Fejlean Angelica S.

Antineo
IV. BS Nursing
a. Definition of the Case
Multiple Drug Resistant Tuberculosis Case Scenario
A 45-year-old man presented with a concerned that he had been coughing up blood over the
previous 3 days. In addition to hemoptysis, he revealed that, since his previous visit, he had
continued to feel malaise, He had lost 4kg in weight, and had been experiencing night sweats.
The emergency room physician immediately transferred the patient for isolation in a local
hospital. Two months PTA the client had a 2-week history of coughing and breathlessness but
had no history of night sweats or haemoptysis. Crepitations were audible over the lung apices;
there were no other physical signs. He was given mucolytic for the treatment of the cough.

Upon enquiry, he was seen to be a smoker and alcoholic. Patient lived with his daughter. He
stated that he had received treatment for tuberculosis several times over the past 2 years. He
states that he has never completed more than six consecutive months of treatment.Several
investigations were performed to evaluate the patient's condition. His haemoglobin and white
cell count were normal but the CRP was 231 mg/l. A positive sputum smear test indicated that
the patients tuberculosis was still active. Chest X ray was conducted on this patient and minor
lesions at the apical segments of the upper lobe were seen. The chest radiograph revealed
progressive bilateral fibronodular disease with a miliary pattern This is a typical radiographic
representation of patients with tuberculosis. Three sputum smears were negative for AFB. On the
fifth day, growth in broth was detected for one out of three specimens. A gene probe for
tuberculosis was positive. Because of the patient's history of multiple prior incomplete courses
for therapy for TB, he was started on five drugs (INH, rifampin, PZA, ethambutol, and
ofloxacin). After 3 weeks, the susceptibility report was received demonstrating resistance to both
INH and rifampin.

I.
General

Objectives of the Case Study

The general objective of this case study is to use the knowledge about Multi Drug
Resistant Tuberculosis in promoting awareness to the people so that they will seek for
medical care in order to prevent the development and progression of Multiple Drug
Resistant Pulmonary Tuberculosis

Specific:

To define Multiple Drug Resistant Pulmonary Tuberculosis as well as on how it is

acquired, factors, signs and symptoms.

To trace the pathophysiology of Multiple Drug Resistant Pulmonary Tuberculosis.
To apply skills learned in the classrooms to actual handling and caring of a patient

who suffered from Multiple Drug Resistant Pulmonary Tuberculosis.

To focus on preventive measures for raising awareness of Multiple Drug Resistant

Pulmonary Tuberculosis
To determine the possible nursing intervention that will be a great help in patients

prognosis.
To give the appropriate health teaching and better understanding of the disease to the
patient, family and significant others.

II.

Introduction:

Pumonary Tuberculosis (abbreviated TB for tubercle bacillus or Tuberculosis) is a common

and often deadly infectious disease caused by Mycobacterium tuberculosis. Tuberculosis usually
attacks the lungs (as pulmonary TB) but can also affect the central nervous system, the lymphatic
system, the circulatory system, the genitourinary system, the gastrointestinal system, bones,

joints, and even the skin. Tuberculosis is spread through the air, when people who have the
disease cough, sneeze, or spit. Most infections in human beings will result in asymptomatic,
latent infection, and about one in ten latent infections will eventually progress to active disease,
which, if left untreated, kills more than half of its victims. The classic symptoms of tuberculosis
are a chronic cough with blood-tinged sputum, fever, night sweats, and weight loss. Infection of
other organs causes a wide range of symptoms.
Resistance to anti-TB drugs can occur when these drugs are misused or mismanaged.
Examples include when patients do not complete their full course of treatment; when health-care
providers prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs;
when the supply of drugs is not always available; or when the drugs are of poor quality.
Multidrug-resistant TB (MDR TB) is caused by an organism that is resistant to at least isoniazid
and rifampin, the two most potent TB drugs. These drugs are used to treat all persons with TB
disease.
The most important thing a person can do to prevent the spread of MDR TB is to take all of
their medications exactly as prescribed by their health care provider. No doses should be missed
and treatment should not be stopped early. Patients should tell their health care provider if they
are having trouble taking the medications. If patients plan to travel, they should talk to their
health care providers and make sure they have enough medicine to last while away. Health care
providers can help prevent MDR TB by quickly diagnosing cases, following recommended
treatment guidelines, monitoring patients response to treatment, and making sure therapy is
completed.

b. Etiology
The bacteria that cause tuberculosis (TB) can develop resistance to the antimicrobial
drugs used to cure the disease. Multidrug-resistant TB (MDR-TB) is TB that does not respond to
at least isoniazid and rifampicin, the 2 most powerful anti-TB drugs.
The 2 reasons why multidrug resistance continues to emerge and spread are
mismanagement of TB treatment and person-to-person transmission. Most people with TB are

cured by a strictly followed, 6-month drug regimen that is provided to patients with support and
supervision. Inappropriate or incorrect use of antimicrobial drugs, or use of ineffective
formulations of drugs (such as use of single drugs, poor quality medicines or bad storage
conditions), and premature treatment interruption can cause drug resistance, which can then be
transmitted, especially in crowded settings such as prisons and hospitals.
c. Incidence
According to the World Health Orgaization (2012 )Tuberculosis (TB) is a deadly disease. It is the
worlds No. 1 cause of death around the world; about 3 million persons die of TB every year. In
2015, an estimated 480 000 people worldwide developed MDR-TB, and an additional 100 000
people with rifampicin-resistant TB were also newly eligible for MDR-TB treatment. India,
China, and the Russian Federation accounted for 45% of the 580 000 cases. It is one of the 10
top killer diseases in the Philippines; 75 Filipinos die of TB every day.
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.
Tuberculosis (TB) is the sixth leading cause of morbidity and mortality in the Philippines; the
country is ninth out of the 22 highest TB-burden countries in the world and has one of the
highest burdens of multidrug-resistant TB. Annual treatment success rates were over 85% with
an average of 90%; the annual cure rates had an eight-year average of 82.1%.
d. General Signs and symptoms
The general symptoms of TB disease include feelings of sickness or weakness, weight loss,
fever, and night sweats. The symptoms of TB disease of the lungs may also include coughing,
chest pain, and coughing up blood.
e. Theoretical Framework

FLORENCE NIGHTINGALE ENVIRONMENTAL THEORY

Ai
Nutritio

ENVIRONMENT

Ventilatio

client
Cleanline
ss

Beddi
ng
Light

Nightingale viewed the manipulation of the physical environment as a major component

of nursing care. She identified ventilation and warmth, light, noise, variety, bed and bedding,
cleanliness of the rooms and walls, and nutrition as major areas of the environment the nurse
could control. When one or more aspects of the environment are out of balance, the client must
use increased energy to counter the environmental stress. These stresses drain the client of
energy needed for healing. These aspects of physical environment are also influenced by the
social and psychological environment of the individual.
Her contribution to the nursing profession was her Environmental Theory in which
the nurses role is to place the client in the best position for nature to act upon him,
thus encouraging healing.
As a student nurse and part of the medical field, has the role of providing nursing care
with the help of Athe institutions and personnel involve to cure the illness and lower
down the factors causing the patients disease with the help of Nightingales
Environmental Theory.

BETTY NEUMAN SYSTEMS MODEL

In this theory the client can be defined as a person, family, or community that interacts
with different variables that are developmental, psychosocial, spiritual, physiological, and
psychosocial. The variables can be stressors or they can be restorative. These variables make up
the clients environment, which can be internal, external, or both. The Neuman Systems model
introduces the notion of perceived barriers that a person maintains in order to cope with a change
in environment or to preserve a wellness state.
The nurses role within the Systems Model is to recognize the patient as a unique
individual with their own goals, beliefs, values, and coping abilities. While implementing
primary, secondary, and tertiary interventions, the nurse works within a holistic view of the client
and in tandem with their protective barriers to help promote a return to health as defined by the
patient.

Because interactions and reactions a client experiences with their environment is

constantly changing, the nurse is also frequently evaluating and reevaluating interventions to
meet the needs of the client.
As a student nurse I can apply this interventin by wearing a mask and practicing aseptic
tecjniques in the client procedure bcause theses decresaes the occurrence of the disese
transmission, another thing thet I can do is to educate the client about his disease for the
promotion of health.

III.
Patientss Data
a. Patient Data
Name: Eufemia Bugoy y Cia
Age: 46 y/o
Birthplace: Pulangi, Albay
Sex: Female
Religion: Roman Catholic
Civil Status: Married
Address: Baras, Rizal
Date Admitted: September 19, 2008
Time Admitted: 2:10 am
Attending Physician: Dr. San Jose

b. Nursing History
i.
Chief Complaint:
The patient was admitted at Rizal Provincial Hospital last September 19, 2008 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 isolation room of

the hospital for further evaluation of the complaint. She was attended by Dr. San Jose, a
resident physician of the said hospital.
ii.
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 for
food. She also experience stabbing pain on her chest according to the assessment it is
6/10 and it radiates to his back. The patient only took paracetamol for her fever. On the
day of September 19, 2008 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.
iii.
Past 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.
Last two months, the family observed Mr. ADL is loosing weight and decrease of appetite
but instead of eating foods he his more on vices. Then his condition became worsened
according to familys observation.
A month prior to admission, the patient condition became more at it worst and his cough
became productive with intermittent spots of blood in the sputum upon coughing. He also
starting to have night sweat started becoming sluggish and spending lots of time sleeping. He
was advice by the family to have a check-up and visit the nearest hospital or clinic but he
refuse everything that his familys concerned, as verbalized by Mr. ADLs sister.

Based on the statement of his mother, two days prior to admission Mr. ADL experience
body weakness, fatigue, and on the day of admission last August 21, 2009 in Rizal Provincial
Hospital, suddenly he was complaining of difficulty of breathing, one hour after he ate his
lunch.

A. Past medical history

Referring to the statements made by his sister, Mr. ADL was diagnosed with
Pulmonary Tuberculosis (PTB) last 2014, 2 years ago. The six months duration in
curing the disease became successful, he was cured by the medication given by
the sponsored but due to vices like smoking and active drinking of liquor the
disease from the past became active again.

iv. Personal and Social History

v. OB History
vi. Developmental History
vii. Feeding History
viii. Immunization History
ix. Physical Examination History
a. General appearance/survey:
Patient appeared weak looking but was somehow coherent in a high fowlers position due
to CTT attach to his right chest. Mr. ADL ignores my kind interview but he is willing to
cooperate when it comes in taking vital signs, physical assessment and giving medication which
is important. The patients skin was dry especially on the lower extremities. IVF of D5NM 1L +
1 amp of Moriavit at 50cc level was attached to his right hand.

b. Measurement
FIDINGS

NORMAL
VALUES

ANALYSIS/
INTERPRETATION

(Ht, wt)

Height: 55
Weight: 101 lbs

BMI

BMI below normal as a

result of malnutrition

Vital Signs

Temp: 36.0 C
PR: 90 bpm
RR: 29 bpm
BP: 100/70 mmHg

Temp: 37 C
PR: 60-100 bpm
RR: 16-20 bpm
BP: 120/80 mmHg

With some abnormal findings

in the respiratory rate.
Increase RR; difficulty of
breathing (decrease Oxygen
supply in the body)

c. Head to toe Assessment

BODY PARTS
A. HEAD
a. Skull

NORMAL
FINDINGS
Rounded
(normocephalic,
with frontal,
parietal and
occipital
prominences)

ACTUAL
FINDINGS

ANALYSIS/
INTERPRETATION

Normocephalic Normal findings

b. Hair

Evenly
Evenly
distributed; thick distributed
hair; silky
resilient hair; no
infestation or
infection; variable
amount of body
hair

Typical hair type of

men

c. Face

Symmetric facial
features,
palpebral fissures
equal in size,
symmetric
nasolabial folds

Symmetric
facial features

Normal findings

Shape is round;
size equal

Round,
uniform in size

Normal findings

4.2 Lid margins

Protects eyes,
anteriorly meet at
the medial and
lateral corners of
eye.

Close
symmetrical

Normal findings

4.3 Conjunctiva

Delicate
Smooth and
membrane; covers pale
part of the outer
surface of the

d. Eye/vision
4.1 Eyeball

Undernourished, lack
of vitamins

eyeball
4.4 Sclera

Outermost tunic,
thick white
connective tissue.

Appears white

Normal findings

4.5 Pupils

Pupils constrict
when looking at
near objects,
pupils converge
when object is
moved towards
the nose

Normal pupil
constriction

Normal findings

4.6 Eyebrow, lashes, color,

symmetry, quality of hair,
placement

Hair evenly
distributed, intact
skin

Hair evenly
distributed,
intact skin

Normal findings

4.7 Eye movement in all

directions
B. VISION TESTING
a. Visual field

Equal movement

Equal
movement

Normal findings

When looking
straight ahead
clients can see
objects in
periphery

Client can see

from his
periphery

Normal peripheral
vision

Able to read
newspaper

Able to read
newspaper

Normal visual
findings

Same color as
facial skin, pinna
recoils after it is
folded

Same color as
facial skin,
pinna recoils
after it is
folded

Normal ear features

b. External canal

Dry ear wax

grayish-tan color
or sticky wet
cerumen in
various shades of
brown/ pearly
gray color;
semitransparent

Wet and
sticking
cerumen with
transparent
color

Normal findings

c. Hearing acuity

Responds to
moderately loud
voice tone
Symmetric,

Responds to
Normal findings
moderately
loud voice tone
No deformity, (+) dyspnea, patient

b. Visual acuity
C. EARS
a. Pinna

D. NOSE

normal breathing,
able to identify
familiar smell

(+) difficulty
of breathing.
With runny
nose

have cough which

reflex is not the only
way to protect our
airways which causes
patient to have runny
nose.

Pink gums; moist

firm texture

Dark gums

Gums darkened due to

smoking history

b. Teeth

32 adult teeth
smooth, white
yellowish shiny
tooth enamel

Yellowish with
few cavities
and some
missing teeth

Needs dental work

c. Tongue

Central position,
pale in color

Central
position, pale
in color

No remarkable
findings

d. Palate-hard/soft

Pink and smooth;

freely movable

Pale in color

No remarkable
findings

e. Oropharynx/ Tonsil

Pink and smooth

posterior wall

Pale posterior
wall
Hollow in
appearance
Lymph nodes
freely movable
(+) difficulty
of breathing,
with abnormal
sound in the
right lower
lobe

No remarkable
findings
Indicates malnutrition,
due to weight loss
Normal findings

E. MOUTH/LIPS
a. Gums

F. CHEECKS
B. NECK
C. CHEST
a. Anterior
b. Posterior

Lymph nodes
freely movable
Quiet rhythmic
and effortless
respirations; full
symmetric
excursions

Localized pain
around
thoracostomy
site.

Presence of crackles
caused by fluid often
associated with
inflammation or
infection of the
alveoli.
Indicates respiratory
problems such us TB,
Pneumohydrothorax
No air leak on
drainage system:
manageable incision
pain.
Normal findings

D. HEART
E. BREAST
F. ABDOMEN

Full and
symmetric

Full and
symmetric

Flat, rounded
(convex) or
scaphoids

Flat,
scaphoidal in
shape

Client is not well

nourished.
It is also due to weight

G. UPPER EXTREMETIES

H. LOWER EXTREMETIES

Equal in size on
both sides of the
body; no muscle
atrophy; normally
firm; smooth
coordinated
movements
Equal in sixe on
both sides of the
body; no muscle
atrophy; normally
firm; smooth
coordinated
movements

Equal in size
but muscular
atrophy
evident.
Unable to
move freely
due to pain in
incision site.
With muscular
atrophy
evident.
Occationally
stands up for
short time. (2
days post-op)

loss.
Client is not well
nourished
Struggling movements
due to wounds,
incision pain.
Client is not well
nourished
Weakness and pain
hinder client from
actively moving
around.

I.

Category

Normal Findings

Actual Findings

Analysis and interpretation

Mental Status
Level of
Consciousness

Alert

Alert

Normal

Oriented

Oriented to person, time and

place.
Coherent

Normal

Able to state what happened

to her in the past.

Normal

Orientation
Coherent

Normal

Language test
Able to remember
Recall

Cranial Nerves
CN 1
Olfactory

Able to smell and

recognize stimuli

Able to identify the scent of

the alcohol

Normal

CN 11
Optic

20x20 vision, able to

read, 3-5 mm [pupil
size]

Pupil size is 3 mm, able to

read, myopia or
nearsightedness.

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.

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

CN V
Trigeminal

Able to feel and

clearly identify
stimulus, with
bilateral facial
sensation. With
active corneal reflex.

Able to feel my finger on

her face while covering her
eyes.

CN VII
Facial

Able to hear clearly,

can maintain balance

(+) gag reflex, uvula

at the center, soft
palate rises

CN XI
Accessory (Spinal)
Able to shrug
shoulders against
resistance and able
to turn the head side
and against
resistance.
CN XII
Hypoglossal

Normal

Normal

(+) Facial symmetry

(+) Corneal reflex ,
Facial asymmetry

CN VIII
Vestibulocochlear

CN IX, X
Glossopharyngeal
Vagus

edition, page 1963).

Able to move tongue

from side to side

Normal

Can hear clearly and can

walk.

Normal

Present gag reflex, able to

swallow and able to idebtify
the taste of the food.

Normal

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

Muscle Strength

MNT Grading
System:

Left Arm
(+5) Active motion
against full
resistance
Right Arm
(+5) Active motion
against full
resistance

Left Leg
Right Leg

(+5) Active motion

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

Functional Health Pattern

Prior to Hospitalization

+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.

+4 active motion against

some resistance.

(http://en.wikipedia.org/wiki/Muscle_weakness)

+4 active motion against

some resistance.
+4 active motion against
some resistance.

Abnormal
Abnormal
Abnormal

Norms and Standards

Health perception- Health Management

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.
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.
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.
(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-medicine000351.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 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.

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.

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 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/Adult-Nutrition.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

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.

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 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 exercisethat 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 pancreasthe organ that produces insulin
can 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.

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).
Sleep and Rest

The patient regularly sleeps at 8:00pm and wakes up at 1:00 pm.

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.

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.

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
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-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.
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 ways:
acceptance, denial, withdrawal and depression are common. (Kozier et.al, Fundamentals
of Nursing 7th ed. Pages 957-962).
Role-relationship

She was the fourth child in her family.

She is married to Arsenio 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.

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 parent-child 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-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.

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 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-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.

Coping

mechanisms

which are behaviors used to decrease stress and anxiety. Many coping behaviors are
learned, based on ones family past experiences, and socio-cultural influences and
expectations.
(Fundamentals of Nursing 5th edition by Taylor, page 855)
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.

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 wellbeing 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 selfcare 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).
a. Course in the ward

Course in the ward

August 21, 2009
2:00pm 10:00pm
Admitted a 24 years old male accompanied by relatives with a complained of difficulty of
breathing.
Vital signs are taken and recorded with a BP: 100/70 mmHg, HR: 81 bpm, RR: 35 bpm
Seen and examined by Dra. Magtoto
Consent signed and secured
Tuberculin skin test done; due at 3:30 pm
IVF of D5NM 1L + 1 ampule of Lysmix inserted and regulated with 31 gtts/min

Laboratory requested by the attending physician such as; Urine analysis, Ultrasound of
right lung, BUN and Creatinine, and chest X-ray
Transferred to Charity Medical Ward, bed 22
Endorsed

August 22, 2009

2:00pm 10:00pm
Received on bed with an IVF of D5NM 1L + 1 ampule of Lysmix @ 600ml level
Conscious and coherent
Vital signs are taken and recorded with blood pressure of 100/70 mmHg
A febrile 36.5
NPO was advice
2:30pm
Consent signed and secured
3:00pm
Undergone CTT @ right lung
Vital signs recheck
Needs attended
Endorsed
August 23, 2009
2:00pm 10:00pm
Received on bed with an IVF of D5NM 1L + 1 ampule of Moriavit X 8 hours @
consuming level
Vital signs taken and recorded with Blood Pressure of 100/70 mmHg
4:00pm
Cefuroxime 200mg TIV after negative skin test
6:00pm
Vital signs recheck with no significance finding
Needs attended
Endorsed
August 24, 2009
2:00pm 10:00pm
Received on bed with an IVF of 1L @ 400cc level
Vital signs taken and recorded BP: 90/60 mmHg, PR: 90 bpm, RR: 29 bpm and
Temperature: 36.6 C
With abnormal RR: 29 bpm
Diet as tolerated maintained
Due medication given and recorded

4:00pm
Cefuroxime 200mg TIV after negative skin test
7:00pm
Rifampicin 1 tablet before dinner
Vital signs recheck with no significance finding
Needs attended
Endorsed
August 25, 2009
2:00pm 10:00pm
Received on bed alert, coherent, cooperative.
With an IVF of D5NM 1L + 1 ampule of Moriavit @ 700cc level and regulated with 31
gtts/min on the right hand
Vital signs taken and recorded
Afternoon care rendered
Health teaching done
Medication given
Needs attended
No other complaints
Endorsed

c. Anatomy and Physiology

i. Anatomy and physiology

UPPER RESPIRATORY TRACT

Respiration is defined in two ways. In common usage, respiration refers

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

The upper respiratory tract conducts air from outside the body to the
lower respiratory tract and helps protect the body from irritating

substances. The

upper respiratory tract consists of the following

structures:
The nasal cavity, mouth, pharynx, piglottis, larynx, and upper trachea;
the oesophagus leads to the digestive tract.

One of the features of both the upper and lower respiratory tracts is
the mucociliary apparatus that protects the airways from irritating
substances, and is composed of the ciliated cells and mucus-producing
glands in the nasal epithelium. The glands produce a layer of mucus that
traps unwanted particles as they are inhaled. These are swept toward the
posterior pharynx, from where they are swallowed, spat out, sneezed, or
blown out.
Air passes through each of the structures of the

respiratory tract on its way to the

upper

lower respiratory tract. When a

person at rest inhales, air enters via the nose and mouth. The nasal cavity
filters, warms, and humidifies air. The pharynx or throat is a tube like
structure that connects the back of the nasal cavity and mouth to the larynx,
a passageway for air, and the esophagus, a passageway for food. The
pharynx serves as a common hallway for the respiratory and digestive tracts,
allowing both air and food to pass through before entering the appropriate
passageways.
The pharynx contains a specialised flap-like structure called the
epiglottis that lowers over the larynx to prevent the inhalation of food and
liquid into the

lower respiratory tract.

The larynx, or voice box, is a unique structure that contains the vocal
cords, which are essential for human speech. Small and triangular in shape,
the larynx extends from the epiglottis to the trachea. The larynx helps
control movement of the epiglottis. In addition, the larynx has specialised
muscular folds that close it off and also prevent food, foreign objects, and
secretions such as saliva from entering the lower respiratory tract.
LOWER RESPIRATORY TRACT
The

lower respiratory tract begins with the trachea, which

is just below the larynx. The trachea, or windpipe, is a hollow, flexible, but
sturdy air tube that contains C-shaped cartilage in its walls. The inner portion
of the trachea is called the lumen.

The first branching point of the respiratory tree occurs at the lower end
of the trachea, which divides into two larger airways of the lower respiratory
tract called the right bronchus and left bronchus. The wall of each bronchus
contains substantial amounts of cartilage that help keep the airway open.
Each bronchus enters a lung at a site called the hilum. The bronchi branch
sequentially into secondary bronchi and tertiary bronchi.
The tertiary bronchi branch into the bronchioles. The bronchioles
branch several times until they arrive at the terminal bronchioles, each of
which subsequently branches into two or more respiratory bronchioles.
The respiratory bronchiole leads into alveolar ducts and alveoli. The
alveoli are bubble-like, elastic, thin-walled structures that are responsible for
the lungs most vital function: the exchange of oxygen and carbon dioxide.
Each structure of the

lower respiratory tract, beginning

with the trachea, divides into smaller branches. This branching pattern
occurs multiple times, creating multiple branches. In this way, the
lower respiratory tract resembles an upside-down tree that
begins with one trachea trunk and ends with more than 250 million alveoli
leaves. Because of this resemblance, the

lower respiratory

tract is often referred to as the respiratory tree.

d. Pathophysiology
e. Laboratory Examinations
a. Hematology report
Test
Hemoglobin

Results
110 g/L

August 21, 2009

Normal Value
140 170 g/L

Analysis
Decrease
Insufficient oxygen
circulating in the
bloodstream.

Hematocrit

0.33

0.40 0.50

WBC

15.2 x 10

5.0 10.0 x 10

Neutrophils

0.78

0.45 0.65

Lymphocytes

0.21

0.25 0.40

Monocytes

0.01

0.02 0.06

Platelets

320

150 - 450

b. Chest X-ray

Indicates Anemia due

to blood loss after
surgery.
Decrease
Insufficient oxygen
circulating in the
bloodstream.
Indicates Anemia due
to blood loss after
surgery.
Increase
Leukocytosis
Indicates infection
Increase
Acute bacterial
infection
Decrease
low absolutely
lymphocyte
concentration,
associated with
increase rates of
infection
Decrease
Depleted in
overwhelming
bacterial infection
Normal

August 21, 2009

Impression: Pulmonary Tuberculosis (PTB)

Right sided Pneumohydrothorax
c. Urinalysis
Color:
Transparency:

August 21, 2009

Yellow
S/I Fubid

Chemical Strips
Reaction:
Specific Gravity:
Albumin:

5.2
1.025 (above normal) dehydration and
contamination
Trace

Microscopic
WBC
RBC
Epithelial Cells
Mucus treads
Amorphous Urates

8-12
1-3
Rare
Moderate
Plenty

f. Drug Study
g. Nursing Care Plan
h. Discharge Planning (METHODS)

M- Medications
Medications should be taken as ordered and prescribed by the
physician to avoid complications and help mange the condition of the
patient.

There are a lot of main anti-Tuberculosis medications such us:

Isoniazid, Fifampicin, Ethambutol and Pyrazinamide.

E- Exercise

Instruct the patient to have a time for deep breathing exercise

everyday for several times at home to helps achieved maximal lung

expansion and for relaxation.

Start with exercises that you are already comfortable doing. Starting

slowly makes it less likely that you will injure yourself.

Immediately stop any activities that might causes undue fatigue,
increased shortness of breath or chest pain.

T- Treatment

Remind the importance of taking the medication in the right time and

dose.
Sleep in a room with good ventilation.
Limit your activity to avoid fatigue. Frequent rest is advice.
Maintained wound integrity on the surgical site.

H- Health Teachings

Advise to take the medication on time and with the right dosage.
Semi-fowlers position is advice most of the time for breathing

relaxation.
Avoid close contact with others until the doctor finds it Okay.
Advise the client to turn your head when coughing. Keep tissues with
you and cover your mouth when you cough then throws the tissues

used in the plastic bag.

Keep your hands clean. Maintain proper hygiene.
Isolate techniques is one of the best way to prevent the speared of

the bacteria; separation of dining ware.

Advise the relatives to clean the environment regularly since it is one

of the factor that contribute to the speared of bacteria.

Discuss to the client and significant others the cardinal signs of
infection such as; redness, heat, induration, swelling and separation
of drainage.

O- Out- patient follow- up

Most of the treatment to cure Pulmonary Tuberculosis can be given at
home but must be taken as explained by the health care worker. The family
has the responsibility to check the status of the patient and the progress of
it.

D- Diet

Diet as tolerated is advice by the attending physician, to sustain his

nutritional needs.

High protein diet for tissue repair - meat and green leafy vegetables.

S- Spiritual practice
Mr. ADLs religion is Catholic, encourage the patient pray daily, go to
church regularly and increase his faith with God Almighty.

i. Implications of the case study to the following areas:

a. Nursing Research
b. Nursing Educations
c. Nursing Practice
j. Bibliography

Barabara Gould