Pulmonary Tuberculosis

I INTRODUCTION

A. Background of the Study

Pulmonary tuberculosis, a chronic sub-acute or acute respiratory disease commonly affecting the lungs
characterized by the formation of tubercles in the tissues which tend to undergo cessation, necrosis and calcification. It is
also known as poor man’s disease or consumption disease. The causative agent in this disease is Mycobacterium
Tuberculosis, a rod shaped bacteria. The disease is transmitted by deliberate inoculation of microorganisms by droplet.
This disease is transmitted to other people through the inhalation of organisms directly into the lungs from contaminated
 air. According to the department of Health (DOH) PTB is the 6th cause of mortality and morbidity in the Philippines as of
2007. (Navales, Handbook of Common Communicable and Infectious disease revised edition, pages 280-281.)
This disease is can be acquired easily by person being in contact with an infected one, when you are living in a
crowded area like the squatter’s area and when you have poor nutrition. It is commonly present in third world or
developing countries like the Philippines.
In 2004, mortality and morbidity statistics included 14.6 million chronic active cases, 8.9 million new cases, and
1.6 million deaths, mostly in developing countries. In addition, a rising number of people in the developed world are
contracting tuberculosis because their immune systems are compromised by immunosuppressive drugs, substance
abuse, or AIDS. The distribution of tuberculosis is not uniform across the globe with about 80% of the population in many
Asian and African countries testing positive in tuberculin tests, while only 5-10% of the US population testing positive.
(http://en.wikipedia.org/wiki/Pulmonary_tuberculosis)

B. Rationale for Choosing the Case

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

C. Significance of the Study

This study will help the nursing profession by providing information about the proper management and care for
PTB patient. It will also educate the people, especially those with PTB and vulnerable individuals to seek medical care in
order to prevent TBM. It will increase awareness about the importance of having a healthy lifestyle and clean
environment.
This study will elaborate the inter relatedness of environment, life style habits and acquiring Pulmonary
Tuberculosis.
D. Scope and Limitation of the Study
This study is focused on the nursing aspect of care to those patients who have Pulmonary Tuberculosis. This study
will only be used in the nursing profession. The researchers only focused their attention on the medications, diagnostics,
care plan, pathophysiology and discharge planning. This study is not limited to the PTB patients only, but it is for all
people who are interested in PTB. We are more focused on primary prevention through health education because
primary prevention is the true prevention.

II CLINICAL SUMMARY

A. General Data
 • Name: 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

A. 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.

B. History of Present Illness:

Patient’s 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 can’t 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.

C. Past Medical History

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

D. Familial History

Telesporo Cia, Eugenia Chavez 65

75 Deceased
Deceased VA
 Carlito, 75 Flusofida, 48 Junior, 44 Josephine, 42 Gaudiocio, Blencio,
Litsilda, 50
Eufemia, 46 40 38
PTB

Arsenio, 50

Allan,25 Analyn, 23 Analiza, 19

Anabel, 22 Ana Marie, 15 Arnold, 10

Legends

Male

Female

PTB
E. Pulmonary
Physical Tuberculosis
Assessment
CVA• Cerebro Vascular Attack
Upon Admission Date: September 19, 2008
VA • Vehicular Accidentto 3 spheres-(E4M6V5)
GCS-15 oriented Height: 62 inches
• V/S: BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-37.5 C Weight: 31.5 kilograms
• LOC: Oriented BMI: 12.5 (Severe Malnutrition)

AREA TECHNIQUE NORMS FINDINGS ANALYSIS and INTERPRETATION

A. SKULL

1. Size, shape and Inspection Rounded Rounded(normocephalic); Normal

Palpation
symmetry of the skull (normocephalic and
 symmetrical, with smooth skull contour
frontal, parietal, and
occipital
prominences);
Smooth skull contour

2. Presence of nodules, Palpation Smooth, uniform Has no tenderness; no Normal

Inspection
masses, and consistence; absence masses nor nodules
depressions of nodules or masses

3. Facial Features Inspection Symmetric or slightly Symmetrical and Normal

Palpation
asymmetric facial palpebral fissure equal in
features; palpebral size, nasolabial folds are
fissure equal in size; symmetrical
symmetric nasolabial

4. Presence of edema Inspection No edema and Has Hollowness Abnormal, Volume deficiency of fat within
and hollowness in the hollowness the orbit (the space inside of the bony eye
socket). This condition of the patient is
eye. related to his nutritional status, she is
malnourished. Her BMI is 12.5.
(http://www.drmeronk.com/hollowed/under-eye-
hollows.html)
C. HAIR

1. Evenness of growth, Inspection Evenly distributed Evenly distributed with Normal

Palpation
thickness, or thinness of and covers the whole no patches of hair loss;
hair scalp; Maybe thick or thick hair
thin

2. Texture and oiliness Inspection Silky; resilient hair Silky, smooth and Normal.
Palpation
over the scalp resilient hair

3. Presence of infection Inspection No infection and Presence of lice Abnormal, There is pediculosis, a type of
Palption
and infestation infestation parasitic infection. Lice may be contracted
 from infcetd clothes and direct contact with
an infected person. The idea is that an oily
substance, such as oil, smothers the lice
and they may die. (Kozier, Fundamentals of
Nursing 7th ed. Page 733)

D. FACE

Facial features, Inspection Symmetric or slightly Symmetrical facial Normal

symmetry of facial asymmetric facial features while talking or
movements features; palpebral elevating the eyebrow.
fissures equal in size; Equal palpebral fissure,
symmetric nasolabial symmetrical nasolabial
folds folds.

IV. EYES

A. EYEBROWS

Hair distribution, Inspection Symmetrical and in Symmetrical and aligned Normal

alignment, skin quality line with each other; with each other; black;
and movement maybe black, brown evenly distributed.
or blond depending Movements are
on race; evenly symmetrical.
distributed

B. EYELASHES

Evenness of distribution Inspection Evenly distributed; Turned outward Normal

Palpation
and direction of curl turned outward eyelashes; hair equally
distributed

C. EYELIDS
Surface characteristics Inspection Upper eyelids cover Able to close the eyes Normal
and position (in relation the small portion of and has the ability to
to the cornea, ability to the iris, cornea, and blink.
blink, and frequency of sclera when eyes are
blinking) open; eyelids meet
completely when the
eyes are closed;
symmetrical

D. CONJUNCTIVA

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

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

E. SCLERA

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

F. CORNEA

Clarity and texture Inspection No irregularities on Clear and smooth in Normal

 the surface; looks texture
smooth; clear or
transparent

G. IRIS

Shape and color Inspection Anterior chamber is Dark brown in color; Normal
transparent; no noted transparent anterior
visible materials; chamber
color depends on the
person’s race

H. PUPILS

1. Color, shape, and Inspection Color depends on the Pupil size is 3mm. Normal
symmetry of size person’s race; size
ranges from 3-7 mm,
and are equal in size;
equally round

2. Light reaction and Inspection Constrict Dilates when looking at Normal

accommodation briskly/sluggishly far objects and constricts
when light is directed when looking at near
to the eye, both objects. Constricts when
directly and there is light.
consensual

I. VISUAL ACUITY

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

Palpability and Palpation No edema or No tenderness and Normal

tenderness of the tenderness over edema noted.
lacrimal gland lacrimal gland

K. EXTRAOCULAR
MUSCLES

Eye alignment and Inspection Both eyes Moves in Unison Normal

coordination coordinated, move in
unison, with parallel
alignment

L. VISUAL FIELDS

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

V. EARS

A. AURICLES

1. Color, symmetry of Inspection Color same as facial Same color as the facial Normal
size, and position skin; symmetrical; skin; tip of auricle aligned
auricle aligned with at the outer canthus of
outer canthus of eye, the eye.
about 10 degrees
 from vertical

2. Texture, elasticity Palpation Mobile, firm, and not Smooth in texture, Normal
and areas of tenderness tender; pinna recoils flexible and elastic pinna;
after it is folded no tenderness

C. HEARING ACUITY
TESTS

1. Client’s response to Inspection Normal voice tones Can hear normal volume Normal
normal voice tones audible tones or words.

VI. NOSE

1.Any deviations in Inspection Symmetric and Symmetric and straight; Abnormal, Nasal flaring suggests airway
shape, size, or color and straight; no discharge Uniform color with nasal obstruction. Nasal discharge shows the
flaring or discharge or flaring; Uniform flaring. presence of mucus secretions in the air
from the nares color tract.

2. Nasal septum Inspection Nasal septum intact Nasal septum intact and Normal
(between the nasal Palpation and in midline in midline
chambers)

3. Patency of both nasal Inspection Air moves freely as Only left nares is patent. Abnormal, not patent right nares show the
cavities the client breathes Right nares is with presence of mucus secretions and would
through the nares secretion. suggest there is an infection in the
respiratory system.

4. Tenderness, masses, Palpation Not tender; no lesions Nor tenderness nor Normal
and displacements of lesions.
bone and cartilage
VII. SINUSES

Identification of the Inspection Not tender Not painful when Normal

sinuses and for palpated
tenderness

VIII. MOUTH

A. LIPS

Symmetry of contour, Inspection Uniform pink color; Pink in color, dry and Abnormal, May suggest cellular
color and texture Palpation soft, moist, smooth cracked lips dehydration. (Black, Medical Surgical
texture; symmetry of Nursing7th edition, page 208).
contour; ability to
purse lips

B. BUCCAL MUCOSA

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

C. TEETH

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

D. GUMS

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

E. TONGUE/FLOOR OF
THE MOUTH

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

2. Position, color and Inspection Central position; pink Located and positioned in Normal
texture, movement and color; smooth tongue the center.
base of the tongue base with prominent
veins

3. Any nodules, lumps, Palpation Smooth with no No tenderness nor Normal

or excoriated areas Inspection palpable nodules, masses
lumps, or excoriated
areas

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

2. Position of the uvula Inspection Positioned in midline Positioned at the center Normal
and mobility (while of soft palate of the oropharynx
examining the palates)

G. OROPHARYNX and
TONSILS

1. Color and texture Inspection Pink and smooth Dry, pinkish in color. Abnormal, May suggests dehydration.
posterior wall (Black, Medical Surgical Nursing7th edition,
page 208).

2. Size, color, and Inspection Pink and smooth; no Has no discharge; pinkish Normal
discharge of the tonsils discharge; of normal
size

3. Gag reflex Inspection Present Present Normal

X. THORAX

A. ANTERIOR
THORAX

1. Breathing patterns Inspection Quiet, rhythmic, and
effortless respirations
Difficulty of breathing
Abnormal, labored breathing is a common
manifestation affecting clients with cardiac
and pulmonary disorders. It is related to
obstructed airway. It also related to the
decreased size of the lungs due to PTB.
(Black, Medical Surgical Nursing7th edition,
 page 1566).

2. Temperature, Palpation Skin intact; uniform Has an intact skin; has Normal
tenderness, masses temperature; chest equal warmth on both
wall intact; no sides. No masses.
tenderness; no
masses

3. Anterior thorax Auscultation Bronchovesicular and Has crackles sounds on Abnormal, crackles or rales are audible
auscultation vesicular breath the upper thorax & lower when there is a sudden opening of small
sounds thorax airways that contain fluid. It is usually heard
during inspiration. (Black, Medical Surgical
Nursing7th edition, page 1756).

B. POSTERIOR
THORAX

1. Shape, symmetry, Inspection Anteroposterior to Has a anteroposterior to Normal

and comparison of Palpation transverse diameter transverse diameter ratio
anteroposterior thorax in ratio 1:2; Chest of 1:2, elliptical in shape
to transverse diameter symmetric and symmetrical chest

2. Spinal alignment Inspection Spine vertically Has a vertical alignment Normal

aligned

3. Temperature, Palpation Skin intact; uniform No masses nor Normal

tenderness, and temperature; chest tenderness; has equal
masses wall intact; no warmth on each side
tenderness; no
masses

7. Posterior thorax Auscultation Vesicular and Has crackles heard on Abnormal, the condition is related to the
auscultation bronchovesicular the anterior and middle decreased size of the right lung and poor
breath sounds part of right and left inspiratory effort due to pain.
lungs. Diminished lung (http://www.nurse411.com/Heart_Lung_Sounds.asp)
sound on the posterior
right lung.

XI. CARDIOVASCULAR

A. AORTIC and Auscultation No pulsations No pulsations felt Normal

PULMONIC AREAS

B. TRICUSPID AREA Auscultation No pulsations; no lift No pulsations of lifts Normal

or heave

C. APICAL AREA Auscultation Pulsations visible in Has full pulsation Normal

50% of adults and
palpable in most PMI
in fifth LICS at or
medial to MCL

D. EPIGASTRIC AREA Auscultation Aortic pulsations Has pulsation Normal

E. CARDIOVASCULAR Auscultation S1: Usually heard at Has full and rapid Normal
AREAS all sites pulsation. 84
AUSCULTATION bpm/minute.
Usually louder at the
apical area Sounds on the aortic and Normal
pulmonic areas; has a lub
S2: Usually heard at sound on the apex and
all sites dub sounds on the
tricuspid area.
Usually louder at the
Normal
base of heart Blood pressure is 90/70

Systole: silent
 interval; slightly mm Hg.
shorter duration than
diastole at normal
heart rate (60 to 90
beats/min)

Diastole: silent
interval; slightly
longer duration than
systole at normal
heart rates

S3: in children and

young adults

S4: in many older

adults

XII. CAROTID
ARTERIES

1. Carotid artery Palpation Symmetric pulse Has weak pulsation. Abnormal, decreased amount of blood
palpation volumes; full Symmetrical pulse. volume passing the artery. (Black, Medical
pulsations, thrusting Surgical Nursing7th edition, page 1574).
quality; quality
remains same when
the client breathes,
turns head, and
changes from sitting
to supine position;
elastic arterial wall

XIV. AXILLAE
1. Axillary, Inspection No tenderness, Have no masses and Abnormal, The appocrine glands located in
subclavicular, and masses, or nodules nodules. Presence of a the axillae produces sweat. The secretion of
supraclavicular lymph foul smelling odor. these glands is odorless, but when
nodes decomposed or acted upon by bacteria in
the skin, it takes on a musky, unpleasant
odor. (Kozier et.al, Fundamentals of Nursing
7th ed. Page 699)

XV. ABDOMEN

1. Skin integrity Inspection Unblemished skin; Uniform color and has no Normal
uniform color blemishes

2. Abdominal contour Inspection Flat, Has a concave abdomen. Normal

rounded(convex), or
scaphoid(concave)

3. Enlargement of liver Inspection No evidence of No enlargement of the Normal

or spleen enlargement of liver spleen and liver seen
or spleen

4.Symmetry of contour Inspection Symmetric contour Has a symmetrical Normal

abdominal contour

5. Abdominal Inspection Symmetric Abdominal movements Normal

movements associated movements caused noted when inhaling.
with respirations, by respiration; visible
peristalsis or aortic peristalsis in very
pulsations lean people; aortic
pulsations in thin
persons at epigastric
area

6. Vascular pattern Inspection No visible vascular Has no blood vessels Normal

 pattern visible

XVI.
MUSCULOSKELETAL
SYSTEM

A. MUSCLES

1. Muscle size and Inspection Proportionate to the Proportionate to the Normal

comparison on the body; even in both body; even in both sides
other side sides

2. Fasciculation and Inspection No fasciculation and Has no fasciculation and Normal

tremors in the muscles tremors tremors

3. Muscle tonicity Palpation Even and firm muscle Weak muscle tone Abnormal, possibly related to the amount of
food that patient is eating. Possible
tone
exhaustion experienced by the patient
when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)
4. Muscle strength Palpation Has equal muscular Weak muscle strength Abnormal, possibly related to the amount of
food that patient is eating. Possible
strength on both
exhaustion experienced by the patient
sides when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)
C. JOINTS

1. Joint swelling Inspection No swelling, no No swelling, no warmth, Normal

warmth, no redness, no redness, no pain, no
no pain, no crepitus crepitus

EXTREMETIES Inspection, No swelling, no No edema, no pain when Normal

Palpation warmth, no redness, moved.
no pain.
 Neurologic Assessment:

Category Normal Findings Actual Findings Analysis and interpretation

Mental Status

Level of Consciousness Alert Alert Normal

Orientation Oriented Oriented to person, time Normal

and place.
Language test Coherent Coherent Normal

Recall Able to remember Able to state what Normal

happened to her in the
past.
Cranial Nerves

CN 1 Able to smell and Able to identify the scent Normal

Olfactory recognize stimuli of the alcohol

CN 11 20x20 vision, able to Pupil size is 3 mm, able to Abnormal, it is a refractive defect of the eye in
Optic read, 3-5 mm [pupil read, myopia or which collimated light produces image focus in front
size] nearsightedness. of the retina when accommodation is relaxed. It is
caused by an eyeball that is longer than normal,
which may be a familial trait. Transient mayopia
occurs due to influenza, steroids, sever dehydration
and large intake of antacids. (Black, Medical Surgical
Nursing7th edition, page 1963).
CN III, IV, VI (+) Extraoccular Pupils react to light. There Normal
Occulomotor Movement (EOM); is constriction and
Trochlear Lateral Upward and consensual
Abducens downward; pupils accommodation. Able to
reactive to light. move the eyes in any
direction in unison.

CN V Able to feel and Normal

Trigeminal clearly identify Able to feel my finger on
stimulus, with her face while covering her
bilateral facial eyes.
sensation. With
active corneal reflex.
CN VII Normal
Facial (+) Corneal reflex , (+) Facial symmetry
Facial asymmetry

CN VIII
Vestibulocochlear Normal
Able to hear clearly, Can hear clearly and can
can maintain balance walk.

CN IX, X
Glossopharyngeal Normal
Vagus (+) gag reflex, uvula Present gag reflex, able to
 at the center, soft swallow and able to
palate rises idebtify the taste of the
CN XI food.
Accessory (Spinal) Normal
Able to shrug
shoulders against Can shrug shoulders
resistance and able against resistance and can
to turn the head side turn the head fro right to
and against right.
resistance.
CN XII Normal
Hypoglossal Able to move tongue
from side to side
Able to protrude the
tongue and move it side to
side.
Muscle Strength MNT Grading System:

Left Arm (+5) Active motion +4 active motion against Abnormal, possibly related to the amount of food
against full some resistance. that patient is eating. Possible exhaustion
resistance experienced by the patient when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)
Right Arm +4 active motion against Abnormal
(+5) Active motion some resistance.
against full
Left Leg resistance +4 active motion against Abnormal
some resistance.
Right Leg (+5) Active motion +4 active motion against Abnormal
against full some resistance.
resistance
(+5) Active motion
against full
resistance

A. Patterns of Functioning

The researchers utilized the Gordon’s typology in assessing the pattern of functioning of our patient in her life.
How does she manages and takes care of herself based on Eleven Patterns.
 Functional Health Pattern
Prior to Hospitalization
Health perception- Health Management
• The patient doesn’t have complete immunization because
according to her it is not available during those days and
having immunization during those years are expensive and
they cannot afford it.
• She was never been hospitalized.
• No known allergies to any foods and drugs. She can eat fish,
oyster and others.
• Does not experience any accidents.
• When she had a disease, she used herbal medicines like guava
leaves, oregano, lagundi, etc.
• For her, being healthy is important. A person is healthy when
she is strong, she can do what she wants and does not
experience any diseases.
• She does not have any regular medical and dental check-ups.
• 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 get’s 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.
Norms and Standards
Measure for personal cleanliness and grooming, called personal
hygiene, promote physical and psychological well-being. Various
studies have confirmed that improved personal hygiene practices
reduce illness rates. (Larson, 2002; Larson and Aiello, 2001).
Personal hygiene practices vary widely among people. The time of
the day one bathes and how often one shampoo or changes the bed
linens, and sleeping garments are relatively unimportant. What is
important is that personal care be carried out conveniently and
frequently enough to promote personal hygiene.
Illness, hospitalization and institutionalization generally require
modifications in hygiene practices. In these situations, the nurse
helps the patient to continue some hygiene practices, and can teach
the patient and family members, when necessary, regarding hygiene.
Nurses assist the patient with basic hygiene must respect individual
patient preferences, providing only the care that patients cannot or
should not provide for themselves.
(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
 • The patient is non-smoker and she does not drink any
alcoholic beverages.
• She denies the use any illicit drugs.
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.
handling raw meat, fish, or poultry, or any other situation leading to
potential contamination. Hands should also be washed before eating,
handling or cooking food. Conventionally, the use of soap and warm
running water and the washing of all surfaces thoroughly, including
under fingernails is seen as necessary. Alcohol rub sanitizers kill
bacteria, multi-drug resistant bacteria (MRSA and VRE), tuberculosis,
and viruses (including HIV, herpes, RSV, rhinovirus, vaccinia,
influenza, and hepatitis) and fungus.
(http://en.wikipedia.org/wiki/Hand_washing)
Herbalists treat many conditions such as asthma, eczema,
premenstrual syndrome, rheumatoid arthritis, migraine, menopausal
symptoms, chronic fatigue, and irritable bowel syndrome, among
others. Herbal preparations are best taken under the guidance of a
trained professional. Be sure to consult with your doctor or an
herbalist before self-treating. Some common herbs and their uses are
discussed below. Please see our monographs on individual herbs for
detailed descriptions of uses as well as risks, side effects, and
potential interactions. (http://www.umm.edu/altmed/articles/herbal-medicine-
000351.htm)
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

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.
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 can be affected by a person’s 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 one’s 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 person’s 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.

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.
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).
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 rate”—the number of
calories your body burns in order to keep you alive. By having a high
metabolism, you burn calories 24 hours a day—even while you sleep!
You can literally turn your body into a fat-burning machine!
This has many benefits: With a strong metabolism comes a strong
immune system. When you burn fat, the toxins are released into the
bloodstream, and are quickly carried out of the body through sweat.
This inoculates you against the probability of developing cancerous
and diseased cells. Therefore, hard exercise—that makes you sweat—
is very good for you.
Exercise also helps to regulate the amount of insulin released into
the bloodstream. Insulin is commonly referred to as “the fat-making
hormone.” Its job is to metabolize blood sugar into energy. But too
much insulin in the bloodstream keeps your body from burning stored
fat. Years of an overworked pancreas—the organ that produces

Cognitive-perceptual
• The patient is an elementary graduate.
• She stops studying because of financial problem
• She can read and write properly.
• She is aware to different people or happening around her.
• She can talk properly.
• During the interview her voice is weak.
• According to her she is sensitive to the feelings of the people
around her.
• There are no any blockages of communication noted.
• She is not always reading any books like pocket books.
• She can express her feelings appropriately.
• She does not have any difficulty when it comes to
communication.
Sleep and Rest
• The patient regularly sleeps at 8:00pm 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.
insulin—can lead to “onset (type 2) diabetes.” However, if you use—
burn—more 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)
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 person’s intelligence, perceptual ability and
ability to process information. It represents a progression of mental
abilities from illogical to logical thinking, from simple to complex
problem solving and from concrete to abstract ideas. (Kozier et.al,
Fundamentals of Nursing 7th ed. Page 359).
For no known reason, 8 hours of sleep a night has been the
accepted standard for adults despite obvious variations seen in the
general population. It is important however that a person follows a
pattern of rest that maintains well-being. Many factors affect a
person’s 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
 • 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.
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.
(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 concept is one’s mental image of oneself. A positive self
concept is essential to a person’s 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 person’s body image closely resembles one’s ideal body, the
 • She is simple.
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.
Sexuality-reproductive
• She is engage in sexual activity to her husband only.
• Presently she is still active in her sex life.
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).
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 individual’s 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 is defined not only by a person’s 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
 • 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.
Coping-stress
• Whenever she has problem, she asks guidance from our Lord
• She watches television as her stress management.
• She always listen to radio programs when she feels lonely.
• When she gets mad, she just keep quiet.
• When she experiences coughing and difficulty of breathing she
just relaxes and breathes deeply.
• Her husband or children taps her back when she coughs.
Value-belief
• She is a Roman Catholic
• She attends mass occasionally.
• She always ask the guidance of our Lord
• Whenever there are Christian events, like Holy week, she
participates in the activities like fasting.
behaves in relationships with others.
(Fundamentals of Nursing 5th edition by Taylor, page 931)
Sexuality is a crucial part of a person’s 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 people’s emotional,
psychologic, physical and spiritual make up, which plays a significant
role in the satisfaction. Sexual desires fluctuates within each person
and varies from person to person. If people suppresses or block out
conscous sexual desires, they may not experience any physiological
respose. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages
975,980).
Coping mechanisms which are behaviors used to decrease stress and
anxiety. Many coping behaviors are learned, based on one’s family
past experiences, and socio-cultural influences and expectations.
(Fundamentals of Nursing 5th edition by Taylor, page 855)
Spiritual well-being is the condition that exists when the universal
spiritual needs for meaning and purpose, love and belonging, and
forgiveness are met. O’ Briens conceptual model of spiritual well-
being in illness identified three empirical referents of spiritual well-
being: personal faith, religious practice and spiritual contentment.
Spiritual beliefs are of special importance to nurses because of the
• 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.
many ways they can influence a patient’s level of health and self-care
behaviors. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages
975,979).
Spiritual well-being is manifested by a generally feeling of being
alive, purposeful and fulfilled. People nurture or enhance their
spirituality in many ways. Some focus on development of the inner
self or world; others focus on the expression of their spiritual energy
with others or outer world. Relating to one’s inner self or soul may be
achieved through conducting an inner dialogue with a higher power
or with one’s self through prayer or medications. The expression of a
person’s 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. Activities of Daily Living

ASPECT PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION INTERPRETATION and ANALYSIS

1. Nutrition Patient loves to eat meat, fish and
vegetables. She eats anything that is
being served to her. She does not eat
junk foods. She is not taking food
supplements like vitamins frequently.
She eats 4 spoons of rice with viand
because according to her it is due to
her cough. She eats thrice a day.
2. Elimination Patient voids 7 times a day, and
defecate twice a week. She doesn’t
experience any pain and difficulty in
terms of urination. Previously her
defecation pattern is daily, but when
her condition exacerbated, it is also
affected.
The patient is on diet as tolerated
with aspiration precaution. She eats
dry, thickened food on a small
frequent feeding. She is advised to
chew food properly.
The patient does not defecate or
urinated during the conduct of the
interview.
The patient can eat any food she wants
as long as it is dry, thickened, and
frothy. It should be in a small frequent
feeding, as to avoid aspiration.
The patient does not defecate for more
than a week due to decreased gastric
motility related to decrease physical
activity. For most people defecation is
a private affair experienced easily only
in the comfort of one’s own bathroom.
Defecation may be difficult in shared
hospital room with only a curtain for
privacy.
(Fundamentals of Nursing 5th edition by
 Taylor, page 975 & 979)

3. Exercise Cleaning their house is the only Deep breathing and coughing The patient performs deep breathing
activity she considered as her exercises are advised and performed. exercise as instructed by the nurse.
exercise. She does not have routine The patient has decreasing function
exercise. However, she is aware that as the disease progresses.
her activity is not enough, and she
recognizes the importance of having
regular exercise. She loves to listen
to radio programs usually in the
afternoon.
When after all the chores are done
she will rest and watch television.

4. Hygiene Patient takes a bath every day, Not applicable

brushes her teeth once a day. She
wears slippers while inside their
house. She feels that her hygienic
practices are adequate, and she feels
clean and neat. There is body odor
noted.
5. Substance Patient is a non-smoker and denies The patient doesn’t use any The patient does not use any addictive
Use use of illicit drugs. She does not drink prohibited substances like alcohol, substances. Illicit drugs are strictly
alcohol. cigarettes and illicit drugs. prohibited in the hospital premises,
even cigarette smoking and alcohol
drinking.
6. Sleep and Sleeping is important to her. She is Not applicable
Rest experiencing intermittent sleep
disturbance because according to her
she feels difficulty of breathing and
cough. She takes a nap in the
morning from 8 am to 11 am. She
sleeps together with her husband.
The patient regularly sleeps at
8:00pm and wakes up at 1:00 pm.
She feels that her sleep and rest is
inadequate because of her
 conditions.

7. Sexual She dresses appropriately, based on Not applicable

Activity her gender. She still has regular
menstruation. She is engage in
sexual activity to her husband only.
Presently she is still active in her sex
life

A. Patients Concept about Health, Illness and Hospitalization

HEALTH ILLNESS HOSPITALIZATION

The patient believes that being healthy is
being strong, does not experience any
sickness and energetic.
- Health is defined as a state of complete
physical, mental and social well-being and
not merely the absence of disease or
infirmity. WHO definition
For the patient, an individual is weak and eats
little amount of food.
-Is a disease, sickness or the condition of
being in a poor health, either physically or
mentally. (Blackwell’s Nursing Dictionary)
The patient looks at hospitalization as the last
recourse when one has an illness. For the
patient, it is the place where an individual is
being treated from severe cases.
- Placement of an individual in a hospital for
observation, diagnostic test, or treatment for
some diseases. (Blackwell’s Nursing
Dictionary)

B. Laboratory and Diagnostic Examination

DATE PROCEDURE NORMS RESULT INTERPRETATION and ANALYSIS

Sept. 19, 2008 Hemoglobin 120-160g/L
Hematocrit 0.38-0.40 g/L
RBC count 4’2-5.4x 1012 per liter
WBC 5-10x109/L
Neutrophils 81.3%
Lymphocytes 10.2%
Basophils 0.1%
Monocytes 7.5%
Eosinophils 0.9%
Platelets 150-450x109/L
 Fasting Blood Sugar 70-110 mg/dl
Urinalysis
Creatinine 44.2-106.08 umol/L

Na 135-145mmol/L

K 3.6-5.5mmol/L

Sputum Test/AFB Negative

• Electro Cardiogram

• Chest X-ray
The patient had undergone chest x-ray upon admission. The film shows presence of infiltrates or clouds.
The right is smaller than the left lung, particularly the lower lobe of the right lung.

A. Impression/Diagnosis

Dr. San Jose, the patient’s attending physician, who diagnosed the disease as Pulmonary tuberculosis. This
diagnosis is supported by the pathognomonic signs that manifested by the patient. These include intermittent fever in
the afternoon, difficulty of breathing, coughing, weight loss and chest pain. This diagnosis is supported by the following
diagnostic exam such as Culture and Sensitivity of the sputum and chest x-ray.

B. Course in the Ward

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

DATE MEDICAL PROCEDURES/ORDERS NURSING ASSESSMENT and FUNCTION

September 19, - History taking Upon admission:

2008 - Physical assessment -GCS E4 V5 M6
- Neurological Assessment - Vital signs BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-31.5
- Chest-x-ray C
- IVF of PNSS 1 liter 20 gtts/min to run for 12 hours. - IV insertion done at the right arm, infusing well.
- Medications -Due meds given
• Nausil 1 ampule TIV stat, then every 6 hours. - X-ray result obtained.
 • B complex 2 ampules TIV stat - History taking
• Cefuroxime 500 mg/Cap - Physical assessment done
• Theophylline 1 cap TID - Neurologic assessment done
• Salbutamol and Guiafene Sin + tab TID PO -crackles noted upon auscultation.
- Diet as Tolerated with aspiration precaution. 2:40 AM
-Received from ER to Medical surgical ward.
- Placed in isolation room
- Patient was oriented.
- Kept rested
-Advised relatives to use mask and hand washing regularly.
- On DAT with AP

A. Ecologic Model

Hypothesis
The patient developed PTB thru the inhalation of mycobacterium tuberculosis due to being exposed to an environment,
specifically in their community, where in some people around her have Pulmonary Tuberculosis. Not always covering her nose
and doing proper hand washing are the practices that have predisposes the patient to develop the disease. She had come in
close contact with people who had PTB.

Agent
• Tuberculosis is a common and deadly infectious disease caused by mycobacterium mainly Mycobacterium
tuberculosis.
• Mycobacterium tuberculosis. A rod-shaped organism.
• The disease is directly transmitted through inhalation of organisms directly into the lungs.
•
Host
➢ 46 yrs old
➢ Female
➢ Filipino, Roman Catholic
➢ Highest educational attainment: Elementary graduate.
➢ Living together with her family in Baras, Rizal
➢ Have incomplete vaccination.
➢ Practices hand washing but improper without soap.
➢ Takes a bath once a day and brushes teeth once.
➢ Does not always cover her nose and mouth in situations needed to.
➢ Does not have a regular medical check up.
 ➢ Exposed to a person who is carrier of M. Tuberculosis.

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

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

Financial insufficiency.
Does not always cover her nose and mouth when exposed to a person who coug

Does not regularly take vitamins and minerals

Does not have a regular medical check up.
 Educational attainment. HOST
Inadequate of knowledge about health management. .
Infected of Tuberculosis Meningitis.
Weakened immune system
Lack of immunizations

Degeneration of healthy cells..

Airborne transmission
Does not practice proper hand washing.

ng a bath once a day and brushing teeth only once.

Exposure to a carrier of M. tuberculosis.

Mayco Bacterium Tuberculosis

Analysis
PTB is caused by mycobacterium tuberculosis. This bacterium enters the host thru the nose and mouth. It first affects the
alveoli of the lungs then this bacterium spreads thru the bloodstream. This bacterium migrates to other parts of the body.
Hand washing has been the most effective means of preventing transfer. It is the true prevention. Not covering the nose
and mouth when someone sneezes or coughs causes the bacteria in their sputum to travel through the air. The so called
airborne transmission will now take place affecting the individual.
Living in an unhealthy place predisposes the individual to develop certain diseases especially those within the respiratory
system. (Brunner and Suddarth’s Textbook of Medical- Surgical Nursing 11th ed by Smeltzer et al p. 643)

Conclusion and recommendation

The researchers therefore conclude that PTB can be prevented if we always clean the environment, practicing proper
hand washing, personal hygiene and use of personal protective equipments are the things that are very important. Personal
discipline is a crucial factor. As nurses, they are focused on promoting wellness through health education especially to that of
the poor.
II CLINICAL DISCUSSION OF THE DISEASE

A. Anatomy and Physiology

Respiration is the process by which living organisms take in oxygen

and release carbon dioxide. The human respiratory system, working in
conjunction with the circulatory system, supplies oxygen to the body's
cells, removing carbon dioxide in the process. The exchange of these
gases occurs across cell membranes both in the lungs (external
respiration) and in the body tissues (internal respiration). Breathing, or
pulmonary ventilation, describes the process of inhaling and exhaling air.
The human respiratory system consists of the respiratory tract and the
lungs.

Respiratory tract

The respiratory tract cleans, warms, and moistens air during its trip to
the lungs. The tract can be divided into an upper and a lower part. The
upper part consists of the nose, nasal cavity, pharynx (throat), and larynx
(voice box). The lower part consists of the trachea (windpipe), bronchi,
and bronchial tree.
The nose has openings to the outside that allow air to enter. Hairs inside
the nose trap dirt and keep it out of the respiratory tract. The external
nose leads to a large cavity within the skull, the nasal cavity. This cavity
is lined with mucous membrane and fine hairs called cilia. Mucus
moistens the incoming air and traps dust. The cilia move pieces of the
mucus with its trapped particles to the throat, where it is spit out or swallowed. Stomach acids destroy bacteria in swallowed
mucus. Blood vessels in the nose and nasal cavity release heat and warm the entering air.
Air leaves the nasal cavity and enters the pharynx. From there it passes into the larynx, which is supported by a framework of
cartilage (tough, white connective tissue). The larynx is covered by the epiglottis, a flap of elastic cartilage that moves up and
down like a trap door. The epiglottis stays open during breathing, but closes during swallowing. This valve mechanism keeps
solid particles (food) and liquids out of the trachea. If something other than air enters the trachea, it is expelled through
automatic coughing.

Alveoli: Tiny air-filled sacs in the lungs where the exchange of oxygen and carbon dioxide occurs between the lungs and the
bloodstream.

Bronchi: Two main branches of the trachea leading into the lungs.

Bronchial tree: Branching, air-conducting subdivisions of the bronchi in the lungs.

Diaphragm: Dome-shaped sheet of muscle located below the lungs separating the thoracic and abdominal cavities that
contracts and expands to force air in and out of the lungs.

Epiglottis: Flap of elastic cartilage covering the larynx that allows air to pass through the trachea while keeping solid particles
and liquids out.

Pleura: Membranous sac that envelops each lung and lines the thoracic cavity.

Air enters the trachea in the neck. Mucous membrane lines the trachea and C-shaped cartilage rings reinforce its walls. Elastic
fibers in the trachea walls allow the airways to expand and contract during breathing, while the cartilage rings prevent them
from collapsing. The trachea divides behind the sternum (breastbone) to form a left and right branch, called bronchi
(pronounced BRONG-key), each entering a lung.

The lungs

The lungs are two cone-shaped organs located in the chest or thoracic cavity. The heart separates them. The right lung is
somewhat larger than the left. A sac, called the pleura, surrounds and protects the lungs. One layer of the pleura attaches to the
wall of the thoracic cavity and the other layer encloses the lungs. A fluid between the two membrane layers reduces friction and
allows smooth movement of the lungs during breathing.
The lungs are divided into lobes, each one of which receives its own bronchial branch. Inside the lungs, the bronchi subdivide
repeatedly into smaller airways. Eventually they form tiny branches called terminal bronchioles. Terminal bronchioles have a
diameter of about 0.02 inch (0.5 millimeter). This branching network within the lungs is called the bronchial tree.
The terminal bronchioles enter cup-shaped air sacs called alveoli (pronounced al-VEE-o-leye). The average person has a total of
about 700 million gas-filled alveoli in the lungs. These provide an enormous surface area for gas exchange. A network of
capillaries (tiny blood vessels) surrounds each alveoli. As blood passes through these vessels and air fills the alveoli, the
exchange of gases takes place: oxygen passes from the alveoli into the capillaries while carbon dioxide passes from the
capillaries into the alveoli.
This process—external respiration—causes the blood to leave the lungs laden with oxygen and cleared of carbon dioxide. When
this blood reaches the cells of the body, internal respiration takes place. The oxygen diffuses or passes into the tissue fluid, and
then into the cells. At the same time, carbon dioxide in the cells diffuses into the tissue fluid and then into the capillaries. The
carbon dioxide-filled blood then returns to the lungs for another cycle.
Breathing

Breathing exchanges gases between the

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

GENERIC / ACTION CLASSIFICATI INDICATION CONTRAINDICATION SIDE EFFECTS NURSING

BRAND NAME ON INTERVENTION

Theophylline -The main - Mild stimulant - For chronic - Hypersensitivity -Stomach - Monitor patients’
mechanism of -Bronchodilator obstructive - Pregnant. stomach heart rate.
action of diseases of the -pain - Assess for CNS
theophylline is that airway. -Diarrhea effects.
of adenosine -COPD -Headache - Teach the patient to
receptor - Restlessness avoid smoking.
antagonism. - Insomnia - Educate the
- Irritability importance of taking
- Theophylline is a the right amount in
non-specific the right time of
adenosine medications.
antagonist, - Assess for any
antagonizing A1, hypersensitivity.
A2, and A3
receptors almost
equally, which
explains many of
its cardiac effects
and some of its
anti-asthmatic
effects.

SAlbutamol - A short-acting β2- - -Relief and -Contraindicated with -Dizziness, - Assess for any
adrenergic Bronchodialtor prevention of hypersensitivity to drowsiness, hypersensitivity to
receptor agonist bronchospasm in albuterol. fatigue, albuterol.
used for the relief patients with -Use cautiously with headache. - Be cautious when
of bronchospasm reversible diabetes mellitus - vomiting, driving.
in conditions such obstructive (large IV doses can change in taste -Eat food is a small
as asthma and airway disease aggravate diabetes frequent way.
chronic obstructive and ketoacidosis). - Maintain beta-
pulmonary -Inhalation: adrenergic blocker on
disease. Treatment of stand by.
 acute attacks of
bronchospasm

-Prevention of
exercise-induced
bronchospasm.

Vitamin B - Support and - Water soluble - Encourage patient

increase the rate Vitamin to take the vitamin
of metabolism. regularly.
- Maintain healthy - Encourage them to
skin and muscle go to the doctor
tone before drinking any
- Enhance immune vitamins.
and nervous
system function.
- Promote cell
growth and
division including
that of the red
blood cells that
help prevent
anemia.

Cefuroxime - Inhibits bacterial - Antibacterial - Treatment of - Hypersensitivity to - GI bleeding - Observe for signs
cell wall synthesis infections caused cefuroxime and other - Headache and symptoms of
by binding to one by staphylococci cephalosphorine. - Nausea anaphylaxis during
or more of the and other - Dizziness first dose; with
penicillin-binding microorganisms - Vomiting prolonged therapy,
proteins (PBPs) like klebsiella. - Increased BUN monitor renal,
which in turn - Treatment of and Creatinine hepatic, and
inhibits the final susceptible hematologic function.
transpeptidation infections of the - Educate the
step of lower respiratory importance of taking
peptidoglycan tract the right amount in
synthesis in the right time of
bacterial cell walls, medications.
thus inhibiting cell - Assess for any
wall biosynthesis. hypersensitivity.
-Bacteria
 eventually lyse
due to ongoing
activity of cell wall
autolytic enzymes
(autolysins and
murein hydrolases)
while cell wall
assembly is
arrested.
Guiafen - Most - Decongestant -Used to relieve - MEDICINE IS NOT - Nervousness, - Assess for any
decongestants - Expectorant congestion and to RECOMMENDED if you dizziness, trouble allergies.
cause response treat cough due have a history of sleeping, nausea, -Instruct the patient
from to colds, flu, or severe high blood vomiting and to consult a doctor
adrenoreceptor a1, hay fever. pressure, severe headache. when the side effects
chiefly responsible coronary artery continues.
for disease, or if you have - Be careful when
vasoconstriction problems where the driving or operating
(a2 modulates supply of blood and machines.
adrenaline/noradre oxygen to the heart is - Instruct the patient
naline levels, b1 is reduced also known as that they should
the most ischemic heart swallow the
stimulating and disease. medication whole.
increases cardiac
output, b2 dilates
the bronchial
walls, and b3
induces lipolysis).

FLUIMUCIL -Is any agent Mucolytic -Acute & chronic -Contraindicated with -Urticaria, -Should be taken with
(nausil) which dissolves respiratory tract asthmatic patients bronchospasm, food
thick mucus affections w/ and patients with nausea, -The sachet should be
usually used to abundant mucus history of peptic vomiting. dissolve into a glass
help relieve secretions. ulceration. -Aerosol of cold or warm
respiratory -Used in the treatment: water, and drink
difficulties. treatment of wet Rhinitis, immediately.
(hydrolyzing cough. stomatitis. -Do not dissolve other
glycosaminoglycan medicines together
s: tending to break with Fluimucil, since
down/lower the both Fluimucil and
viscosity of mucin- the other drug effect
 containing body could be influenced
secretions/compon or cancelled.
ents). - Assess for any
allergies.

IV Fluid

Treatment /
Classification Indication Contraindication Nursing Responsibilities
Infusion

*Do not connect flexible plastic containers of

intravenous solutions in series, i.e., do not
piggyback connections. Such use could result
in air embolism due to residual air being
*Hypovolemia drawn from one container before
administration of the fluid from a secondary
*Heat-related container is completed.
emergencies *Pressurizing intravenous solutions contained
Plain NSS Isotonic *CHF in flexible plastic containers to increase flow
*Freshwater drowning rates can result in air embolism if the residual
air in the container is not fully evacuated
*Diabetic prior to administration.
ketoacidosis(DKA) *Use of a vented intravenous administration
set with the vent in the open position could
result in air embolism. Vented intravenous
administration sets with the vent in the open
position should not be used with flexible
plastic contain.

III NURSING PROCESS

A. Long Term Objective

After two month of intensive treatment the patient will not experience the signs and symptoms of PTB. The
complications brought about by PTB will be prevented through proper participation to the different medical and nursing
interventions.

B. Problem List
 CUES NURSING PROBLEM RANK JUSTIFICATION
Subjective Cues: Ineffective airway 1 ➢ Airway must be given the first attention as based
- Patient verbalized, “Matagal na clearance related to on the rule of ABC which is Airway, Breathing and
akong inuubo. Wala namang plema. retained secretions in the Circulation. In addition, difficulty of breathing can
Nahihirapan akong huminga”. respiratory tract cause anxiety to the client that is why, immediate
secondary to bacterial attention must be done. Addressing the problem
Objective Cues: infection as evidenced by to proper health care provider will give patent
- Presence of adventitious breath crackles upon airway to the client. Oxygenation is a vital need
sound (Crackles) upon auscultation. auscultation. for every cell, if there are any problems related to
-The patient is coughing without it can easily affect the functioning of the
phlegm. individual.
- Oriented ➢ Retained secretions can cause blockage of airway
- GCS E4V5M6 which will further cause difficulty of breathing
- BP- 90/70 mmHg, CR: 84 bpm, RR: (Fundamentals of Nursing 7th ed by Kozier et al. p.
36 cpm, T-37.5 C 1299)
- Difficulty vocalizing
- Has hallow eyes.
- Bluish nail beds.

Subjective: Hyperthermia related to 2 ➢ This demands immediate treatment/care and

-The husband of the client verbalized, infection as evidenced by subsequent medical attention, as they can result
“Naku hindi na nawala ang lagnat ng increased WBC in delirium and convulsions. This is an actual
asawa ko, pabalik-balik na lang” problem that needs to addressed.
➢ Lack of action in this health care problem may
Objective: cause dehydration which may later cause a bigger
-Flushed skin; warm to touch threat to the health of the client.
-Increase body temperature higher
than normal range
-Increased respiration
-The patient is sweating
-T: 37.5˚C

Subjective: Imbalanced Nutrition: 3 ➢ This condition needs to be addressed immediately

- The patient is only eating 4 spoons Less than Body for the client to be able to gain enough strength in
of rice with viand. Requirements related to performing her usual activities.
- The relative verbalized “Hindi siya inability to ingest food ➢ The body obtains energy in the form of calories
nakakakain ng maayus dahil sa because of prolonged from carbohydrates, protein and fat. The body
 kanyang ubo”.
Objective:
- The patient weight is 31.5 kilograms.
- Poor muscle tone.
- Appears weak.
- Minimal subcutaneous fat.
Subjective:
- The husband verbalizes that her wife
is easily getting tired. Her maximum
work is one hour only, and then she
would go to rest.
- Her usual activities is cleaning the
house, cooking and washing the
clothes. Their children help her wife.
Subjective:
- The patient regularly sleeps at
8:00pm and wakes up at 1:00 pm.
- She usually sits because according to
her she can breath more easily.
- She takes a nap in the morning from
8 am to 11 am.
- She is experiencing intermittent
sleep disturbance because according
to her she feels difficulty of breathing
and cough.
A. Nursing Care Plan
ASSESSMENT NURSING BACKGROUND
DIAGNOSIS KNOWLDEGE
cough as evidenced by
decreased BMI.
Activity intolerance 4 ➢ This nursing diagnosis is not life threatening and
related to inadequate
oxygen supply as
evidenced by easy
fatigability.
Sleep Deprivation related 5 ➢ This condition doesn’t need immediate attention
to prolonged physical
discomfort (dyspnea) as
evidenced by inability to
concentrate
GOAL and
OBJECTIVES
uses energy for voluntary activities such as
walking and in involuntary activities such as
breathing. (Fundamentals of Nursing 7th ed by
Kozier et al.)
doesn’t need immediate attention, however, it can
affect the body’s normal functioning
➢ Individuals who have inactive lifestyles or who are
faced with inactivity because of illness or injury
are at risk for many problems that can affect
major body systems. Clients experience a
significant decrease in the muscular strength and
agility whenever they do not maintain a moderate
amount of physical activity. (Fundamentals of
Nursing 7th ed by Kozier et al. p. 1068).
➢
but needs to be addressed for sleep is a basic
human need.
➢ A lack of rest for long periods can cause illness or
worsening of existing illness. (Fundamentals of
Nursing, 6th ed by Potter and Perry p. 1206)
NURSING RATIONALE EVALUATION
INTERVENTION
Subjective Ineffective Intermediate Goal: Effectiveness
Cues: airway clearance Cause: Within 4 hours Objective 1: - Was the patient
- Patient related to - Retained of nursing Independent- - Health status is able to maintain
verbalized, retained secretions in the intervention, the Facilitative: regulated through patent airway?
“Matagal na secretions in the respiratory tract. patient will be 1. Obtain vital signs of homeostatic -Was the patient
akong inuubo. respiratory tract able to maintain the patient. mechanisms. A able to mobilize her
Wala namang secondary to Intermediate patent airway change in V/S might secretions?
plema. bacterial Cause: through the indicate health -Was the patient
Nahihirapan infection as - Inflammatory mobilization of change. (Taylor et.al, able to have patent
akong huminga”. evidenced by response secretions as FON 5th ed. Page 523) airway?
crackles upon evidenced by 2. Observe for
Objective Cues: auscultation. Root Cause: productive respiratory rate and -Nasal flaring and use Adequacy
- Presence of - Bacterial cough. rhythm; presence of of accessory muscles -Was all the
adventitious infection of the nasal flaring; and use of indicates increased planned nursing
breath sound respiratory Objectives: accessory muscles when effort is required for interventions are
(Crackles) upon system. breathing like the breathing. enough in achieving
auscultation. 1. For 10 diaphragm and coastal and maintaining
-The patient is Health minutes, the muscles. patent airway?
coughing without Implication: relative will 3. Perform the Blanch -Was all the
phlegm. This condition assess the Test. - Blanch test reflects resources of the
- Oriented can cause Acute physical the adequacy of o2 nurse like time and
- GCS E4V5M6 Respiratory condition of the circulation in the effort are enough?
- BP- 90/70 Distress client by periphery.
mmHg, CR: 84 Syndrome accepting at Appropriateness
bpm, RR: 36 cpm, (ARDS) which least 4 nursing 4. Auscultate the lungs -Crackles are -Was the
T-31.5 C results from the interventions to to note any lung intermittent sounds interventions
- Difficulty combination of be done in the sounds. that occur when air mentioned are
vocalizing infection and patient. moves through airway applicable and
- Has hallow eyes. inflammatory that contain fluids. beneficial to the
- Bluish nail beds. response. The 2. After 3 hours (Taylor et.al, FON 5th patient?
lungs become the client will be ed. Page 1386)
quickly filled with able to mobilize Objective 2:
fluid and become her secretions Independent- -Tapping the chest can Acceptability
very stiff. This through the Facilitative: loosen the secretions. - Was the family
stiffness, interventions 1. Perform Chest (Taylor et.al, FON 5th willfully accepted
combined with done by the physiotherapy. ed. Page 1251) the interventions
difficulties nurse at least 4. done to the patient.
extracting -Suction removes
oxygen due to 3. After 50 Dependent-Facilitative: secretions through the
the alveolar fluid minutes, the 1. Suction secretion as use of a strong
creates a need nurse will needed. pressure.
for ventilation. maintain patent
Septic shock is airway of the
one potential patient through 2. Increase the amount - Current data
complication. the of oral fluid intake as indicates that fluid
performance of ordered by the doctor. restriction may
(Black, Medical at least 3 actually reduce blood
Surgical Nursing interventions. volume and decrease
7th ed. Page cerebral circulation.
1896) The lack of volume
causes the blood to be
thick and sluggish and
may decrease the
mobilization of
nutrition and toxins
out of the circulation.
Patient should be
maintained in a
euvolemic state rather
Dependent- than a fluid-restricted
Supplemental: state. (Black, MSN 7th
1. Administer ed. Page 2201)
bronchodilators as - They act on the
ordered. respiratory tract, it
opens narrowed
airways.
(Black, MSN 7th ed.
Objective 3: Page 1652)
Independent-
Facilitative: - For maximal lung
1. Elevate the head of expansion that will
the bed. improve oxygen
delivery.
2. Position the head in
the midline of the body.
-Position changes
allow free movement
of the diaphragm and
expansion of the chest
wall. (Taylor et.al, FON
 5th ed. Page 1396)

Asessment Nursing Background Goal And Nursing Rationale Evaluation

Diagnosis Knowledge Objectives Interventions

EFFECTIVENESS

Subjective: Hyperthermia Etiology After 30 minutes

related to of nursing
-The husband of inflammatory Immediate interventions, the 1. After 1 minute of
the client response as Cause: client will be able nursing
verbalized, evidenced by to lessen intervention, was
“Naku hindi na warm to touch Inflammatory temperature of at the family of the
nawala ang skin. response of the least 1˚C range client able to
lagnat ng asawa body against from that of 39˚C- assess for the
ko, pabalik-balik microorganism 41˚C to 38˚C-39˚C causative/
na lang” s. and be free of contributing
INDEPENDENT
chills factor/s?
Objective: • Identify • To know for the
-Flushed skin; Yes____
Intermediate underlying cause (eg. right treatment to be
warm to touch hypothalamic given.
Cause: 1. After 1 minute No_____
-Increase body dysfunction, such as
temperature of nursing
Infection of M. drug overdose and Why_____
higher than intervention, the
Tuberculosis infection).
normal range family of the client
-Increased will be able to
Root Cause:
respiration assess for the 2. After 12 minutes
-The patient is Weakened causative/
of nsg. Int., was the
sweating immune contributing family of the client
-T: 37.5˚C system. factor/s and be
able to evaluate
able to participate effects of
in one
hyperthermia and
intervention. INDEPENDENT
• Temperature of able to participate
• Monitor patient’s 102˚F- 106˚F (38.9˚C- in at least 5 out of 7
Health vital signs. Give 41.1˚C) suggests interventions?
Implication: particular attention to acute infectious
2. After 12 the temperature. disease process. Fever Yes____
Fevers of 104 F minutes of nursing pattern may aid in
(40 C) or interventions, the diagnosis; eg 24 hour No_____
higher demand family of the client period suggest septic
immediate will be able to episode, septic Why_____
home evaluate effects of endocarditis or
treatment and hyperthermia and Tuberculosis (TB).
subsequent be able to Chills often precede
medical participate in at temperature spikes.
attention, as least 3 out of 4 [Nursing Care Plans 3. After 15 minutes
they can result interventions. Edition 6, page 667. of nursing
in delirium and Copyright 2002 by intervention, was
convulsions, Marilyn E. Doenges, the family of the
particularly in RN, BSN, MA, CS] client able to assist
children. with measures to
• To note for reduce body
• Assess for further care to be temperature and
presence of posturing or given. participate in at
seizures. least 6 out of 7
interventions?
• Monitor/ record • Oliguria and/or
all sources of fluid loss renal failure may be Yes____
such as urine. occurring due to
hypotension, No_____
dehydration. [NANDA]
Why_____

• Note presence/ • Evaporation is

absence of sweating as decreased by
body attempts to environmental factors 4. Was the family of
increase heat loss by of high humidity and the client able to
evaporation, conduction high ambient attain wellness
and diffusion. temperature as well after the 2
as body factors interventions?
producing loss of
DEPENDENT ability to sweat or Yes____
sweat gland
• Administer No_____
dysfunction. [NANDA]
 antipyretics. Why_____

• Used to reduce Efficiency:

fever by its central
action on the Were interventions
hypothalamus; fever done within the
should be controlled time frame?
in patients who are
neutropenic or ___Yes
asplenis. However,
___ No, Why?
fever may be
beneficial in limiting
_______________
growth of organisms
and enhancing Appropriateness:
autodestruction of
infected cells. Were the
[Nursing Care Plans interventions
Edition 6, page 667. realistic to the
INDEPENDENT Copyright 2002 by norms?
Marilyn E. Doenges,
• Provide tepid RN, BSN, MA, CS] ___Yes
3. After 15 sponge baths; avoid use
minutes of nursing of alcohol. ___ No, Why?
interventions, the
family of the client _______________
will be able to
assist with • May help Acceptability:
measures to reduce fever. Note:
reduce body use of ice water/ Were the
temperature and alcohol may cause interventions
participate in at chills, actually accepted by the
least 3 out of 4 elevating client and his
interventions. temperature. In family?
addition, alcohol is
very drying to skin. ___Yes
[Nursing Care Plans
Edition 6, page 667. ___ No, Why?
DEPENDENT
Copyright 2002 by
_______________
• Administer Marilyn E. Doenges,
replacement fluids and
 electrolytes. RN, BSN, MA, CS] Adequacy:

Were all the plans

adequate? ___Yes

• Provide high- ___ No, Why?

calorie diet, tube • To support
feedings or parenteral circulating volume
nutrition. and tissue perfusion.
[NANDA]

• To meet
INDEPENDENT increased metabolic
demands.
• Discuss [NANDA]
4. After 2 minutes importance of adequate
of nursing fluid intake.
intervention, the
family of the client
will be able to • Review signs and
promote wellness symptoms of
and give 2 out of 2 hyperthermia (eg.
interventions. Flushed skin, increased • To prevent
body temperature, dehydration. [NANDA]
increased
respiratory/heart rate).

• Indicates need
for prompt
intervention.

A. Discharge Planning

Medications Continue Taking the Anti-TB drugs. The intensive phase is for 2 months and the maintenance phase is for 4
months. Medicines are readily available at the health center.
Exercise/Economic Factor
Treatment
Health Teaching
Out patient Follow-up
Diet
Spiritual/Sexual Activities
Practice deep breathing exercise and coughing exercises. Resume previous activities. Prevent extraneous
work. Have a regular physical exercise like brisk walking for 30 minutes daily. For financial insufficiency, there
are government drug stores available. The patient may continue her work in the factory.
Follow faithfully the regimen for tuberculosis, especially the medications. Have a regular sputum test, as
ordered by the doctor.
You should practice hand washing regularly. Always cover the mouth and the nose when exposed to person
who coughs or sneezes. You should not spit anywhere, instead spit in a single container to prevent transfer of
M. Tuberculosis.
Always have a regular check up at your nearest health center, at least once a week to monitor the progress of
the treatment. The client should report immediately to the physician if there is difficulty of breathing, there is
productive cough more than 5 days and there is chest pain and experiencing fatigue.
The diet should be high caloric. Always drink a lot of water. Also eat fruits and vegetables. Don’t escape meals.
If there are any food supplements available, consult it with the doctor. Eat vitamin c rich food to strengthen
immune systems.
Always pray for the guidance of the Lord. Spiritual health affects the wellness of an individual greatly.
Strengthen relationship with Lord by showing love and respect to the people around you.