Pulmonary Tuberculosis

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 6 th cause of mortality
and morbidity in the Philippines as of 2007.
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.

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.

I. HEALTH HISTORY

A. Demographic Data:

1. Name: Orly Calinawan Reyes

2. Gender: Male

3. Age: 37

4. Birth date: October 08, 1972

5. Civil status: Single

 6. Nationality: Filipino

7. Religion : Roman Catholic

8. Address : Sulok, Panapaan 3 Bacoor, Cavite

9. Occupation:

B. Source and Reliability of Information:

C. Chief Complaint:

The patient was diagnosed pulmonary tuberculosis March 4, 2009 at the Health Center in Panapaan. The
patient was due to the complaint of difficulty of breathing (DOB) and cough for more than 1 month. He was
attended at that day in Health Center and had taken a clinical history and physical assessment.

D. History of Present Illness:

Patient’s condition started about 1 month 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
him it was relieved by an intake of paracetamol.
One week prior to admission the patient experienced worsening of the condition, he had productive cough
bloody with whitish secretions. There is also difficulty of breathing, and weakening. The patient can’t eat properly
 because he has no appetite for food. He 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 March 4, 2009 he
was rushed to the health center because of difficulty of breathing. Previously when he started experiencing these
conditions, he does not seek for any medical care from the physician because according to him it is still tolerable.

E. Past Medical History:

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

F. Family History:

G. Socio-economic:

H. Developmental History:
 I. Review of System:

1. Physical Assessment

AREA TECHNIQUE NORMS FINDINGS ANALYSIS and INTERPRETATION

A. SKULL

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

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

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

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

3. Facial Features Inspection Symmetric or Symmetrical and Normal

Palpation slightly asymmetric palpebral fissure equal in
facial features; size, nasolabial folds are
palpebral fissure symmetrical
equal in size;
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
eye. socket). This condition of the patient is
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 Inspection Evenly distributed Evenly distributed with no Normal

growth, thickness, or Palpation and covers the patches of hair loss; thick
thinness of hair whole scalp; hair
Maybe thick or thin

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

3. Presence of Inspection No infection and Presence of lice Abnormal, There is pediculosis, a type of
infection and Palption infestation parasitic infection. Lice may be contracted
infestation 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 Symmetrical facial Normal

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

IV. EYES

A. EYEBROWS

Hair distribution, Inspection Symmetrical and in Symmetrical and aligned Normal

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

B. EYELASHES

Evenness of Inspection Evenly distributed; Turned outward Normal

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

C. EYELIDS

Surface Inspection Upper eyelids Able to close the eyes Normal

characteristics and cover the small and has the ability to
position (in relation to portion of the iris, blink.
the cornea, ability to cornea, and sclera
blink, and frequency when eyes are
of 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
the presence of Palapation color; with texture to the low RBC level of the patient.
lesions in the bulbar presence of small (Fundamentals of Nursing 5th edition by
conjunctiva capillaries; moist; Taylor, page 642)
no foreign bodies;
no ulcers

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

E. SCLERA

Color and clarity Inspection White in color; White sclera with some Normal
clear; 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 transparent anterior
noted visible chamber
materials; color
depends on the
person’s race

H. PUPILS

1. Color, shape, and Inspection Color depends on Pupil size is 3mm. Normal
symmetry of size the 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 when looking at near
directed to the eye, objects. Constricts when
both 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
newsprint (Myopia) eye in which collimated light produces
 image focus in front of the retina when
accommodation is relaxed. It is caused by
an eyeball that is longer than normal,
which may be a familial trait. Transient
mayopia occurs due to influenza, steroids,
sever dehydration and large intake of
antacids. (Black, Medical Surgical
Nursing7th 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 Inspection When looking Can see objects in the Normal
fields straight ahead, periphery.
client can see
objects in the
periphery
V. EARS

A. AURICLES

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

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

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 straight; no Uniform color with nasal obstruction. Nasal discharge shows the
and flaring or discharge or presence of mucus secretions in the air
discharge from the flaring; Uniform flaring. tract.
nares color

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 Inspection Air moves freely as Only left nares is patent. Abnormal, not patent right nares show the
nasal 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 lesions. Normal
and displacements of
bone and cartilage

VII. SINUSES

Identification of the Inspection Not tender Not painful when palpated Normal
sinuses and for
tenderness

VIII. MOUTH

A. LIPS

Symmetry of contour, Inspection Uniform pink color; soft, Pink in color, dry and cracked Abnormal, May suggest cellular dehydration.
color and texture Palpation moist, smooth texture; lips (Black, Medical Surgical Nursing7th edition, page
symmetry of contour; 208).
ability to purse lips
B. BUCCAL MUCOSA
Color, moisture, texture,
and the presence of
lesions
C. TEETH
Color, number and
condition and presence of
dentures
D. GUMS
Color and condition
E. TONGUE/FLOOR OF
THE MOUTH
1. Color and texture of the
mouth floor and frenulum.
2. Position, color and
Inspection Uniform pink color; Pink color and dry. Abnormal, May suggests dehydration. (Black,
moist, smooth, soft, Medical Surgical Nursing7th edition, page 208).
glistening, and elastic
texture
Inspection 32 adult teeth; smooth, Have 31 adult teeth. The Abnormal, most unpleasant odors are known to
white, shiny tooth patient has yellowish teeth. arise from proteins trapped in the mouth which are
enamel; smooth, intact Have bad breath. Have tooth processed by oral bacteria. The most common
dentures decay in the lower right second location for mouth-related halitosis is the tongue. It
molars. is also related to dental carries and frequency of
tooth brushing.
Inspection Pink gums; no Pink gums; has no visible Normal
retraction retractions
Inspection pink color; moist; Pink and moist. Tongue moves Normal
freely and no pain felt.
slightly rough; thin
whitish coating; moves
freely; no tenderness
Inspection Central position; pink Located and positioned in the Normal
texture, movement and color; smooth tongue center.
base of the tongue base with prominent
veins

3. Any nodules, lumps, or Palpation Smooth with no No tenderness nor masses Normal
excoriated areas Inspection palpable nodules,
lumps, or excoriated
areas

F. PALATES and UVULA

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

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

G. OROPHARYNX and
TONSILS

1. Color and texture Inspection Pink and smooth Dry, pinkish in color. Abnormal, May suggests dehydration. (Black,
posterior wall 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 Difficulty of breathing Abnormal, labored breathing is a common
effortless respirations 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 equal Normal
tenderness, masses temperature; chest wall warmth on both sides. No
intact; no tenderness; masses.
no masses

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

B. POSTERIOR THORAX

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

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

2. Spinal alignment Inspection Spine vertically aligned Has a vertical alignment Normal
3. Temperature, Palpation Skin intact; uniform No masses nor tenderness; Normal
tenderness, and masses temperature; chest wall has equal warmth on each
intact; no tenderness; side
no masses

7. Posterior thorax Auscultation Vesicular and Has crackles heard on the Abnormal, the condition is related to the decreased
auscultation bronchovesicular anterior and middle part of size of the right lung and poor inspiratory effort due
breath sounds right and left lungs. to pain.
Diminished lung 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 or No pulsations of lifts Normal

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 all Has full and rapid pulsation. 84 Normal
AREAS AUSCULTATION sites bpm/minute.

Usually louder at the Sounds on the aortic and

apical area pulmonic areas; has a lub

XII. CAROTID ARTERIES
1. Carotid artery palpation
S2: Usually heard at all sound on the apex and dub Normal
sites sounds on the tricuspid area.
Usually louder at the Blood pressure is 90/70 mm
base of heart Hg.
Systole: silent interval; Normal
slightly 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
Palpation Symmetric pulse Has weak pulsation. Abnormal, decreased amount of blood volume
volumes; full Symmetrical pulse. passing the artery. (Black, Medical Surgical
pulsations, thrusting Nursing7th edition, page 1574).
quality; quality remains
same when the client
breathes, turns head,
and changes from

XIV. AXILLAE
1. Axillary, subclavicular,
and supraclavicular lymph
nodes
XV. ABDOMEN
1. Skin integrity
2. Abdominal contour
3. Enlargement of liver or
spleen
4.Symmetry of contour
5. Abdominal movements
associated with
respirations, peristalsis or
aortic pulsations
sitting to supine
position; elastic arterial
wall
Inspection No tenderness, Have no masses and nodules. Abnormal, The appocrine glands located in the
masses, or nodules Presence of a foul smelling axillae produces sweat. The secretion of these
odor. glands is odorless, but when 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)
Inspection Unblemished skin; Uniform color and has no Normal
uniform color blemishes
Inspection Flat, rounded(convex), Has a concave abdomen. Normal
or scaphoid(concave)
Inspection No evidence of No enlargement of the spleen Normal
enlargement of liver or and liver seen
spleen
Inspection Symmetric contour Has a symmetrical abdominal Normal
contour
Inspection Symmetric movements Abdominal movements noted Normal
caused by respiration; when inhaling.
visible peristalsis in
very lean people; aortic
 pulsations in thin
persons at epigastric
area

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

XVI.
MUSCULOSKELETAL
SYSTEM

A. MUSCLES

1. Muscle size and Inspection Proportionate to the Proportionate to the body; Normal
comparison on the other body; even in both even in both sides
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 exhaustion
tone
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 exhaustion
strength on both sides
experienced by the patient when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)
C. JOINTS
1. Joint swelling Inspection No swelling, no No swelling, no warmth, no Normal
warmth, no redness, no redness, no pain, no crepitus
pain, no crepitus

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

Palpation warmth, no redness, no moved.
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 and Normal

place.
Language test Coherent Coherent Normal

Recall Able to remember Able to state what happened to Normal

her in the past.
Cranial Nerves
CN 1 Able to smell and
Olfactory recognize stimuli
CN 11 20x20 vision, able to
Optic read, 3-5 mm [pupil size]
(+) Extraoccular
CN III, IV, VI Movement (EOM);
Occulomotor Lateral Upward and
Trochlear downward; pupils
Abducens reactive to light.
Able to feel and clearly
CN V identify stimulus, with
Trigeminal bilateral facial sensation.
With active corneal
reflex.
(+) Corneal reflex ,
CN VII Facial asymmetry
Facial
CN VIII Able to hear clearly, can
Vestibulocochlear maintain balance
Able to identify the scent of the Normal
alcohol
Pupil size is 3 mm, able to Abnormal, it is a refractive defect of the eye in which
read, myopia or collimated light produces image focus in front of the retina
nearsightedness. 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).
Normal
Pupils react to light. There is
constriction and consensual
accommodation. Able to move
the eyes in any direction in
unison.
Normal
Able to feel my finger on her
face while covering her eyes.
(+) Facial symmetry Normal
Can hear clearly and can walk. Normal
Present gag reflex, able to
CN IX, X (+) gag reflex, uvula at swallow and able to idebtify Normal
Glossopharyngeal the center, soft palate the taste of the food.
Vagus rises

Can shrug shoulders against

CN XI Able to shrug shoulders resistance and can turn the Normal
Accessory (Spinal) against resistance and head fro right to right.
able to turn the head
side and against
resistance.

Able to move tongue Able to protrude the tongue

from side to side and move it side to side. Normal
CN XII
Hypoglossal

Muscle Strength MNT Grading System:

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

Left Leg (+5) Active motion +4 active motion against some Abnormal
against full resistance resistance.
Right Leg (+5) Active motion +4 active motion against some Abnormal
against full resistance resistance.
 2. Laboratory Studies / Diagnostics

Classification of TB:

• Pulmonary:

Category
1.2HRZE / 4HR
Smear (+)

SPUTUM EXAMINATIN RESULTS / WEIGHT RECORD

DATE OF
MONTH DUE DATE EXAMINATON RESULT WEIGHT (kg)
O 3/02/09 3+ 50 kg
2 4/22/09 4/22/09 0 50 kg
3
4 6/10/09 6/10/09 1+ 55 kg
5 7/16/09 +5 55 kg
6 7/15/09 8/18/09 0 58 kg
7 9/15/09 9/09/09 0 58 kg

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

3. Other Assessment Tools

• 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.
 J. Functional Assessment:
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.
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
 • 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.
• 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.
deficiencies. (http://en.wikipedia.org/wiki/Malnourishment)
The main purpose of washing hands is to cleanse the hands of pathogens
(including bacteria or viruses) and chemicals which can cause personal harm or
disease, particularly diarrhea and pneumonia. To maintain good hygiene, hands
should always be washed after using the toilet, changing a diaper, tending to
someone who is sick, or handling raw meat, fish, or poultry, or any other
situation leading to potential contamination. Hands should also be washed
before eating, handling or cooking food. Conventionally, the use of soap and
warm running water and the washing of all surfaces thoroughly, including under
fingernails is seen as necessary. Alcohol rub sanitizers kill bacteria, multi-drug
resistant bacteria (MRSA and VRE), tuberculosis, and viruses (including HIV,
herpes, RSV, rhinovirus, vaccinia, influenza, and hepatitis) and fungus.
(http://en.wikipedia.org/wiki/Hand_washing)
Herbalists treat many conditions such as asthma, eczema, premenstrual
syndrome, rheumatoid arthritis, migraine, menopausal symptoms, chronic
fatigue, and irritable bowel syndrome, among others. Herbal preparations are
best taken under the guidance of a trained professional. Be sure to consult with
your doctor or an herbalist before self-treating. Some common herbs and their
uses are discussed below. Please see our monographs on individual herbs for
detailed descriptions of uses as well as risks, side effects, and potential
interactions. (http://www.umm.edu/altmed/articles/herbal-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
 • 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.
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.
choices are related to wellness and affect health, fitness, weight management,
and the prevention of chronic diseases such as osteoporosis, cardiovascular
diseases, cancer, and diabetes.
For adults (ages eighteen to forty-five or fifty), weight management is a key
factor in achieving health and wellness. In order to remain healthy, adults must
be aware of changes in their energy needs, based on their level of physical
activity, and balance their energy intake accordingly.
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. 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

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.
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 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

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.
• 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.
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.
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 (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

Self-perception
• According to her there is something wrong in her health and body.
• As a mother, she sometimes feels sad because she cannot do the
previous things like going with her husband in the farm.
• According to her husband she is a good mother and a good wife.
• Her strength is her family, when there are any circumstances that
involving any family member she is concerned and make some moves.
• She is simple.
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 individual is more likely to think positively about the physical and
non-physical concept of self.
Self concept is also affected by role-strains. People undergoing role-strains
are frustrated because they feel or made to feel inadequate or unsuited to a
role.
Illness and trauma can also affect the self-concept. People responds to
different stressors such as illness and alterations in function related to aging in
a variety of ways: acceptance, denial, withdrawal and depression are common.
(Kozier et.al, Fundamentals of Nursing 7th ed. Pages 957-962).
Role-relationship
• She was the fourth child in her family.
• She is married to Arsenio and they have 6 children.
• She is performing the trypical responsibilities of a plain house wife.
• Her children have a good relationship to her.
• She is being cared by her children who are very supportive to her.
• Her husband is a good husband he is a provider who does everything
for the family to have food.
• She has a harmonious relationship with her brothers and sisters.
Whenever there are any problems, they are helping each other.
• She can form a healthy relationship with others.
• She is the person who chooses her friends.
• She is a very quite person.
• She does not have any enemies.
Sexuality-reproductive
• She is engage in sexual activity to her husband only.
• Presently she is still active in her sex life.
• She still have regular menstruation.
• She is aware that she will have cessation of her menstruation.
• She dresses appropriately, based on her gender.
• She is also able to express her feminine attitudes.
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 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

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.
• 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.
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 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

G. Activities of Daily Living
ASPECT PRIOR TO HOSPITALIZATION
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.
3. Exercise Cleaning their house is the only activity
she considered as her exercise. She does
not have routine exercise. However, she is
aware that 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.
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).
DURING HOSPITALIZATION INTERPRETATION and ANALYSIS
The patient is on diet as tolerated with The patient can eat any food she wants as
aspiration precaution. She eats dry, long as it is dry, thickened, and frothy. It
thickened food on a small frequent should be in a small frequent feeding, as to
feeding. She is advised to chew food avoid aspiration.
properly.
The patient does not defecate or urinated The patient does not defecate for more than
during the conduct of the interview. 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)
Deep breathing and coughing exercises The patient performs deep breathing
are advised and performed. The patient exercise as instructed by the nurse.
has decreasing function as the disease
progresses.
4. Hygiene Patient takes a bath every day, brushes Not applicable
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 Use Patient is a non-smoker and denies use of The patient doesn’t use any prohibited The patient does not use any addictive
illicit drugs. She does not drink alcohol. substances like alcohol, cigarettes and substances. Illicit drugs are strictly prohibited
illicit drugs. in the hospital premises, even cigarette
smoking and alcohol drinking.
6. Sleep and Rest Sleeping is important to her. She is Not applicable
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 Activity She dresses appropriately, based on her Not applicable

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
 II. ANATOMY AND PHYSIOLOGY

III. PATHOPHYSIOLOGY

IV. CONCEPT MAPPING

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)

V. PROBLEM LIST

VI. NURSING CARE PLAN

ASSESSMENT NURSING BACKGROUND GOAL and NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS KNOWLDEGE OBJECTIVES

Subjective Cues: Ineffective airway Intermediate Goal: Effectiveness

- Patient verbalized, clearance related Cause: Within 4 hours of Objective 1: - Was the patient able
“Matagal na akong to retained - Retained nursing Independent-Facilitative: - Health status is to maintain patent
inuubo. Wala secretions in the secretions in the intervention, the 1. Obtain vital signs of the regulated through airway?
namang plema. respiratory tract respiratory tract. patient will be able patient. homeostatic -Was the patient able
Nahihirapan akong secondary to to maintain patent mechanisms. A change in to mobilize her
huminga”. bacterial infection Intermediate airway through the V/S might indicate health secretions?
as evidenced by Cause: mobilization of change. (Taylor et.al, -Was the patient able
crackles upon - Inflammatory secretions as FON 5th ed. Page 523) to have patent airway?
Objective Cues: auscultation. response evidenced by
2. Observe for respiratory
- Presence of productive cough. -Nasal flaring and use of Adequacy
rate and rhythm; presence
adventitious breath Root Cause: accessory muscles -Was all the planned
sound (Crackles) - Bacterial infection Objectives: of nasal flaring; and use of indicates increased effort nursing interventions
upon auscultation. of the respiratory accessory muscles when is required for breathing. are enough in
-The patient is system. 1. For 10 minutes, breathing like the achieving and
coughing without the relative will diaphragm and coastal maintaining patent
phlegm. Health assess the muscles. airway?
- Oriented Implication: physical condition 3. Perform the Blanch Test. - Blanch test reflects the -Was all the resources
- GCS E4V5M6 This condition can of the client by adequacy of o2 of the nurse like time
- BP- 90/70 mmHg, cause Acute accepting at least circulation in the and effort are enough?
CR: 84 bpm, RR: 36 Respiratory 4 nursing periphery.
cpm, T-31.5 C Distress Syndrome interventions to be Appropriateness
- Difficulty vocalizing (ARDS) which done in the -Crackles are intermittent -Was the interventions
4. Auscultate the lungs to
- Has hallow eyes. results from the patient. sounds that occur when mentioned are
note any lung sounds.
- Bluish nail beds. combination of air moves through airway applicable and
infection and 2. After 3 hours that contain fluids. (Taylor beneficial to the
inflammatory the client will be et.al, FON 5th ed. Page patient?
response. The able to mobilize 1386)
lungs become her secretions
quickly filled with through the Objective 2: -Tapping the chest can Acceptability
fluid and become interventions done Independent- Facilitative: loosen the secretions. - Was the family
very stiff. This by the nurse at 1. Perform Chest (Taylor et.al, FON 5th ed. willfully accepted the
stiffness, combined least 4. physiotherapy. Page 1251) interventions done to
with difficulties the patient.
extracting oxygen 3. After 50 -Suction removes
due to the alveolar minutes, the nurse Dependent-Facilitative: secretions through the
fluid creates a need will maintain 1. Suction secretion as use of a strong pressure.
for ventilation. patent airway of needed.
Septic shock is one the patient through
potential the performance - Current data indicates
complication. of at least 3 2. Increase the amount of that fluid restriction may
interventions. oral fluid intake as ordered actually reduce blood
(Black, Medical by the doctor. volume and decrease
Surgical Nursing 7th cerebral circulation. The
ed. Page 1896) lack of volume causes the
blood to be thick and
sluggish and may
decrease the mobilization
of nutrition and toxins out

Dependent-Supplemental:
1. Administer
bronchodilators as ordered.
Objective 3:
Independent-Facilitative:
1. Elevate the head of the
bed.
2. Position the head in the
midline of the body.
VII. MEDICAL- SURGICAL MANAGEMENT
of the circulation. Patient
should be maintained in a
euvolemic state rather
than a fluid-restricted
state. (Black, MSN 7th ed.
Page 2201)
- They act on the
respiratory tract, it opens
narrowed airways.
(Black, MSN 7th ed. Page
1652)
- For maximal lung
expansion that will
improve oxygen delivery.
-Position changes allow
free movement of the
diaphragm and expansion
of the chest wall. (Taylor
et.al, FON 5th ed. Page
1396)
 GENERIC/ ACTION CLASSIFICATION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING
BRAND NAME INTERVENTION

Ethambutol -Ethambutol is
bacteriostatic against
actively growing TB
bacilli, it works by
obstructing the
formation of cell wall.

-Mycolic acids attach

to the 5'-hydroxyl
groups of D-
arabinose residues
of arabinogalactan
and form mycolyl-
arabinogalactan-
peptidoglycan
complex in the cell
wall.

- It disrupts
arabinogalactan
synthesis by
inhibiting the enzyme
arabinosyl
transferase.

-Disruption of the
arabinogalactan
synthesis inhibits the
 formation of this
complex and leads to
increased
permeability of the
cell wall.

Isoniazid -Isoniazid is a -rashes

prodrug and must -abnormal liver
be activated by function tests
bacterial a -hepatitis
catalase- -sideroblastic
peroxidase enzyme -anemia
called KatG.[5] KatG -peripheral
couples the neuropathy
isonicotinic acyl -mild central
with NADH to form nervous system
isonicotinic acyl- (CNS) effects,
NADH complex. drug

-This complex -interactions

binds tightly to resulting in
ketoenoylreductase increased
known as InhA, phenytoin
thereby blocking (Dilantin) or
the natural enoyl- disulfiram
AcpM substrate (Antabuse)
and the action of levels and
fatty acid synthase. intractable
-This process seizures
inhibits the
synthesis of -Peripheral
mycolic acid, neuropathy and
required for the CNS effects are
mycobacterial cell associated with
wall. A range of the use of
radicals are isoniazid and
produced by KatG are due to
activation of pyridoxine
Isoniazid, including (vitamin B6)
nitric oxide[6] which depletion, but
has also been are uncommon
shown to be at doses of 5
important in the mg/kg.
action of another
antimycobacterial -Persons with
prodrug PA-824.[7] conditions in
which
-Isoniazid is neuropathy is
bactericidal to common (e.g.,
rapidly-dividing diabetes,
mycobacteria but is uremia,
bacteriostatic if the alcoholism,
mycobacterium is malnutrition,
slow-growing HIV-infection),
Isoniazid inhibits as well as
the P450 system. pregnant
women and
persons with a
seizure
disorder, may
be given
pyridoxine
(vitamin B6)
(10-50 mg/day)
with isoniazid.

-Hepatotoxicity
can be avoided
with close
clinical
monitoring of
the patient,
specifically
nausea,
vomiting,
abdominal pain
and appetite.

-Isoniazid is
metabolized by
the liver mainly
by acetylation
and
dehydrazination.
The N-
acetylhydrazine
metabolite is
believed to be
responsible for
the hepatotoxic
effects seen in
patients treated
with isoniazid.
The rate of
acetylation is
genetically
determined.
Approximately
50% of blacks
and Caucasians
are slow
inactivators; the
majority of Inuit
and Asians are
rapid
inactivators. The
half-life in fast
acetylators is 1
to 2 hours while
in slow
acetylators it is
2 to 5 hours.
Elimination is
largely
independent of
renal function,
however the
half-life may be
prolonged in
liver disease.
The rate of
acetylation has
not been shown
to significantly
alter the
effectiveness of
isoniazid.
However, slow
acetylation may
lead to higher
blood
concentrations
with chronic
administration of
the drug, with
an increased
risk of toxicity.
Isoniazid and its
metabolites are
excreted in the
urine with 75 to
95% of the dose
excreted in 24
hours. Small
amounts are
also excreted in
saliva, sputum
and feces.
Isoniazid is
removed by
hemodialysis
and peritoneal
dialysis.[9]

Headache, poor
concentration,
poor memory
and depression
have all been
associated with
isoniazid use.
The frequency
of these side
effects is not
known, and the
association with
isoniazid is not
well validated.
On the other
hand, all
patients and
health-care
workers should
be aware of this
serious adverse
effect,
especially if
suicidal thinking
or behavior
occurs.[10][11][12]
 INH therapy will
decrease the
efficacy of
hormonal birth
control when
combined with
Rifampin.

VIII. DISCHARGE HEALTH TEACHING

IX. PROGRESS NOTES