She consulted a physician with the assistance of her
daughter-in-law and was given an unrecalled Anti-Koch’s medication. It was taken
with good compliance. The pt also experienced constipation so she was given an
enema to pour-out stools. There was no abdominal pain, nausea, and vomiting noted.
One week prior to admission, she still experienced the above symptoms.
There was no fever and chest pain. She experienced difficulty of breathing when she
was assisted in the bathroom 6 hours prior to admission. She prompted consult,
hence, was admitted.
D. Past Medical History
The pt had a Diabetes Mellitus but with an unrecalled year. She has
Hypertension but with an unrecalled highest and lowest BP. She had also suffered stroke 2
years ago, which made her to be bedridden, and left extremities paralysis.
E. Family History
Unremarkable
F. Obstetrical/Menstrual History
Unremarkable
G. Psychosocial / SocioculturalHistory
The pt is a non-smoker and non-alcoholic beverage drinker. She is
currently living with her daughter-in-law and grandson. All her sons and daughters are living
outside the country.
H. Activities of Daily Living
1. Nutrition
The pt is used to eat rice and different kinds of viands. She drinks at least 3-4 glasses
of water everyday.
2. Elimination
The pt urinates at least 4 times a day. She is having a difficulty in
defecating.
3. Rest
The pt sleeps and wakes up anytime she wanted. She has no
definite time of waking up and sleeping
4. Hygiene
The pt takes a bath everyday through the help of her daughter-in-
 law and grandson.

5. Activity
Upon waking, the pt is used to sit in the wheel chair.

I. PHYSICAL EXAMINATION
Vital Signs: T= 36.50C PR= 89 bpm RR=29 bpm BP= 130/80 mm Hg
Head > symmetrical
> have no masses
> normocephalic
Eyes > no redness
> eyebrows are bilateral
> eyelashes are evenly distributed
> eyeballs are aligned normally
Ears > are of equal size
> no discharge on the external auditory meatus
> no lesions
Nose > symmetric and lies in the midline
> no discharges
> with O2 inhalation via nasal cannula 2-3lpm but was discontinued the following
day
Mouth > no bleeding of gums
> with dry lips
> decrease salivation
Neck > no masses
> with limited movements
> symmetrical
Breast/Chest > no discharges
> no lesions
> (+) crackles
> (-) Wheezes
Abdomen > slightly scaphoid
> Umbilicus is in midline and inverted
> No scar and lesions
> Hypoactive bowel sounds
Extremities > no fracture
> Symmetrical
> Left upper and lower extremities cannot be moved freely
> Right upper and lower extremities can be move freely but with
limitations
Skin > color is light to brown
> No edema
> Poor skin integrity
> Poor skin turgor
> Dehydrated
ANATOMY AND PHYSIOLOGY

The left and right lung

The two lungs, which fill most of the thorax, are each enclosed within a double membrane
known as the pleura. The right lung is the larger, being divided into three lobes, while the left
is divided into two lobes. The lobes are further divided into bronchopulmonary segments, each
of which has a segmental bronchus.

The bronchi and bronchioles

The trachea branches off into the two main tubes of the lungs – the right and left bronchi.
Within the lungs the bronchi branch again, forming secondary and tertiary bronchi, then
smaller bronchioles, and finally terminal bronchioles. At the end of the terminal bronchioles
are the alveoli.

The alveoli

The alveolar sacs are made up of groups of alveoli at the end of the terminal bronchioles. Each
lung contains approximately 300 million alveoli, giving a total surface area of 40—80m2. The
epithelial lining of the alveoli consists mainly of type 1 pneumocytes which provide a thin
layer for gas exchange. They are connected to type II pneumocytes (from which they are
derived) by tight junctions. These tight junctions limit the fluid movement in and out of the
alveoli. Although more numerous than the type I pneumocytes, type II pneumocytes cover less
epithelium. They contain vacuoles that produce the pulmonary surfactant. The alveoli also
contain macrophages which contribute towards the defense mechanisms of the lungs.

Physiology of the lungs

Contraction and relaxation of the muscles of the chest and the diaphragm are responsible for
inspiration and expiration. When air is inhaled, the diaphragm contracts and flattens and the
intercostal muscles between the ribs contract, pulling the ribcage upwards and outwards.
During exhalation, the intercostal muscles and the diaphragm relax, pulling the ribcage down
and contracting the lungs. This reduces the volume of the chest and forces the air out of the
lungs.

The respiratory centre, located in the brain stem, controls breathing. Although breathing is an
involuntary process, the depth and rate of breathing can be altered voluntarily.

Oxygen from inhaled air passes through the alveoli into the bloodstream. The blood is then
taken to the left side of the heart via the pulmonary veins, and from here it is pumped around
the body. Deoxygenated blood, which returns from the body to the right side of the heart, is
pumped back to the lungs via the pulmonary arteries. Carbon dioxide passes from the
capillaries, which surround the alveoli, into the alveolar spaces, and is breathed out.
 DISEASE ENTITY
PULMONARY TUBERCULOSIS
A. Definition
 A communicable bacterial disease typically marked by wasting fever, and, and
formation of cheesy tubercles often in the lungs (The Merriam-Webster
Online Dictionary)
 Is a chronic, sub acute, or acute disease that most commonly affects the
respiratory system, usually the lungs, but may involve parts of other systems
such as the lymphatic, osseous, urogenital, nervous, and gastrointestinal
(Compilation of Communicable Diseases in Nursing – SLH)
 An acute or chronic infection characterized by pulmonary infiltrates and
formation of granulomas with caesation, fibrosis, and cavitation (Medical-
Surgical Nursing made Incredibly Easy by Lippincott Williams and Wilkins)

B. Synonym
 Consumption. Phthisis

C. Infectious Agent
 The causative agent is Mycobacterium Tuberculosis, discovered by Koch in
1882
 The term Mycobacterium is descriptive of the organism, which is a bacterium
that resembles a fungus.
 The organism multiplies slowly and is characterized as acid-fast aerobic
organism, which can be killed by heat, sunshine, drying, and UV light.
 Sputum of persons with TB is the most common source of the organism

D. Incubation Period
 From 2 to 10 weeks

E. Etiology
 Factors that heavily contributes to the high incidence and mortality rate of TB:
1. Poverty/overcrowded homes
2. Energy/Protein undernutrition
3. Deficiencies in Vitamin A, D, and C
4. Debilitation to intercurrent infections prevalent among poor-
decreased resistance against infection
5. Children below five years old- prone to infection due to
inadequate levels of immunity

F. Mode of Transmission
 TB is an airborne infection transmitted by droplet nuclei; usually from within
the respiratory tract of an infected person who expels them during coughing,
sneezing, or singing.
  From person-to-person, generally from adult to child and not vice versa nor
from child-to-child. The seeder is an infectious case with productive cough
freely expelling bacilli, usually an adult member of the household.
 Being an airborne infection the common route of entry is the respiratory tract.
The initial lesion is therefore pulmonary in location.
 When an uninfected susceptible person inhales the droplet containing air, the
organism is carried into the lung to the pulmonary alveoli.

G. Pathophysiology

Susceptible person M. bacilli airways to the alveoli transported to the

lymph system and bloodstream to other parts of the body and lungs

Inflammatory reaction by the body’s immune system

 A susceptible person inhales Mycobacterium bacilli and becomes infected.
The bacteria are transported via the lymph system and bloodstream to other
parts of the body (kidneys, bones, cerebral cortex) and other areas of the lungs
(upper lobes). The body’s immune system responds by initiating an
inflammatory reaction.

Phagocytes destroy the bacilli and normal tissue accumulation of

exudates in the alveoli initial infection (2-10wks after exposure)

 PHAGOCYTES (neutrophils & macrophages) engulf many of the bacteria, &
tubercle bacilli specifically lymphocytes lyse (destroy) the bacilli & normal
tissue. This tissue reaction results in the accumulation of exudates in the
alveoli, causing bronchopneumonia. The initial infection usually occurs 2-10
weeks after exposure.

Granulomas surrounded by macrophages forms protective wall

Transforms to fibrous tissue mass ( central portion of it is the Ghon tubercle)

 GRANULOMAS, new tissue masses of live & dead bacilli, are surrounded by
macrophages, which form a protective wall around the granulomas.
Granulomas are then transformed to a fibrous tissue mass, the central portion
of which is called GHON TUBERCLE.

Bacteria and macrophages necrotic cheesy mass calcified

Bacteria may become dormant Collagenous scar

 The material (bacteria & macrophages) becomes necrotic, forming a cheesy
mass. This mass may become calcified & form a collagenous scar. At this
 point, the bacteria become dormant, & there is no further progression of active
disease.

 After initial exposure & infection, the person may develop active disease
because of a compromised or in adequate immune system response. Active
disease may also occur with reinfection & activation of dormant bacteria.

Activation of dormant bacteria Ghon tubercle ulcerates

release of cheesy material into the bronchi

ulcerated tubercle heals and forms scar tissue

causes infected lung become more inflamed

 In this case, the Ghon tubercle ulcerates, releasing the cheesy material into the
bronchi. The bacteria then become airborne, resulting in further spread of the
disease. Then, the ulcerated tubercle heals & forms scar tissue. This causes
the infected lung to become more inflamed, resulting in further development
of bronchopneumonia & tubercle formation.

 Unless the process is arrested, it spreads slowly downward to the hilum of the
lungs and later extends to the lobes. The process maybe prolonged &
characterized by long remission when the disease is arrested, only to be
followed by periods of renewed activity. Approximately 10% of people who
are initially infected develop active disease.

H. Signs and Symptoms

 Low-grade fever
 cough (nonproductive/ mucopurulent)
 night sweats
 fatigue
 Weight loss
 Hemoptysis
 MEDICATIONS

Generic/ Action Dose/ Indications C/I Adverse Effects Nsg.

Brand Frequenc Management
Name y
INH + INH – interferes 1 tbsp OD Pulmonary Hepatic and hepatotoxicity; - Administer on
Pyridoxine with DNA before tuberculosis renal disease, hypersensitivity; an empty
(Comprilex) synthesis and breakfast convulsive skin reactions; stomach for
syrup affects the disorders, DM, tingling; maximum
mycolic acid chronic numbness; nausea; effectiveness.
coating of alcoholism, vomiting; - Caution the pt
bacterium pregnancy, and or the relative of
Pyridoxine – lactation the pt not to
coenzyme immerse feet or
necessary for hands in water
many metabolic without first
functions testing the
affecting CHO, temperature.
lipid , and - Monitor the
CHON effectiveness of
utilization in the comfort and
body safety measures
and compliance
with the regimen.
Rifampicin Antibiotic 100 mg/5 Mycobacterial Hypersensitivity Reddish-orange -Advise client to
(Rimactane) (Blocks key ml, 20 ml infections to Rifampicin secretions in take the meds on
metabolic OD urine, feces, empty stomach 1
pathways saliva, sputum, hr before or 2 hrs
needed for sweat, tears; after meals.
mycobacterium) nausea; vomiting; -Advise not to
anorexia; take alcoholic
headache; drinks.
abdominal -Advise the client
 cramping; fatigue; that urine and
rash; secretions may
thrombocytopenia; turn red-orange.
jaundice -Notify physician
for any
undesirable
effects
Centrum Multivitamins 1 tab OD Complete -Encourage pts to
with Minerals multivitamin comply with diet
(It supplements and mineral recommendations
nutrition to the formula of physician or
body to ensure other health care
adequate intake professionals.
of vitamins and -Explain that the
minerals) best source of
vitamins is a
well-balanced
diet with foods
from the four
basic food groups
Levofloxacin Bactericidal Pneumonia 500 mg via Epilepsy, Headache; -If pt experiences
(Levox) Antibiotic IV OD pregnancy, photosensitivity; symptoms of
(Kills bacteria lactation, insomnia; excessive CNS
by inhibiting hypersensitivity dizziness; stimulation
DNA synthesis to quinolones palpitations; back (restlessness,
and cell wall pain tremor,
synthesis) confusion,
hallucinations),
stop drug and
notify the
physician.
-Advise pt to take
drug with plenty
 of fluids
-Advise pt to
avoid over
exposure to light
Nacl Replaces Fluid and hyponatremia Edema when -Advise the pt to
(Sodium sodium and Electrolyte given too rapidly report adverse
Chloride) chloride and imbalances or in excess; reactions
maintains hypernatremia promptly.
levels.
(PRN meds) Antipyretic (It 500 mg 1 Mild pain or Hypersensitivity Rash; urticaria; -If the pt has
Paracetamol relieves fever tab q4o fever to drug hepatotoxicity fever, note
by the central (overdose); renal presence of
action in the failure (chronic associated signs
hypothalamic use) (diaphoresis,
heat-regulating tachycardia, and
center) malaise)
-Administer with
a full glass of
water.
Duphalac Laxative (acts 30 cc HS Treatment of Galactosemia, Distention; -Assess color,
as a stool chronic bowel flatulence; consistency, and
softener by constipation obstruction diarrhea amount of stool
increasing the in adults and product.
osmotic geriatric pts -Administer with
pressure and a full glass of
pulling water water or juice.
into the colon) May be
administered on
an empty
stomach for rapid
results.
-Caution pt
regarding the
side effects
 LABORATORY EXAMS

CHEST X-RAY
Date Performed: December 4, 2005

Result:
Previous film not available
Hazed infiltrates seen in the right upper lung
Haziness noted in the left lower lungs
Heart is not enlarged
The aorta is prominent and calcified
Comment:
PTB, right upper lung
Pneumonia, left base
Artherosclerostic aorta

URINALYSIS
Date Performed: December 5, 2005

PHYSICAL
Color Amber
Reaction 6.0
Transparency Turbid
Quantity 20 mL
Specific Gravity 1.025
CHEMICAL
Albumin (+)
Sugar Negative
MICROSCOPIC
CELLS
Pus Innumerable
RBC 18-20/hpf
Epithelial Few
Bacteria Many

INTERPRETATION:

The amber or yellowish-brownish color of the urine of the pt is due to the effect of
her medication (Rifampicin). She has an acidic urine based from the ph level reaction. A
normal specific gravity is between 1.003-1.025 which means that the pt is within normal range
although it’s on the highest normal value. The urinalysis result may conclude or indicate that
the pt has a urinary tract infection based from the cloudy appearance of her urine, and the
presence of pus, RBC, epithelial cells, and bacteria. The presence of albumin also indicates
infection and diabetes mellitus.
CHEMISTRY

Date Performed: December 6, 2005

TEST RESULT NORMAL VALUES

Chloride 98.20 98-109 mmol/L
Sodium 132 137-145 mmol/L
Potassium 3.3 3.5-5.1 mmol/L

INTERPRETATION:

The pt has low sodium and potassium level in the body while its chloride is on the
lowest level of the normal values. This lab results shows that the pt is experiencing fluid and
electrolyte imbalance in the body may be due to inadequate intake of fluids and food.

HEMATOLOGY

Date Performed: December 6, 2005

TEST RESULT UNIT NORMAL

VALUES
Leukocyte 6.90 10^9/L 5.0 – 10.00
Erythrocytes 3.22 10^12/L M: 4.6-6.2
F: 12.0-17.0
Hgb 9.5 g/dl M: 12.0-17.0
F: 11.0-15.0
Hct 28.00 % M: 40.0-54.0
F: 37.0-47.0
Thrombocyte 365 10^9/L 150-450
Lymphocyte 18.800 % 20.0-40.0
Monocyte 2.900 % 0.0-7.0
Granulocyte 78.300 % 50.0-70.0

INTERPRETATION:

The decrease of the patient’s erythrocyte, hemoglobin, and hematocrit may

indicate anemia. This may also is a factor why the pt is experiencing fatigue and difficulty of
breathing because she lacks the portion of the protein in the blood which binds with oxygen in
the lungs. The decrease of lymphocyte may interpret that the patient’s body cannot totally fight
of the infection so there is an increase of granulocyte as a support to fight off the foreign
substances in the body.
VI. NURSING CARE PLAN
CUES BACKGROUND NURSING NURSING GOAL NURSING RATIONALE EVALUATION
KNOWLEDGE DIAGNOSIS INTERVENTION

SUBJECTIVE: Ineffective Breathing Ineffective Breathing At the end of my > Elevate the head of the > Promote Goal met; The pt was
“Nahihirapan sya na Pattern – the state in Pattern related to duty, the pt must be bed as needed. physiologic/ relieved somehow.
huminga”, as which an individual’s altered oxygen supply able to demonstrate psychologic ease of Her O2 inhalation was
verbalized by the inhalation and/or as manifested by improved maximal inspiration already discontinued.
relative of the pt since exhalation pattern does increased respiratory ventilation, > Administer inhalation 2-3 > Supplies oxygen in
she do not totally not enable adequate rate (29 bpm) adequate lpm via nasal cannula, as the body
speak at all. pulmonary inflation or oxygenation, ordered by the physician.
emptying absence of signs and > Reposition pt. frequently > Promotes
symptoms of if immobility is a factor. ventilation
respiratory distress > Maintain an adequate >Mobilizes
intake and output of fluids secretions
and secretions.
> Monitor vital signs > Provides baseline
data

OBJECTIVE:
> Bedridden Impaired Physical Impaired Physical At the end of my > Turn the pt side to side > Facilitate Goal partially met;
Mobility – a state in Mobility related to duty, the pt must be and position her for ventilation and The pt is still on bed
which the individual past stroke as able to maintain optimum comfort prevent skin and was able to
experiences a limitation manifested by inability position of function breakdown maintain skin integrity.
of ability for to purposefully move and skin integrity > Provide for safety > Prevents injury
independent physical within the physical and to prevent bed measures (e.g. side rails up)
movement environment including sores > Encourage to increase oral >Prevents
mobility, transfer, and fluid intake and intake of constipation
ambulation high fiber diet

Goal partially met;

> Constipation Altered Bowel Alteration in Bowel At the end of my > Encourage balanced diet > These The pt is still having a
Elimination – a state in elimination: duty, the pt must be high in fiber and bulk, as interventions is done hard time in defecating
which an individual Constipation related to able to establish/ appropriate to promote bowel but the same
experiences difficulty, lack of exercise, return to normal > Turn the pt side to side functioning and intervention is still
disturbance in bowel inadequate intake diet patterns of bowel every 2 hours defecation established by the
elimination and fluid intake as functioning. > Promote increase oral relative as advised by
manifested by fluid intake including fruit the health care
Constipation – a state decreased bowel juices. Suggest intake of provider.
in which an individual sounds and absence of warm fluids upon arising
experiences a change in stool passage for two >Administer laxatives, as
normal bowel habits weeks prescribed by the physician.
characterized by a
decreased in frequency
 and/or passage of dry
hard stools

Goal partially met;

> Inability to receive Impaired Social Impaired Social At the end of my > Establish therapeutic > Provides easiness The pt. still do not
or communicate a Interaction – the state Interaction related to duty, the pt must be relationship using positive and trust on the part speak and tends to
sense of in which an individual communication involved in regard for the patient of the pt stare at one place most
understanding participates in an barriers (stroke) as achieving positive of the time but she was
insufficient or manifested by changes in social > Observe and describe able to follow to the
excessive quantity or observed inability to behaviors and social/ interpersonal > Provides baseline HC provider’s
ineffective quality of receive or interpersonal behaviors in objective on the patterns of instruction
social exchange communicate a relationships and terms, noting body language behavior of the pt as
satisfying sense of give self-positive and behaviors towards HC to when and how the
belonging, caring and reinforcement for provider HC provider would
interest changes that are approach her
achieved. > Provide positive
reinforcement towards the > To improve social
case of the pt behaviors and
interactions

(All information and

ideas on this section
are from Nurse’s
Pocket Guide:
Nursing Diagnoses
with Interventions by
Doenges and
Moorhouse fourth
edition)