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LRT
Is a membraneous tube
that consists of dense
regular connective and
smooth muscle
reinforced with 15-20
"C"-shaped pieces of
cartilage.
Cartilages form the
anterior and lateral sides.
Protect the trachea
and maintain an open
passageway for air.
Posterior wall contains no
cartilage and consists of
a ligamentous membrane
and smooth muscle
which can alter the
diameter of the trachea.
Esophagus lies
immediately posterior to
the cartilage-free
posterior wall of the
trachea.
· Trachea is lined with
pseudostratified ciliated
columnar epithelium that
contains numerous
goblet cells.
Bronchi
Trachea divides into the
right and left primary
bronchi.
Right bronchus is shorter
and wider and is more
vertical than the left
bronchus.
Primary bronchi extend
from the mediastinum to
the lungs.
The lining of the bronchi
is the same as the
trachea and the bronchi
are supported by
"C"-shaped cartilage
rings.
How Does Lungs protect themselves:
◙ First, the nose acts as a filter when breathing in, preventing
large particles of pollutants from entering the lungs.
◙ If an irritant does enter the lung, it will get stuck in a thin layer of
mucus (also called sputum or phlegm) that lines the inside of the
breathing tubes.
◙ Mucus is "swept up" toward the mouth by little hairs called cilia
that line the breathing tubes.
WBC
RBC
He matolo gy 0 8-2 5
15.1 x 10 9/L
3.0 x 10 12/L
5-10 x 10 9/L
M 4.5-5.5
F 4.0-5.0
DIFFERENTIAL COUNT
EOSINOPHIL 0-0.01
MONOCYTE 0.03-0.05
WBC
He matolo gy 0 8-2 6
9.6 5-10 x 10 9/L
DIFFERENTIAL COUNT
EOSINOPHIL 0-0.01
LU 90 Mg/dl 70-105
LT 7 IU/L 10-40
ST 14 IU/L 10-42
RESUL NORMAL
T VALUES
Impression:
Extensive PTB with destroyed left lung.
Empyema in the legt hemithorax is suspected. Suggest doing a left
lateral decubitus film.
Sp utu m te st 08-2 8
AFB Stain
Day 3
Greater than 25 polymorphonuclear cells
Less than 25 epithelial cells
Positive for acid fast bacilli: 3+
More than 10 AFB/OIF in at least 20 visual fields
Day 2
Greater than 25 polymorphonuclear cells
Less than 25 epithelial cells
Positive for acid fast bacilli: 3+
More than 10 AFB/OIF in at least 20 visual fields
Day 1
Greater than 25 polymorphonuclear cells
Less than 25 epithelial cells
Positive for acid fast bacilli: 3+
More than 10 AFB/OIF in at least 20 visual fields
He moglobin A1 C
RESUL NORMAL
T VALUES
Chest ultrasound
Real time scanning of the left lung shows
fluid with estimate volume of 157cc.
Impression:
Pleural effusion, left.
Blo od c hem 0 8-2 6
RESUL NORMAL
T VALUES
PHYSICAL
Ur in alysi s 0 8-2 5
COLOR
TRANSPARENCY
Yellow
Hazy
Straw - Dark yellow
Clear - Hazy
pH 6.0 4.5-7.8
SPECIFIC GRAVITY 1.020 1.003-1.029
MICROSCOPIC
CHEMICAL
Troponin – 1 negative
Med ical
Man age me
nt
Admit to room of choice under Dr.
August 25, 2008 Jarcia
Secure consent
Hgt: 214mg/dl TPR every shift
Diabetic diet
Complete Blood Count
Accurate Platelet Count
Hemoglucotest
Electrocardiogram
Chest x ray
Urinalysis with urine ketones
Stat serum sodium, potassium
Creatinine
Fasting Blood Sugar
Glycosylated hemoglobin
Blood Urea Nitrogen
Uric acid
Lipid profile
Alanine Aminotransferase (ALT),
Aspartate Aminotransferase (AST)
IVF: Plain NSS 1 L to run for
8 hours
Plain NSS 1 L to run for 12
hours
Humulin R 5 units
subcutaneous
Vital sign every 1 hour and
record
Refer accordingly
Esomeprazole (Nexium)
ampule 40 mg once a day IV
Erdosteine (Ectrin) 300 mg
tablet twice a day by mouth
Cefuroxime 750 mg every 8
hours IV After negative skin
test
1 Nebule Salbutamol every 4
hours
August 25, 2008 Prepare and
4:55 pm transfuse 2 units
Packed Red Blood
Cell properly typed
and cross matched
to run 5 hours each
with 2 hours interval
Benadryl 1 ampule
prior to each blood
transfusion
Oxygen at 4
liters/minute as
needed for dyspnea
August 25 Refer to Dr. Jennie
Estrada for co-
management
Incorporate 40 mEq
Potassium Chloride to
the present IVF
Kalium Durule 1 tablet
twice a day
hemoglucotest every 6
hours and record
Transderm patch 5 mg
anterior chest wall once
a day
7:35 pm Incorporate 40 mEq
Potassium Chloride
to the next IVF
Plain NSS 1 L x KVO
once on blood
transfusion. Please
insert another line
8:20 pm Paracetamol tablet
500 mg tablet
every 4 hours as
needed for
temperature ≥
37.6 C
August 26, 2008 Please do chest
9:15 am ultrasound with
marking
1:30 pm IVF to follow: Plain
NSS 1 L + 40 mEq
Potassium Chloride x
10 hours
August 26 Repeat Complete
Blood Count 6 hours
post blood
transfusion
August 26 For hemoglucotest
twice a day pre
meals
8:00 pm
IVF to follow Plain
NSS 1L + 40 mEq
Potassium Chloride x
10 hours
August 27, 2008 No need for now
3:48 am Discontinue on the
Attending physician left (IVF)
informed IVF to
follow x KVO
8:45 am IVF to follow 1L Plain
NSS 1L x KVO
August 27 Please maintain
oxygen at 5
liters/minute
August 27 Please maintain
oxygen at 5
liters/minute
5:20 pm Decrease
nebulization to every
6 hours
August 27 Glimepiride 1 mg 1
tablet pre breakfast
Transfer service to
Dr. Jennie Estrada
August 28, 2008 Culture and
12:30 pm sensitivity and
sputum acid fast
bacilli smear results
Ferrous Sulfate
(United Home) 325
mg 1 tablet twice a
day
5:30 pm Please advise her to
Informed of Hgt: 54 eat on schedule.
mg/dl Increase Hgt
Asked if for repeat Hgt monitoring to three
afterwards times a day
8:30 pm Hold Nitroglycerin
Informed of blood patch for now
pressure: 90/60
Asked if Nitroglycerin
patch should be
continued
August 29, 2008 Let the patient eat
5:00 am then re-check after 1
Attending physician’s hour
informed regarding
61 mg/dl and
resident on duty
informed
6:30 am
Attending physician
regarding the latest
Hgt result 71 mg/dl
9:30 am To follow: Plain NSS
1 L x KVO
10:45 am Hemoglucotest:35
Please give D50-50
IV now
Repeat
hemoglucotest after
1 hour
11:00 am Hold antibiotic
Attending physician medications
informed Give D50-50 IV PRN
hemoglucotest:35 for hemoglucotest
and that D50-50 IV is <80mg/dl
ongoing
12:00 pm Let patient eat her
Hemoglucotest :53 lunch first
mg/dl (premeals)
Referred to resident
on duty
August 29, 2008 To consume tablets if
Kalium durule then
discontinue
Hold Glimeperide
IVF to follow D5NSS 1 L
to run for 12 hours
Start Myrin P Forte 3
tablets OD(before
breakfast)
Please incorporate
Benutrex-C 1 ampule to
present IVF for 3 cycles
5:30 pm Please advise patient
Hemoglucotest : to eat. Repeat
54mg/dl hemoglucotest
Asked if D50-50 is to afterwards. If still low
be given. may give due D5050
1 vial
Attending physician Ok. Thanks
informed of
hemoglucotest:
58mg/dl
Patient was asked to
eat
11:30 pm Give SERC 8mg/tab
Resident on duty Ok give 16mg/tab
informed regarding
patient complaints
Avail stocks 16mg
August 30, 2008 Do ECG, then do
2:20 am hemoglucotest,if the
Resident on duty result is 80 mg/dl
informed about give D50-50
patient’s condition,
cold and clammy BP-
90/60mm/Hg
Hemoglucotest: 38 Give D50-50 again
mg/dl
9:00 am Repeat
Hemoglucotest
11:00 am Refer to
Endocrinologist
Follow up blood c/s
12:30 pm Please elevate left
Resident on duty and leg with 2 pillows
attending physician FD 800 cc then
informed of BP increase hour to 6
80/50. hours
Endocrinologist not
available
2:20 pm To follow: D5NSS to
Resident on duty run for 6 hoursLet
informed of patient the patient eat her
Hemoglucotest: 76 lunch May not repeat
mg/dl as of 7 am hemoglucotest
9:30 pm Please follow blood
c/s result
9:50 pm Problem: BM 8 times
since am, small
amount
For stool examination
Kindly update
attending physician
11:15 pm IVF to follow: D5NSS
1L + Benutrex-C 1
ampule to run for 6
hours
August 31,2008 Facilitate fecalysis
1:30 am
7:00 am IVF to follow: D5NSS
1L + Benutrex-C
1ampule to run for 6
hours
3:40 pm Please do fecalysis
Attending Physician now
informed of 4 times Start Erceflora 1 vial
BM TID
6:35 pm TF: D5NSS 1 L + 1
ampule Benutrex-C
to run for 6 hours for
2 cycles.
11:00 pm TF blood c/s formal
report
To consume tablets
of Kalium durule then
discontinue
Facilitate fecalysis
Start Streptomycin
1.5 mg (ANST) IM 3
times a week (M-W-
R)
September 1, 2008 To consume stocks
2:13 pm of Tazocin then to
Unasyn 750
mg/tablet; 1 tablet
BID
To consume stocks Let the relative look
of Tazocin then to on other drugstores
Unasyn 750 IVF TF: D5NSS + 1
mg/tablet; 1 tablet ampule Benutrex-c to
BID run for 8 hours in 2
cycles
To consume IVF then discontinue
9:15 pm May go home for request tomorrow
am
Therapeutics:
4. Unasyn 750 mg in 2 daysLevox
500 mg OD in 8 days
5. Myrin P Forte 3 tablets OD in 5-7
days
6. Streptomycin 1.5 mg IM 3 times a
week (M-W-R) (ANST)
To consume tablets of other
medications and discontinue.OPD
to follow on September 18, 2008,
Thursday, 10:00 am
11:00 pm Thanks. Discontinue
HGT monitoring
Drug S tudy
Ethambutol
Dosage
-3 tab OD in 5 to 7
days before
breakfast.
Streptomycin
Dosage
Dosage
-750mg IV q 8
ANST (-)
Piperacillin + Na Tazobactam
Classification
-Mucolytics
Dosage
-300mg 1 cap. 1
cap BID PO
USW c Salbutamol
-Transderm patch
5 mg anterior chest
wall once a day
Humulin R
Classification
-Antacid
-Antireflux agents
-Antiulcerants
Dosage
-IV vial 40 mg OD
Bacillus clausii
-1 vial TID
Serc
Dosage
- 8 mg 1-2 tab. To
be taken tid.
Paracetamol
Dosage
- PRN 500mg/tab
every 4 hrs for
T≥37.6
Ferrous Sulfate
Intervention Rationale
•Assess respiratory status. Note depth, rate, and character of ►symptoms may be masked by chronic respiratory conditions
breathing.
►it becomes frequent and productive, maybe accompanied with chest pain
•Assess cough ( productive, weak, or hard )
►hemoptysis maybe present in advanced cases
•Assess nature of secretions: color, amount, consistency
•Auscultate lungs for presence of normal and abnormal lung ►Bronchial breath sounds and crackles maybe present
sounds
►low- grade fever occurs
•Monitor vital signs
•Monitor oxygen saturation through arterial blood gas/ pulse ►decreased oxygen saturation and increased PaCo2 are signs of hypoxia and
oximetry respiratory compromise
•Position the client on fowler’s/ orthopneic ►to allow for maximum chest expansion
•Encouraging or providing frequent changes in position every 2 ►to keep the lungs open and clear of secretions
hours
►help shift respiratory secretions in the airway
•Encouraging ambulation
•Deep breathing and coughing exercises ►allows for the removal of secretions from the airway
Intervention rationale
•Induce sputum with heated aerosol if needed to expedite ►precautions to prevent airborne transmission are important
diagnosis and start early treatment during and after procedures that stimulate coughing
►indicated until the patient responds to the medication
•Monitor sputum cultures
►this decreases airborne contaminants
•Have patient cover mouth when coughing or sneezing
•Teach patient hand washing techniques to use after handling ►friction and running water effectively remove microorganisms
sputum from hands
•Provide a high- protein, high- calorie, increased- fluid diet ►This maintains optimal nutritional status
•Refer patient contacts to be assessed for possible infection and ►this prevents spread or development of infection
for chemoprophylactic treatment
►anti- TB drugs treatment should be promptly initiated for
•Administer medications as ordered. patients with TB disease.
•Report all confirmed TB cases to the health department ►coordination of follow-up care and contact investigation to
facilitate propylaxis for patient contacts.
Nutrition, Altered , Less than Body requirements
intervention rationale
•Document patient’s nutritional status on admission, ►useful in defining degree/ extent of problem and appropriate
noting skin turgor, current weight and degree of weight choice of interventions
loss, integrity of oral mucosa, ability/ inability to
swallow, presence of bowel tones, history of nausea/
vomiting or diarrhea
•Ascertain patient’s usual dietary pattern, likes/ dislikes ►helpful in identifying specific needs.
•Monitor intake/ output and weight periodically ►Useful in measuring effectiveness of nutritional
and fluid support
•Encourage and provide for frequent rest periods. ►Helps to conserve energy
•Investigate anorexia, nausea and vomiting and note ►May affect dietary choices and identify areas for problem
solving, to enhance intake
possible correlation to medication
•Encourage small frequent meals with foods high in ►Maximize nutrient intake
protein and carbohydrates
•Encourage SO to bring foods from home and share ►Creates a normal social environment
meals with patient
Nu r si ng Ca r e
Pla n
Nursing Care Plan
Name: L. L.
Age/Sex: 49/F
Medical Diagnosis: Pulmonary Tuberculosis Stage III Category II
Nursing Diagnosis: Ineffective airway clearance related to accumulation of excessive mucus secretions on tracheobronchial as evidence by difficulty of
Short term goal: At the end of intervention, the patient will expel secretions easily to promote airway clearance.
Long term goal: The patient will maintain patent airway with decrease presence of secretions after hospitalization.
S ► “nahihirapan Difficulty in The airway parts of ► Assessed patients ► Patient education will Goal met.
akong huminga” as breathing the respiratory knowledge about her vary on disease as well The patient was
verbalized by the system which air condition. as the patient’s cognitive able to expelled
patient. flows, was blocked level. secretion easily.
to get from the ► Monitored for vital signs ► To gather baseline
O ► RR=38cpm external data and noted changes.
► (+)productive environment to the ► Positioned head midline ► To maintain open
cough alveoli by the with flexion. airway at rest.
► with greenish excessive mucus
phlegm secreted by the ► Elevated head of ► To take advantage of
► weak in goblet cells. bed/change position every gravity decreasing
appearance Ref. two hours. pressure on diaphragm.
► (+) crackles on Medical-Surgical ► Encouraged deep ► To maximize effort in
upper left lung Book breathing and coughing mobilization of
exercises. secretions.
► Increase oral fluid intake ► To promote
to at least 2000 ml/day. systematic hydration
and to help liquefy
secretions,
► Discourage use of oil ► To prevent aspiration
based products around nose. into lungs.
► Monitor vital signs and
observed for signs of ► To assess changes and
respiratory distress. noting complications.
► Provided with ► For the patient to be
information about the aware of the importance
Ref. necessity of expectorating of expectorating
Medical- Surgical secretions. secretions.
book ► Given bronchodilators as ► For mobilization of
ordered by doctor. secretions.
Nursing Care Plan
Name: L. L.
Age/Sex: 49/F
Medical Diagnosis: Pulmonary Tuberculosis Stage III Category II
Nursing Diagnosis: Social isolation related to disease process as evidenced by accommodation on an isolation room.
Short term goal: At the end of my intervention, the patient will be able to verbalize understanding about the purpose of isolation process.
Long term goal: After hospitalization, the patient will express increase sense of self-worth even undergoing isolation process.
S► “Mga pamilya ko loss of self- esteem Tuberculosis is very ►Identified blocks to ►To prevent Goal met.
na lang ang contagious, spread by social contacts. contributing factors The patient
dumadalaw sa’kin” as airborne droplet to problem verbalized
verbalized by the nuclei that are ►Listened to ►To be able to deeply understanding about
patient. produce when an comments of client understand patient’s the purpose of
O► hostile behavior infected person regarding sense of thoughts and isolation process.
►moody coughs or sneezes isolation. condition.
►irritable .Clients with this ►Established ►Promotes trust and
►withdrawn eye condition must be therapeutic nurse- establish rapport.
contact during treated carefully, client relationship.
conversation. some of them were ►Explained the ►To provide client’s
isolated to prevent the nature of disease and awareness.
transmission of mode of transmission.
microorganisms. As a ►Encouraged open ►To maintain
result, the patient’s visitation when involvement with
enduring personality possible and/or others.
characteristics were telephone contact.
decreased. ►Provided positive ►Encouraged client’s
Ref. reinforcement when continuation of efforts
Medical-Surgical patient’s makes move and to enhance self-
Book towards others. esteem.
►Provided with clean ►To provide comfort
and comfortable measures for the
environment. patient.
Nursing Care Plan
Name: L.L.
Age/Sex: 49/F
Medical Diagnosis: Pulmonary Tuberculosis Stage III Category II
Nursing Diagnosis: Risk for activity intolerance related to generalize weakness as evidenced by verbal report of fatigue.
Short term goal:` At the end of my intervention, the patient will be able to walk on short distances with assistance as tolerated by the patient.
Long term goal: After hospitalization, the patient will be able to perform self care activities with minimal assistance.
S► “Nanghihina ako“ body weakness Tuberculosis maybe ► Determined the ► Assessments guide Goal met
as verbalized by the extra- pulmonary and patient’s perception of treatment. The patient walked on
patient. affect organs / tissues causes of fatigue. a short distance with
O► RR=38cpm other than the lungs. ► Assessed the ►To define what the assistance.
► weak in This process causes patient’s level of patients is capable of,
appearance reduction in muscle mobility. which is necessary
► refuse to perform strength and its before setting realistic
daily activities. function, which leads goals.
►functional level to generalized ► Assessed nutritional ►Adequate energy
4 – dyspnea and weakness and impairs status. reserves are required
fatigue at rest the ability to maintain for activity.
activity. ► Assessed emotional ►Depression resulting
Ref: response to change in from the inability to
medical- surgical book physical status. perform required
activities can further
aggravate activity
intolerance.
► Establish guidelines ►Motivation is
and goal of activity enhance if the patient
with the patient. participates in goal
setting.
► Encouraged ►Provides time for
adequate rest periods. energy conservation
and recovery.
► Encouraged ►This promotes a
physical activity sense of autonomy
consistent with the while being realistic
patient’s energy about capabilities.
resources.
► Encouraged active ►Exercise maintains
range of motion muscle strength and
exercises. joint range of motion.
► Provide emotional ►Patient may be
support will fearful of
increasing activity. overexertion and
potential damage to
the heart.
► Encouraged ►Physically inactive
patients to choose patients need to
activities that improve functional
gradually build capacity through
endurance. repetitive exercises
over a longer period
of time.
►Teach the patient to ►Promotes
recognize signs of awareness of when to
physical over activity. reduce activity.
► Involve the patient ►Setting small,
in goal setting and attainable goals can
care planning. increase self
confidence and self-
esteem.
Th e end