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Introduction

Pulmonary tuberculosis is an infectious disease caused by slow- growing bacteria that

resembles a fungus, Mycobacterium tuberculosis, which is usually spread from person to

person by droplet nuclei through the air. The lung is the usual infection site but the disease

can occur elsewhere in the body. Typically, the bacteria from lesion (tubercle) in the alveoli.The lesion may heal, leaving scar tissue; may continue as an active granuloma, heal, then

reactivate or may progress to necrosis, liquefaction, sloughing, and cavitations of lung

tissue. The initial lesion may disseminate bacteria directly to adjacent tissue, through the

blood stream, the lymphatic system, or the bronchi.

Most people who become infected do not develop clinical illness because the bodys

immune system brings the infection under control. However, the incidence of tuberculosis

(especially drug resistant varieties) is rising. Alcoholics, the homeless and patients infected

with the human immunodeficiency virus (HIV) are especially at risk. Complications of

tuberculosis include pneumonia, pleural effusion, and extra pulmonary disease.

Tuberculosis has been a serious public health problem for a long time , tuberculosis continues to be a

deadly disease .

CHAPTER 1

a. Personal Data

Name: PATIENT X

Age: 78 YEARS OLD

Address: 1909 f.Barona , tondo Manila

Date of birth: Dec.16, 1932

Civil Status: Married

Sex: male

Occupation: NONE

Religion: Dating Daan

Nationality: Filipino

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Date of admission: sept.6,201

b.Chief Complaint: the patient was admitted at Gat andress 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. Shewas transferred at the Medical Ward

particularly in the isolation room of the hospital for further evaluation of the complaint.

She wasattended by Dr. San Jose, a resident physician of the said hospital.difficulty of

breathing

admitting Diagnosis: PTBIV with pneumonia

c. History of present illness; Patients condition started about 6 months prior to consultation, as onset of

cough, non-productive and an intermittent feverusually 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 withwhitish secretions. There is also difficulty of breathing and vomiting. The

patient cant eat properly because she has no appetite for food.She also experience stabbing pain on her chest

according to the assessment it is 6/10 and it radiates to his back. The patient only tookparacetamol for her fever.

On the day of September 19, 2008 she was rushed to the hospital because of difficulty of breathing.Previouslywhen she started experiencing these conditions, she does not seek for any medical care from the

physician because according to her it is stilltolerable

d. 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 nohistory of hypertension and Diabetes mellitus. Whenever she had any flu or cough, she uses herbal plants. She

does not have any regular medical anddental check-ups. She does not have allergies to what ever kind of foods

and medications as far as she knows. Whenever she had fever shetakes Paracetamol and Bioflu. She

does experience any severe accidents

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e.family history

PHYSICAL ASSESSMENT

Normal Findings Actual Findings

Skin Generally fine, smooth, firm and

even- Skin texture resilient and moist

- Capillary refill test: immediate

return of color (2-3 sec)

- Limbs not tender

- Symmetric in size

Skin turgor returns rapidly to its

previous shape and position

No primary and secondary

lesions noted

.No edema noted

The client has a white complexion.

Dry skin is noted. A capillary refill of3 seconds was noted.

Head (Skull,

Scalp, Hair)

Skull

Generally round, with

prominences in the frontal and

occipital area. (Normocephalic).

No tenderness noted upon

palpation.

Scalp

Lighter in color than the

complexion.

Can be moist or oily.

No scars noted.

Free from lice, nits and

dandruff.

No lesions should be noted.

No tenderness nor masses on

palpation.

Hair

Can be black, brown or

The clients head has a round

smooth skull contour. The hair is

thick, white, oily and fine which is

evenly distributed. The scalp is

smooth and firm. No lesions noted.

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burgundy depending on the race.

Evenly distributed covers the

whole scalp (No evidences of

Alopecia)

Maybe thick or thin, coarse or

smooth. Neither brittle nor dry.

Face

-Symmetric or slightly

asymmetricfacial features;

-palpebral fissures equal in size,

-symmetric nasolabial folds

-Symmetric facial movements

He has Symmetric facial features;

Periorbital area slightly puffy

but non-tender; symmetric

nasolabial folds.Symmetric facial

movements

Eyes

Eyebrows

Symmetrical and in line with

each other.

Maybe black, brown or blonddepending on race.

Evenly distributed.

Eyes Evenly placed and inline

with each other.

Non-protruding.

Equal palpebral fissure.

Eyelashes

Color dependent on race.

Evenly distributed. Turned

outward.

His eyes are symmetrical, blue in

color, almond shape. Pupils constrict

when diverted to light and dilates

when he gazes afar, conjunctivas arepink. Eyelashes are equally

distributed and skin around the eyes

is intact. The eyes involuntarily blink.

Ears

The ear lobes are bean shaped,parallel, and symmetrical.

The upper connection of the

ear lobe is parallel with the

outer canthus of the eye.

Skin is same in color as in the

complexion.

No lesions noted on inspection.

The auricles are has a firm

cartilage on palpation.

The pinna recoils when folded.

There is no pain or tenderness

on the palpation of the auricles

and mastoid process.

The ear canal has normally

some cerumen of inspection.

No discharges or lesions noted

at the ear canal.

Ears are symmetrical with nodischarge. The clients auricles have

the same color as the facial skin. It is

mobile, firm, and not tender. The

pinna recoils often as it is folded.

Client can hear with ease when

spoken softly.He can hear better in

his left earlobe.

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On otoscopic examination the

tympanic membrane appears

flat, translucent and pearly gray

in

color

Nose

Nose- Symmetric and straight

- No discharge or flaring

- Uniform color

- Not tender and no lesions

- Patent nares

- Mucosa is pink

- Clear, watery discharge

- Nasal septum intact and in

midline

Facial Sinuses

- Not tender

External nose is symmetric andstraight. It appears oily. Nasal hairs

are present upon inspection. Nasal

septum is not deviated. Both nostrils

are patent as each nostrils are being

ocluded. No discharge, tenderness

and lesions noted. The sinuses are

well outlined after transillumination.

Mouth

Teeth and Gums

- 32 adult teeth

- Smooth, white, shiny tooth

enamel

- Pink gums (bluish or dark

patches in dark-skinned clients)

- Moist, firm texture to gums

- Smooth, intact dentures

Tongue/Floor of the Mouth

- Central position

- Pink color (some brown onborders for dark-skinned

clients); moist; slightly rough;

thin whitish coating

- Moves freely; no tenderness

- No prominent veins and

palpable nodules

Uvula

- Midline

Oropharynx and Tonsils

- Pink and smooth posterior wall

- No discharge

He has a complete set of teeth with

minimal dental caries noted. Oral

mucosa and gingival are pink in

color, moist, and there were no

lesions or inflammation noted.

Tongue is pinkish with thin whitish

coating and free of swelling and

lesions.

Neck

1.The neck is straight.

2.No visible mass or lumps.

3. Symmetrical

4.No jugular venous distension

(suggestive of cardiac

congestion)

The clients head is coordinated

with smooth movements and no

discomfort. The neck supports the

head properly. No presence of

abnormal swelling or masses. Lymph

nodes are not palpable. No nodules

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5. The trachea is palpable. It is

positioned in the line and

straight.

Lymph nodes

1.May not be palpable. Maybe

normally palpable in thin clients.2. Non tender if palpable.

3. Firm with smooth rounded

surface.

4. Slightly movable.

5. The thyroid is initially

observed by standing in front of

the client and asking the client to

swallow.

Thyroid

1. Normally the thyroid is non

palpable.2. Isthmus maybe visible in a

thin neck.

are palpable.

Thorax and

Lungs

Posterior Thorax

- Chest symmetric

--Absence of abnormalsounds

like wheezing and crackles

Normal rate (12-25 bpm)

- Spine vertically aligned

- Skin intact; uniform

temperature- Chest wall intact; no

tenderness; no masses

- Full and symmetric chest

expansion (3-5cm gap)

- Bilateral symmetry of vocal

fremitus

Anterior Thorax

- Quiet, rhythmic, and effortless

respirations

- Full symmetric excursion

- Bronchial and tubular breathsounds upon auscultation on

trachea

He has a regular rhythm with a 22

breaths per minute. Breath sounds

are clear on both lungs upon

auscultation. Excursion shows a 3-cm

gap during inspiration. No signs of

swelling or masses noted.

Heart

No murmurs,crackles,gallops

noted.

-Cardiac rate is 80 bpm.Blood

pressure is 130/90 mmHg

- No murmurs,crackles,gallops

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noted.

Breast

- Rounded shape, slightly

unequal in size

- Same skin color as abdomen

- Skin smooth and intact

Areola- Round/oval or bilaterally the

same

- Color varies (pink to dark

brown)

Nipples

- Round, everted, and equal in

size

Axilla

- No tenderness, masses, or

nodules

The clients breast are rounded in

shape, slightly unequal in size, and

generally symmetric and not

enlarged. The skin color of the breast

was the same color as of theabdomen. The breast nipples are

erect and not inverted. No

tenderness noted.

Abdomen

Inspection- Unblemished skin

- Uniform color

- Flat, rounded (convex), or

scaphoid (concave)

- Symmetric contour

- Symmetric movements caused

by respiration

- No visible vascular pattern

Auscultation

- Audible bowel sounds

Palpation- No tenderness; relaxed

abdomen with smooth,

consistent tension

The abdomen is uniform in color.Its rounded and has a symmetric

contour.Symmetric movements

caused by respiration.Audible bowel

sounds.No tenderness was palpated.

Upper

Extremities

-Absence of edema

-Even color and smooth texture

-Unlimited movements such as

adduction,abduction etc

No edema noted.Even color

and smooth texture.Unlimited

movements such as

adduction,abduction but with

slightly pain in the IV site.

Lower

Extremities

- Absence of edema

-Even color and smooth texture

-Unlimited movements such as

adduction,abduction etc

No edema noted .Even color

and smooth texture

-Unlimited movements such as

adduction,abduction etc

Neurologic - Conscious and coherent The patient is conscious and very

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Assessment - Able to respond to reflex tests

- Able to distinguish different

sensory functions.

responsiv upon interaction. He was

able to answer directly and clearly all

questions rendered.. Reflexes such as

Blinking reflex and deep tendon

reflex are present. He was able to

distinguish touch, pain, hot, and cold..

Gordons Functional Health Pattern

Before Hospitalization During Hospitalization

Health

Perception/Management

He always goes to the health

center whenever he feels

sick, and takes the

medications on time.

He always takes the

medication on time and he

realized the good effect of

always consulting a doctor.

Nutritional-Metabolic

Pattern

He usually eats 5-6 times a

day. He loves eating fruits

and vegetables. And usually

drinks 4-5 glass of water a

day.

He only eats 3-4 times a day,

Diet as tolerated, And water

demand was increased due

to his present condition,

usually 8-10 glass a day.

Elimination Pattern He usually urinates 3-4times a day and defecates at

least once a day.

He urinates 5-6 times a dayand defecates once a day.

Activity-Exercise pattern He spends his time watching

TV, reading newspapers,

sleeping and eating. He loves

completing the puzzle in the

newspaper.

He just spend his time

talking with his wife,

eating ,listening to

radio, ,reading newspaper

and sleeping

Sleep-Rest Pattern He usually sleeps 6-7 hours

a day.

He has 7-8 hours of sleep a

day and can sleep very well.

Cognitive-Perceptual Pattern He was very

active ,responsive , and very

talkative.Can understand

and speaks well.

He was still active and

alert,talkative,responds very

well to every question we

asks.Can speak and

communicate well.

Self Perception/Concept He takes a bath He just take sponge

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everyday,always well-

groomed & puts on gel.He

has a high self-esteem

bath,slightly well-

groomed,no gel,still has high

self-esteem.

Role-Relationship Pattern He was the only child,very

responsible & always tryingto help his parents.Living

with his parents happily.

He cant do the thing he

used to do at home,hismother was very loving and

caring,his father visited him

often due to his work.

Sexuality-Reproductive

Pattern

Refused to answer Not Applicable

Coping-Stress Tolerance Whenever he feels stressed

or has a problem, he just

completes the answer in the

puzzle, Read the newspaper

and sometimes go tosomewhere to relieve the

stress

He just eat and sleep as

much as he can to relieve

stress

Value-Belief Pattern

The client goes to church

twice a week with his family

& always pray.

He cant go to church but he

still pray & has strong faith

in God.

Chapter 2

Diagnostic procedures laboratory

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Chapter3

anatomy and physiology

UPPER RESPIRATORY TRACT

Respiration is defined in two ways. In common usage, respiration refers to the act of

breathing, or inhaling and exhaling. Biologically speaking, respiration strictly means theuptake of oxygen by an organism, its use in the tissues, and the release of carbon dioxide.

By either definition, respiration has two main functions: to supply the cells of the body with

the oxygen needed for metabolism and to remove carbon dioxide formed as a waste

product from metabolism. This lesson describes the components of the upper respiratory

tract.

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The upper respiratory tract conducts air from outside the body to the lower respiratory

tract and helps protect the body from irritating substances. The upper respiratory tract

consists of the following structures:

The nasal cavity, the mouth, the pharynx, the epiglottis, the larynx, and the upper trachea.

The oesophagus leads to the digestive tract.One of the features of both the upper and lower respiratory tracts is the mucociliary

apparatus that protects the airways from irritating substances, and is composed of the

ciliated cells and mucus-producing glands in the nasal epithelium. The glands produce a

layer of mucus that traps unwanted particles as they are inhaled. These are swept toward

the posterior pharynx, from where they are either swallowed, spat out, sneezed, or blown

out.

Air passes through each of the structures of the upper respiratory tract on its way to the

lower respiratory tract. When a person at rest inhales, air enters via the nose and mouth.

The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a tube like

structure that connects the back of the nasal cavity and mouth to the larynx, a passageway

for air, and the esophagus, a passageway for food. The pharynx serves as a common

hallway for the respiratory and digestive tracts, allowing both air and food to pass through

before entering the appropriate passageways.

The pharynx contains a specialised flap-like structure called the epiglottis that lowers over

the larynx to prevent the inhalation of food and liquid into the lower respiratory tract.

The larynx, or voice box, is a unique structure that contains the vocal cords, which are

essential for human speech. Small and triangular in shape, the larynx extends from the

epiglottis to the trachea. The larynx helps control movement of the epiglottis. In addition,

the larynx has specialised muscular folds that close it off and also prevent food, foreign

objects, and secretions such as saliva from entering the lower respiratory tract.

LOWER RESPIRATORY TRACT

The lower respiratory tract begins with the trachea, which is just below the larynx. The

trachea, or windpipe, is a hollow, flexible, but sturdy air tube that contains C-shaped

cartilage in its walls. The inner portion of the trachea is called the lumen.

The first branching point of the respiratory tree occurs at the lower end of the trachea,

which divides into two larger airways of the lower respiratory tract called the right

bronchus and left bronchus. The wall of each bronchus contains substantial amounts of

cartilage that help keep the airway open. Each bronchus enters a lung at a site called the

hilum. The bronchi branch sequentially into secondary bronchi and tertiary bronchi.

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The tertiary bronchi branch into the bronchioles. The bronchioles branch several times

until they arrive at the terminal bronchioles, each of which subsequently branches into two

or more respiratory bronchioles.

The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli are bubble-like,

elastic, thin-walled structures that are responsible for the lungs most vital function: theexchange of oxygen and carbon dioxide.

Each structure of the lower respiratory tract, beginning with the trachea, divides into

smaller branches. This branching pattern occurs multiple times, creating multiple branches.

In this way, the lower respiratory tract resembles an upside-down tree that begins with

one trachea trunk and ends with more than 250 million alveoli leaves. Because of this

resemblance, the lower respiratory tract is often referred to as the respiratory tree.

In descending order, these generations of branches include:

trachea right bronchus and left bronchus secondary bronchi tertiary bronchi bronchioles terminal bronchioles respiratory bronchioles alveoli

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THE LUNGS

The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity. There are two

lungs that occupy a significant portion of this cavity.

The diaphragm is a broad, dome-shaped muscle that separates the thoracic and abdominalcavities and generates most of the work of breathing. The inter-costal muscles, located

between the ribs, also aid in respiration. The internal intercostal muscles lie close to the

lungs and are covered by the external intercostal muscles.

The lungs are cone-shaped organs that are soft, spongy and normally pink. The lungs

cannot expand or contract on their own, but their softness allows them to change shape in

response to breathing. The lungs rely on expansion and contraction of the thoracic cavity to

actually generate inhalation and exhalation. This process requires contraction of the

diaphragm.

To facilitate the movements associated with respiration, each lung is enclosed by the pleura,

a membrane consisting of two layers, the parietal pleura and the visceral pleura.

The parietal pleura comprise the outer layer and are attached to the chest wall. The visceral

pleura are directly attached to the outer surface of each lung. The two pleural layers are

separated by a normally tiny space called the pleural cavity. A thin film of serous or watery

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fluid called pleural fluid lines and lubricates the pleural cavity. This fluid prevents friction

and holds the pleural surfaces together during inhalation and exhalation.

PREDISPOSING FACTORS

1. Malnutrition2. Overcrowding3. Alcoholism4. Ingestion of infected cattle5. Virulence6. Over fatigueSIGNS AND SYMPTOMS

1. Productive Cough yellowish in color2. Low fever3. Night sweats4. Dyspnea5. Anorexia, general body malaise, weight loss6. Chest/back pain7. Hemoptysis

PATHOPHYSIOLOGY

V. Pathogenecity

What is Pulmonary tuberculosis?

Pulmonary tuberculosis (TB) is a contagious bacterial infection that mainly

involves the lungs, but may spread to other organs.

Causative OrganismPulmonary TB is caused by M. tuberculosis which is a rod-shaped bacteria with a

waxy capsule. It is non-motile (requires external forces, such as coughing for

example, to move from place to place), does not form spores, and is aerobic.

Risk Factors

-Old Age

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-Infants

-Children

-Alcoholism

-Low Socio economic Status

-Drug addicts

-HIV positive

-People with weakened immune systems

-Severely malnourished

-People with frequent contact to the infected individual

-Have poor nutrition

-Live in crowded or unsanitary living conditions

-Healthcare workers

Symptoms:

Cough (sometimes producing phlegm)

Coughing up blood

Excessive sweating, especially at night

Fatigue

Fever

Unintentional weight loss

Pallor:

Breathing difficulty

Chest pain

Wheezing

Transmission

Mycobacterium tuberculosis is spread by small airborne droplets, called droplet

nuclei, generated by the coughing, sneezing, talking, or singing of a person with

pulmonary or laryngeal tuberculosis. These minuscule droplets can remain

airborne for minutes to hours after expectoration.

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Stages of Tuberculosis:

Latent Tuberculosis

Mycobacterium tuberculosis organisms can be enclosed, as previously

described, but are difficult to completely eliminate. Persons with latent

tuberculosis have no signs or symptoms of the disease, do not feel sick, and are notinfectious, however viable bacilli can persist in the necrotic material for years or

even a lifetime, and if the immune system later becomes compromised, as it does

in many critically ill patients, the disease can be reactivated.

Primary Disease

Primary pulmonary tuberculosis is often asymptomatic, so that the results

of diagnostic tests. are the only evidence of the disease.. Associated paratracheal

lymphadenopathy may occur because the bacilli spread from the lungs through the

lymphatic system. If the primary lesion enlarges, pleural effusion develops, because the

bacilli infiltrate the pleural space from an adjacent area. The effusionmay remain small and

resolve spontaneously, or it may become large enough toinduce symptoms such as fever,pleuritic chest pain, and dyspnea.

Primary Progressive Tuberculosis

When a patient progresses to active tuberculosis, early signs and symptoms

are often nonspecific. Manifestations often include progressive fatigue, malaise,

weight loss, and a low-grade fever accompanied by chills and night sweats. a classic

feature of tuberculosis, is due to the lack of appetite and the altered metabolism

associated with the inflammatory and immune responses. Wasting involves the

loss of both fat and lean tissue; the decreased muscle mass contributes to the

fatigue. Although the cough may initially be nonproductive, it advances to a

productive cough of purulent sputum.. Hemoptysis can be due to destruction of apatent vessel located in the wall of the cavity, the rupture of a dilated vessel in a

cavity, or the formation of an aspergilloma in an old cavity. Hematologic studies

might reveal anemia, which is the cause of the weakness and fatigue.

Possible Complications:

Pulmonary TB can cause

-permanent lung damage if not treated early.

-extra pulmonary tuberculosis (TB spread to areas of the body outside of the lungs)

-tuberculosis pneumonia (massive lobular or lobar pneumonia)

-pleuritis (infection & inflammation of tissue covering the lungs.

Chapter iv NURSING CARE PLAN

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