Right Massive Pleural Effusion with Tension Secondary to Moderately Advanced Pulmonary Tuberculosis (PTB) and Atherosclerotic Aorta

A Nursing Case Study Presented to The Faculty of the College of Nursing Of the University of St. La Salle Bacolod City

In Partial Fulfillment Of the Requirements for the Degree Bachelor of Science in Nursing

By BSN 4A Group II Richard Ejorcadas Rene John Francisco Joffrey Jay Garrido Liza Marie Gatuslao Nicolas Gabriele Gatuslao Francesa Antonnet Hinolan Ma. Jemaimah Isubal Kevin Kee Sheena Joy Lobaton Ma. Angelica Macrohon Jayvee Mangana Sarah Jean Medina Aljay Charyl Mingay Kcyl May Montao

BSN4A (GROUP 2) 2 Mary Joyce Montibor October 4, 2012

I.

Introduction Every day we are exposed to innumerable agents that could threaten the equilibrium of

our health. Among them are the different types of bacteria and viruses present in our environment which bring about different types of diseases. With these diseases are accompanying complications that result after an infection has undergone. In the case of our chosen patient, he has developed a massive pleural effusion as a result of pulmonary tuberculosis (PTB) infection and aortic atherosclerosis. PTB, being caused by pathogenic bacterial specie called Mycobacterium Tuberculosis, is a chronic, recurrent, infection of the lungs. According to the World Health Organization (WHO), TB is considered as the second to HIV/AIDS as the greatest killer worldwide due to a single infectious agent, and based on the latest Philippine Health Statistics from the DOH, which was for the year 2004, TB was listed as the cause of some 25,000 deaths, making it the sixth leading cause of death in the country and at the same time the sixth (6th) leading cause of illness in the country. Tuberculosis is an ancient disease that is already curable today but still prevails due to many factors contributing to its palpable existence not only in our country but as well as to other underdeveloped and developing countries. Poverty is one of the biggest factors why Tuberculosis is still very much prevalent. Having insufficient resources to fund the individual needs of nutrition leads them to a weaker state of immunity which further makes them highly vulnerable to the said disease. In addition, poor housing and congested living conditions increase the risk of acquiring the disease. Having greater percentage of contact with an infected individual poses a higher chance of one getting a TB infection and even without knowing it due its characteristic of being an airborne disease. With this, knowledge deficit and stigma could also alter and influence health practices and preventive measures towards the said disease. Prevention is always better than cure the quote echoes in redundancy, nevertheless it is resoundingly true. Tuberculosis is deadly and produces an array of complications to patients, and in this particular case study, pleural effusion is the culprit.

Pleural effusion, or water on the lungs, is a condition wherein there is excess fluid that accumulates between the two pleural layers; the fluid-filled space that surrounds the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing. Depending on the cause, the excess fluid may be either proteinpoor (transudative) or protein-rich (exudative). These two categories help physicians determine the cause of the pleural effusion, and among them is PTB, which causes the exudative type. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation, and thus leads to oxygen deficits to the body.

Pleural effusion occurs in TB infected individuals thru the presence of irritation on the lining of the pleural cavity, thus altering the permeability of the membrane and decreasing the oncotic pressure needed to drain the excess fluid in the pleural space. The presence of the atherosclerotic aorta in the patient also contributes by pushing blood in the pulmonary veins back to the lungs and therefore causing pulmonary edema which greatly increases the degree of the pleural effusion in the patient.

Out of the patients in our Medical Isolation Ward Exposure, RCs case caught the groups attention due to its complex situation of different existing conditions that contribute to the patients massive pleural effusion. This case study aims to broaden the groups understanding of the current health condition that would serve as a great tool or basis for promoting good and individualized care to clients, especially in extreme cases. Through this case study, we will be able to learn more about the disease process, thus widening our knowledge on how to care for future clients with the same disease.

II.

Objectives of the Study

General Objective

After 1 hour of case presentation the student nurses will be able to: Present information regarding right massive pleural effusion with tension secondary to Moderately Advanced PTB and atherosclerotic aorta in relation to patients clinical manifestations, treatment, and general health status. Specific Objectives After 1 hour of case presentation the student nurses will be able to: Knowledge: 1. Define PTB, massive pleural effusion and atherosclerotic aorta and enumerate its causes and explain its effects to the body. 2. Explain the Anatomy and Physiology of the Respiratory System and the areas affected by the patients condition. 3. Trace the pathophysiology of right massive pleural effusion with tension aggravated by Moderately Advanced Pulmonary Tuberculosis (PTB) and Atherosclerotic Aorta. 4. Enumerate the prioritized nursing problems related to the case. 5. State the importance of the Nursing Case Study in terms of dealing with patients having right massive pleural effusion with tension secondary to MA PTB and atherosclerotic aorta. Skills: 1. Identify the classification, mechanism of action, indication, contraindications and adverse effects of the drugs used by the patient in the drug study. 2. Formulate a Nursing Care Plan on the identified and prioritized problems for substance abuse.

3. Discuss the significance of the deviation of the laboratory results and findings of the patient. 4. Design a comprehensive health teaching plan based on the specific needs of the patient. Attitude: 1. Demonstrate a positive attitude in caring for clients who have massive pleural effusion secondary to MA PTB and atherosclerotic aorta. 2. Participate attentively in presenting the case of the patient. 3. Verbalize changes in outlook towards patients having massive pleural effusion secondary to MA PTB and atherosclerotic aorta. 4. Display a positive behavior towards the possibility of having future patients with such disease.

III. Anatomy & Physiology of the Respiratory System

Overview Cells in the body require oxygen to survive. Vital functions of the body are carried out as the body is continuously supplied with oxygen. Without the respiratory system

exchange of gases in the alveoli will not be made possible and systemic distribution of oxygen will not be made possible. The transportation of oxygen in the different parts of the body is accomplished by the blood of the cardiovascular system. However, it is the respiratory system that carries in oxygen to the body and transports oxygen from the tissue cells to the blood. Thus, cardiovascular system and respiratory system works hand in hand with each other. A problem in the cardiovascular system would affect the other and vice versa.

Functional Anatomy of the Respiratory System Nose The nose is the only external part of the respiratory system and is the part where the air passes through. During inhalation and exhalation, air enters the nose by passing through the external nares or nostrils. Nasal cavity is found inside the nose and is divided by a nasal septum. The receptors for the sense of smell, olfactory receptors are found in the mucosa of the slit-like superior part of the nasal cavity which is located beneath the ethmoid bone. Respiratory mucosa

lines the rest of the nasal cavity and rests on a rich network of thin-walled veins that warms the air passing by. Important information about nose is the presence of the sticky mucus that is produced by the mucosas gland. This important characteristic moistens the air and traps the incoming bacteria and other foreign debris passing through the nasal cavity. Cells of the nasal mucosa are ciliated and it creates a gentle current that moves the contaminated mucus posteriorly towards the throat, where it is swallowed and digested by stomach juices. Conchae

These are three mucosa-covered projections or lobes that greatly increase the surface area of the mucosa exposed to the air. Aside from that, conchae increase the air turbulence in the nasal cavity. Palate A partition that separates the nasal cavity from the oral cavity. Anteriorly, the palate that is supported by a bone called the hard palate and the one which is unsupported is the soft palate. Paranasal Sinuses These are structures surrounding the casal cavity and are located in the frontal, sphenoid, ethmoid and maxillary bones. Pharynx The pharynx is a 13 cm long muscular tube that is commonly called the throat. This muscular passageway serves as a common food and air pathway. This structure is continuous with the nasal cavity anteriorly via the internal nares. Parts of pharynx: 1. Nasopharynx the superior portion of the pharynx. The pharyngotympanic tubes that drain the middle ear open in this area. This is the main reason why children who have otitis

media may follow a sore throat or other tyoes of pharyngeal infections since the two mucosae of these regions are continuous. 2. 3. Oropharynx middle part Laryngopharynx part of pharynx that enters the larynx.

Tonsils clusters of lymphatic tissues found in the pharynx. 1. 2. Palatine tonsils tonsils found at the end of the soft palate. Pharyngeal tonsils lymphatic tissues located high in the nasopharynx. This is also called adenoid. 3. Lingual tonsils located at the base of the tongue.

Larynx The larynx is the one that routes the air and food into their proper channels. Also termed as the voice box, it plays an important role in speech. This structure is located inferior to the pharynx and is formed by: 1. 2. Eight rigid hyaline cartilages Spoon-shaped flap of elastic cartilage, which is called the epiglottis.

Thyroid cartilage this is the largest hyaline cartilage that protrudes anteriorly in males and is referred to as the Adams apple. Epiglottis This is a flap of tissue that serves as a guardian of the airways as it protects the superior portion of the larynx. The epiglottis does not restrict passage of air into the lower respiratory passages when a person is not swallowing. However, when a person swallows food, the epiglottis tips and forms a lid or blocks the opening of the larynx so that food will not be directed to the lower respiratory passages. The food will be then routed to the esophagus and in cases where it enters the larynx, a cough reflex is triggered to expel the substance and prevent it from

continuing into the lungs. This protective reflex does not work when a person is unconscious that is why it is not allowed to offer or administer fluids to an unconscious client. Vocal folds a pair of folds which are also called the true vocal cords that vibrate when air is expelled. Glottis the slit-like passageway between the vocal folds.

Trachea Also called the windpipe, the trachea is about 10 to 12 cm long or about 4 inches and travels down from the larynx to the fifth thoracic vertebra. This structure is reinforced with Cshaped rings of hyaline cartilage and these rings are very important for the eating and breathing. The trachea is lined with ciliated mucosa that primarily serves for this purpose: To propel mucus loaded with dust particles and other debris away from the lungs towards the throat where it can either be swallowed or spat out. Main Bronchi

The main bronchi, both the right and the left, are both formed by tracheal divisions. There is a slight difference between the right and left main bronchi. The right one is wider, shorter and straighter than the left. This is the most common site for an inhaled foreign object to become lodged. When air reaches the bronchi, it is already warmed, cleansed of most impurities and well humidified. Lungs The lungs are fairly large organs that occupy the most of the thoracic cavity. The most central part of the thoracic cavity, the mediastinum, is not occupied by the lungs as this area houses the heart. Divisions of the Lungs

The lungs are divided into lobes by the presence of fissures. The left lung has two lobes while the right lung has three. Pleural Layers

1. Visceral pleura also termed as the pulmonary pleura and covers each surface of the lings. 2. Parietal pleura covers the walls of the thoracic cavity. - Pleural fluid a slippery serous secretion that allows the lungs to slide along over the thorax wall during breathing movements and causes the two pleural layers to cling together. Bronchioles smallest air-conducting passageways.

Bronchial tree or respiratory tree a network formed due to the branching and rebranching of the respiratory passageways within the lungs. Alveoli air sac: This is the only area where exchange of gases takes place.

Respiratory Zone this part includes the respiratory bronchioles, alveolar ducts, alveolar sacs, alveoli. Physiology of Respiration The respiratory primarily supplies oxygen to the body and disposes of carbon dioxide through exhalation. Four events chronologically occur, for respiration to take place. 1. Pulmonary ventilation this process is commonly termed as breathing. With pulmonary ventilation, air must move out into and out of the lungs so that the alveoli of the lungs are continuously drained and filled with air. 2. External respiration this is the exchange of gases or the loading of oxygen and the unloading of carbon dioxide between the pulmonary blood and alveoli. 3. Respiratory gas transport this is the process where the oxygen and carbon dioxide is transported to the and from the lungs and tissue cells of the body through the bloodstream.

4.

Internal respiration in internal respiration the exchange of gases is taking place between the blood and tissue cells.

Mechanics of Breathing Breathing, also called pulmonary ventilation is a mechanical process that completely depends on the volume changes occurring in the thoracic cavity. Thus, a when volume changes pressure also changes, and this would lead to the flow of gases equalizing with the pressure. Inspiration also called inhalation. This is the act of allowing air to enter the body. Air is flowing into the lungs with this process. Inspiratory muscles are involved with inspiration which includes: 1. 2. The diaphragm External intercostals These muscles contract when air is flowing in and thoracic cavity increases. When the diaphragm contracts it slides inferiorly and is depressed. As a result the thoracic cavity increases. The contraction of the external intercostal muscles lifts the rib cage and thrusts the sternum forward. This increases the anteroposterior and lateral dimensions of the thorax. Expiration also called expiration. It the process of breathing out air as it leaves the lungs. This process causes the gases to flow out to equalize the pressure inside and outside the lungs. Under normal circumstances, the process of expiration is effortless.

IV. Definition of Terms

1. Admission - the act of being received into a place, a patient accepted for in patient service in the hospital. 2. Anicteric - pertaining to the absence of jaundice. 3. Aortic atherosclerosis - is the buildup of a waxy plaque on the inside of blood vessels 4. Chamber - a hollow but not necessarily empty space/cavity in an organ. 5. Chest tube thoracotomy - is the insertion of a tube (chest tube) into the pleural cavity to drain air, blood, bile, pus, or other fluids. 6. Chronic - persisting for a long period, often for the remainder of a persons lifetime. 7. Equilibrium - A state of physical balance. 8. Nasal cavity - a large air filled space above and behind the nose in the middle of the face. 9. Oncotic pressure - also known as colloid osmotic pressure, is a form of osmotic pressure exerted by proteins in blood plasma that usually tends to pull water into the circulatory system. 10. Pathogenic - capable of causing disease. 11. Pleura - are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing. 12. Pleural effusion - it occurs when too much fluid collects in the pleural space (the space between the two layers of the pleura). It is commonly known as "water on the lungs."
13. Pulmonary edema - is a condition in which fluid accumulates in the lungs, usually

because the heart's left ventricle does not pump adequately. 14. Ventilation - also known as breathing; the exchange of air between the lungs and the environment, including inhalation and exhalation.

V.

Baseline Data

Name:

R.C.

Home Address:

Purok Manuslok, Brgy. Kapitan Ramon, Silay City

Current Address:

Missionaries of Charity, Brgy. Banago, Bago City

Age:

59 years old

Birth Date:

October 10, 1952

Birth Place:

Silay City, Negros Occidental

Gender:

Male

Marital Status:

Married

Religion:

Roman Catholic

Educational Level:

Elementary School Undergraduate (Grade 5)

Nationality:

Filipino

Occupation:

Farmer & Albularyo

Person next to kin:

R.C.

Number of Dependents: 8

Relationship:

Son

Date of Admission:

August 13, 2012

Attending Physician:

Dr. Jimmy Villo and Dr. Sanchez

Chief Complaint:

Difficulty of Breathing

Medical Diagnosis:

Pulmonary Tuberculosis (PTB), TB effusion

Name of Agency:

Corazon Locsin Montelibano Memorial Regional Hospital (CLMMRH) - Medical Isolation Ward

Financial Support:

Medical Assistance (Mayor Bing Assistance) and Missionaries of Charity

VI. Nursing History

Health Maintenance Perception Pattern

Sin-o man bala nga tawo ang wala ga la-um nga mag-ayo, is one of the statement of R.C. Mr. R.C. views health as an important factor of his life and described his current condition as a great challenge. He is not ashamed of having a PTB because as what his doctor said, PTB has a cure and no one nowadays should keep it for themselves because everyone has the chance to be cured. Mr. R.C. is a well known albularyo in their village. He uses herbal plants and made a concoction out of it as a medicine. He uses ginger as a mean to cure their sick from bad spirits and curse of supernatural beings. R.C. smoke 1-2 sticks of cigarette for almost twenty-five to fifty years already which started when he was young, about twenty-five years as he can remember. Also, he drinks alcohol specifically three bottle of long neck together with his friends. When he first experienced the signs and symptoms of PTB such as fever, productive cough with blood at times, difficulty of breathing, and chills, etc. that made him sick for almost 8 months last year, he started to realize to minimize the bad vices he used to have. Since he was diagnosed with PTB on May 2012 , he already stops his vices. His last intake of alcohol was on November 2011 and refuses to take any if his friends would ask him to join them. He took PTB drugs under DOTS (direct observed short course) of DOH (Department of Health) program such as rifampicin, isoniazid, pyrazinamide and ethambutal hydrochloride. He took it using his own money for almost 20 days because of financial constraint. R.C. claimed that he is not allergic to any form or kind of food, drug, tape or dye. He takes does not take vitamin daily instead he eats more vegetables and fruits from his plants grown in their village. He uses herbal plants as a remedy for his illness such as bayabas, alibhon, and etc. Also, he takes medicines such as paracetamol and other over-the-counter drugs for usual sickness like cough, colds and fever.

Financial constraint and poor family support is one of the problem of Mr. R.C. faced due to the low socioeconomic factors that they have. Luckily, the Missionaries of Charity support him. They are the one who provide his needs and medications. He takes his medications religiously when available. His family does not visit him daily because they are busy and no money to go to the hospital from their village but he is always assisted by his youngest son J. during his confinement. Through the chest X-ray, client was able to find out that there was a pleural effusion in his right lungs. The patient participates in deep breathing and coughing exercise to enhance the unaffected lungs and increase lung expansion. Regarding his current condition, Mr. R.C. fully understands that along with his pleural effusion, he should be cured from his PTB that may progress and metastasize anytime. Patient recognizes that his cousin and nephew who dwell in the same village has a history of PTB infection, but other than that patient knows no medical problems in his family. Nutritional Metabolic Pattern Mr. R.C. is not nourished upon assessment as manifested by cachexia, sunken eyeball and face. He has a normal to poor appetite depending on his condition. According to him, he eats two to three meals a day composed of one-half plate of rice, and viand which he himself cooks for the whole family. Viands contain vegetables, fish, and chicken; he seldom eats pork and meat. He has his own little farm where he get her daily food such as the vegetables and rice. He even claims that he able to drink 8-9 glasses of water a day. During his first day of admission in the medical isolation ward, he was on DAT (diet as tolerated) as ordered. He was able to eat the food catered by the hospital and given by the nuns. It is contains a cup of rice, a cup of vegetables, a slice of chicken or fish and a piece of banana or a slice of mango and drank water at about 50 ml. R.C. experienced poor appetite when he experienced severe pain due to his incision. Patient is not bothered by the sanitation of the food tray and the food process in the hospital because he believed if they will not eat what is serve he will surely feel weaker because the foods from the nuns usually came late

and is not enough for him and J. sometimes. His other family members do not bring food for him on daily basis because they seldom visit him. Elimination Pattern

Mr. R.C. has never experienced having any disease of the digestive system and urinary. But, R.C. has white scar in his lower leg and foot from his previous skin infection due to his daily work in a wet, muddy rice field at their backyard. He usually defecates daily to a well-formed, soft, brownish stool within normal limits. There is no difficulty in defecating as claimed by the patient. R.C. also claimed that he defecate once a week during hospital admission due to his uncomfortable condition. His bladder is within normal limits and no reported pain nor difficulty in urinating. Client is able to void freely to a clear to straw-colored urine approximately at 550 ml at our 6-2 shift. He noticed that before he usually urinate five times a day but lessens to three times a day when he is admitted but he drinks a lot of water especially when taking his medicine but it may be due to his ongoing chest tube drainage. Activity and Exercise Pattern Mr. R.C. develops a routine every day. R.C. is a kargador or sugarcane farmer since he was 8 years old as a primary source of income of his family before. Now, his piece of land for sugarcane is rented by a co-farmer was given him a parcel of harvest or money. Then, his rice field is take care by him and his children. At dawn, he likes to stretch and stroll outside as he prepares his tools for the days work. He also do some chores before he leave. He makes his own lunch and snacks, and cooks for the family. When he was not in the field, he plants vegetables as a source of food and income for him. Sometimes in the afternoon, he likes to walk around the neighborhood and converse with his friends to unwind. In normal condition, he is able to do all these activities without any assisted devices or assistance. But when his body capacity declines, feelings of weakness, severe cough, easy fatigability and difficulty of breathing he restricts activities such as heavy lifting and sowing the fields. He

stays at his house to make him more comfortable. During his admission, he could not independently do his self-care needs such as dressing, grooming, toileting, bed mobility, transferring, ambulating due to his pain in the chest tube drainage incision. He was assisted by his youngest son to recover much faster. Sleep and Rest Pattern Mr. R.C. wakes up at 4:00 in the morning which he used to do since he goes to his rice and sugarcane field before. Then, he usually goes to bed at about nine to ten oclock in the evening for approximately six to seven hours a day. He likes to take morning nap and feels more rested. In the afternoon, he is out with his neighbor friends or does his vegetable planting. Client experience no difficulty of going back to sleep whenever he is disturbed or in urged to urinate. Other than that, there are no sleeping problems reported. He always feels relaxed during sleep. R.C. complains of a decrease of his sleeping hours due to his pain with five to thirty minutes duration of sleep. Therefore, he hardly rested for the whole night. So, he always takes a short nap in between. Cognitive Perception Pattern Mr. R.C. is mentally alert, conscious, and oriented to time, place and person. He does not difficulty in speech. R.C. is a Grade 5 undergraduate and opted to go to the sugarcane fields to help his parents due to financial instability. But he has the ability to read, communicate, and comprehend Hiligaynon and a little English and Cebuano. On the other hand, he can clearly express and comprehend his thoughts and ideas about his condition and family health background. He perceives his pain as a stubbing pain, with a scale of seven. Sometimes, it hinders him to move and do his self-care which irritates him most. Also, the foul smelling from the drainage that sometimes leaks from the incision site makes him more uncomfortable and angry. He also mentioned if he can just go home with his CTT (chest tube thoracostomy) drainage and be monitored accordingly. He mentioned that the procedure is not new to him since his nephew once had a CTT procedure when he was twelve years old

and have a good prognosis as a result of PTB infection as claimed by the patient. Therefore, R.C. is positive that he will soon be okay and all the excess fluid will be drained out. Above all he does not have any problems and difficulties in his hearing, vision, tactile, olfactory, and taste functions at all. Moreover, the client displays having a good memory and responsive to conversation and health intervention. Self-Perception Self Concept Pattern Patient R.C. is conscious of his appearance since he has not taken a bath since admission and only sponge bath. He is eager to go home to take a bath and be free from foul smelling drainage. He sometime he wondered why his CTT site is not cleaned. He said that he loose wait and his appearance makes a big difference unlike before due to his illness and poor appetite sometimes. R.C. does not directly tell his children when he feels something wrong because he does not want to be a burden to his family because he knows they are financial incapable as well. He has a very strong attitude and seldom can hear any resentment towards his family. He is very optimistic regarding his recovery and he knows that it can be medically cured. At the same time, he greatly believes in his faith in God that it is not yet the end because if will by God then thy will be done. Role Relationship Pattern Mr. R.C. is the father of eight children, with five sons and 3 daughters, and lives in a peaceful community. His wife died many years ago and became a sole provider for his children. He supported them in their education but not all of them finish their education because he could not afford to send them to school anymore because he is getting old and the farm cannot sustain their needs. As a result, some of his children go to manila, Bacolod and other big cities to find a job. Some of them had already had a family of their own. One of his sons with a family of two kids lives with him in his own house together with his youngest son who still depends on him. He still looks after for his children whereabouts and advises

them when problems arise. But he became sad lately because his children could not visit him in the hospital. He also thankful because J. is with him always. He is a farmer in his village and respected by many people. He is a person that everyone looks up to. Aside of being a farmer, he is the first one whom the families seek for treatment for their sick children because he is a well-known traditional healers. He has many friends because most of the villagers are his relatives too. During his free time, he would go with them for a drink and have a chat. Until, he became ill he refused to join them in their drinking session. He further expressed that he prefer to stay at home, in order to avoid these vices. Sexuality and Reproductive Pattern Regarding sexuality, R.C. finds contentment with what and who he is. He claimed that he does not have any disease nor experienced any dysfunction of the reproductive system. Client was assessed of his past sexual relations and he claimed he had a wife and have a well-grown eight children. During coitus, he never used any contraceptives and further claimed that he had plain sexual satisfaction from it. According to him, he is contented with his family and children. Coping Stress Pattern Mr. R.C. would go with his friends and drink when we had problems. He do not usually voice out when he feels something wrong. Whenever he encounters problems in their home, he would usually share it to his eldest son and sometimes to his peers though he usually tends to keep it himself. He also likes to hang out with his neighbor and friends just to make him unwind and temporarily forget his problems. Also, he does not pay too much attention to such problems because he believes that it is just a part of our life that we continue to face trials every day. Most importantly, he never forgets to confess and ask for help to the heavenly father.

Values and Belief Pattern According to patient R.C it is important to understand the love and care of those around you and the intentions they have for you. R.C claimed that he is satisfied with his life despite of his condition and accepted it openly. He is aware that problems normally occur, and it should not stop him from living his life. With good catholic Christian values never questioned God about his condition, instead he hopes in Gods will he will be given a chance to get back to his home and family and to do the work he used to have. Most importantly, he has a positive outlook towards life. Furthermore, it is time for him to realize that what he has done was not good to his health and for him to eradicate his vices and initiate a healthy lifestyle. Lastly, patient R.C does not pray the rosary and seldom went to church because of the remote distance of church from their home but he prays at night asking for strength and courage to face lifes challenges every day.

VII. Health History

History of Present Illness

Eight months prior to admission, Patient R.C experienced weakness and fatigue, coughing up of blood for 2 days, night sweats and chills. He doesnt seek consultation rather make a concoction of herbal plants to ease the symptoms. In the month of May, four months prior to admission, due to aggravated symptoms he consulted in Teresita Lacson Jalandoni Provincial Hospital (TLJPH) and was diagnosed of having Pulmonary Tuberculosis (PTB), DOTS medicine were prescribed such as Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol for a duration of only about 20 days due to financial difficulties. At the end of May, he was advised by his eldest son and relatives specifically his cousin who was also diagnosed with PTB to stay at the Missionaries of Charity, Brg. Banago where his children are currently living. Having assured by a nun in charge to eagerly help him for his recovery. He stayed in the institution for two months (June-July) and was treated.. He was provided with all his needs ; physical (food, shelter and medications), spiritual and emotional support. However his condition worsen. He experienced swelling of the feet and severe difficulty of breathing therefore the nun in charge and his nephew (previously diagnosed with PTB) accompany him to CLMMRH to have a checkup about his condition. On Aug. 13, 2012, Patient R.C was brought to CLMMRH for his checkup due to his worsening condition of difficulty of breathing. The doctor in charge decided to admit him in the hospital on the same day and diagnostic findings revealed fluid accumulated in the thoracic area. RC was diagnosed to have Pulmonary Tuberculosis (PTB), TB effusion and was undergoing treatment in Medical Isolation Ward up to the present. The medications prescribed to him were provided by the nuns in the Missionary of Charity.

Past Health History A. Childhood Illness R.C. experienced illnesses such as flu, cough, fever and colds. B. Past Hospitalization R.C. had previous hospitalizations due to severe fatigue for almost 4 months when he was 12 years old as claimed by him. C. Serious Illness/ Chronic Illness R.C. had experienced severe fatigue for almost 4 months. D. Previous Surgery R.C. has not undergone any previous surgery.

Family/ Social History Patient lived with his children at Brgy. Kapitan Ramon, Silay City. According to him, there are no any illnesses or diseases present within their immediate family members but his cousins wife and his nephew have tuberculosis and are being treated currently.

VIII. Physical Assessment Date: August 29, 2012

Time of Assessment: 8:00 AM

GENERAL APPEARANCE

Uncomfortable status on bed as claimed

Tidy hair and with unkempt clothes

With decrease body mass

No piercings noted

LEVEL OF CONCIOUSNESS (LOC)

Lethargic

Awake, lying on bed, conscious and coherent

Responsive to both verbal and non-verbal stimuli

Oriented to time, place and person

HEENT

Head is symmetrical, scalp is intact with no lesions and no swelling noted

Pupils equally round reactive to light and accommodation. Patients eyebrows are symmetrically aligned; with anicteric sclera and pinkish conjunctiva. Eyes are proportional to the face with sunken eyeballs noted.

Ears are symmetrical, firm and non-tender. There are no unusual discharges noted and without hearing difficulty. Color of the skin is the same with the facial skin

Nose is symmetrical with no deviations, uniform in color and non-tender. Patent nares with no discharge noted and client claimed no olfactory problems.

Lips are dry and pale. There is symmetry of contour. Tongue is central in position, pink in color, moist, and moves freely. Tonsils are pink in color. Mouth hygiene is not maintained. Patient has incomplete set of teeth.

CARDIOVASCULAR

With heplock at right cephalic vein

With BP of 80/70 mmHg taken at left arm in semi-fowlers position

With normal heart rhythm and regularity auscultated

With strong palpable pulse of 83 bpm taken at the left wrist; with irregular rhythm

With good capillary refill of <2seconds

With clubbing of fingers noted.

RESPIRATORY

Breathes spontaneously to room air with rapid, shallow breathing at 36 cpm

With difficulty of breathing as claimed

With productive cough to a greenish sputum

With symmetrical rise and fall of chest

With limited chest wall expansion noted

Increased fremitus

Dullness upon percussion on lung fields

Wheezing upon auscultation in left lower quadrant of the lung and crackles upon auscultation in the left upper quadrant of the lung; wheezing to diminished breath sound on the right lung

With right CTT H2O level of 200mL (+) oscillation, with an output of 350 cc of a foul smelling, greenish-colored drainage

GASTRO-INTESTINAL TRACT

On DAT (Diet as tolerated) with poor appetite

With 6 normative bowel sounds on both right and left lower iliac region auscultated

Not able to defecate upon assessment

With no distention in the abdominal area

GENITO-URINARY TRACT

Not able to void upon assessment

With no distention of the bladder upon palpation in the pubic region

No difficulty of urination as claimed

MUSCULOSKELETAL

Able to ambulate with assistance due to weakness of lower extremities

With body weakness and fatigue as claimed

REPRODUCTIVE

With no penile, scrotal lesions and abnormal discharges as claimed

INTEGUMENTARY

With brown-black complexion

With hyperpigmentation noted esp. in the extremities Warm to touch, afebrile at 37 C With dry skin and poor skin turgor

IX. Laboratory and Radiology Test

Complete Blood Count - The complete blood count is the calculation of the cellular (formed elements) of blood. These calculations are generally determined by special machines that analyze the different components of blood in less than a minute. A major portion of the complete blood count is the measure of the concentration of white blood cells, red blood cells, and platelets in the blood. Date of testing: 08-15-12 Exam Name Hematocrit Result 0.29 Unit L/L Normal Value 40-54 Implication Represents anemia, results from chronic inflammatory conditions Low level of hemoglobin indicates anemia Indicates anemia Normal Normal It indicates infection Normal Indicates lung disease and reaction to certain medications
Caused by inflammatory diseases that lead to the increase in the number of platelets

Hemoglobin

88

g/L

130-180

Red Blood Cells Count White Blood Cell Count Segmenters Lymphocytes

3.35 6.7 67 16

1012/L 109/L % %

4.5-5.5 4.5-11.0 50-70 25-35

Monocytes Eosinophils

8 9

% %

0-15 1-5

Platelets

425

109/L

150-400

Complete Blood Count Date of testing: 08-19-12 Exam Name Result Unit Normal Value Implication

Hematocrit

0.30

L/L

40-54

Represents anemia, results from chronic inflammatory

Hemoglobin

104

g/L

130-180

conditions Low level of hemoglobin indicates anemia due to compromised O2

Red Blood Cells Count White Blood Cell Count Segmenters Lymphocytes Monocytes Eosinophils Platelets

4.4 10.9 84 19 8 2 470

1012/L 109/L % % % % 109/L

4.5-5.5 4.5-11.0 50-70 25-35 0-15 1-5 150-400

and CO2 exchange Indicates anemia Normal Indicates infection It indicates infection Normal Normal
Caused by inflammatory diseases that lead to the increase in the number of platelets

Complete Blood Count

Date of testing: 08-28-12 Exam Name Hematocrit Result 0.29 Unit L/L Normal Value 40-54 Implication Represents anemia, results from chronic inflammatory conditions Low level of hemoglobin indicates anemia due to 1012/L 109/L ineffective ventilation. Indicates anemia

Hemoglobin

85

g/L

130-180

Red Blood Cells Count White Blood Cell Count

3.29

4.5-5.5

15.4

4.5-11.0

Presence of infectious process specifically in

the lungs Segmenters Lymphocytes Monocytes Eosinophils Platelets 71 14 12 3 432 % % % % 109/L 50-70 25-35 0-15 1-5 150-400 Indicates infection. Due to infection Normal Normal
Caused by inflammatory diseases that lead to the increase in the number of platelets

Potassium- potassium test checks how much potassium is in the blood. Potassium is both an electrolyte and a mineral. It helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the body. Potassium is also important in how nerves and muscles work. Date of testing: 08-21-12 Exam Name Potassium Result 3.50 Unit mEq/L Normal Value 3.5-4.5 Implication Normal

Creatinine Levels- Creatinine is a chemical waste molecule that is generated from muscle metabolism. Creatinine is produced from creatine, a molecule of major importance for energy production in muscles. Creatinine is transported through the bloodstream to the kidneys. The kidneys filter out most of the creatinine and dispose of it in the urine. Date of testing: 08-15-12 Exam Name Creatinine Result 0.24 Unit mEq/L Normal Value 0.70-1.30 Implication
Low level of creatinine indicates an efficient and effective functioning pair of kidneys.

Pleural Fluid Analysis- Pleural fluid analysis is used to help diagnose the cause of inflammation of the pleura (pleuritis) and/or accumulation of fluid in the pleural space (pleural

effusion). There are two main reasons for fluid accumulation, and an initial set of tests (fluid protein, albumin, or LDH level, cell count, and appearance) is used to differentiate between the two types of fluid that may be produced. Date of testing: 08-14-12 Results: No fungal element seen on smear Implication: Normal

Urinalysis- The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders. It is ordered widely and routinely to detect any abnormalities that require follow up. Often, substances such as protein or glucose will begin to appear in the urine before patients are aware that they may have a problem. It is used to detect urinary tract infections (UTI) and other disorders of the urinary tract. In patients with acute or chronic conditions, such as kidney disease, the urinalysis may be ordered at intervals as a rapid method to help monitor organ function, status, and response to treatment. Date of testing: 08-08-12 Exam Name Uric Acid Result 9.77 Unit mg/dL Normal Value 3.5-7.2 Implication Increase uric acid levels may be due to alcohol consumption, organ such as liver disease, and starvation Decrease level due to chronic illness, medication use such as antibiotics and poor intake of potassium rich foods. Normal

Potassium

2.90

mEq/L

3.6-5.4

IONIZED (Free) Ca SCPT/ALT

1.23

mEq/L

1.12-1.32

11.00

U/L

3-41

Normal

Chest X-ray- The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of the spine and chest. An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. Xrays are the oldest and most frequently used form of medical imaging.

Results: PTB, moderately advanced, left with cavity formation. Massive pleural effusion, right with tension. Arteriosclerotic Aorta

Implication: Inflammation of the lungs due to infectious process of the agent Mycobacterium tuberculi causes accumulation of excessive fluid in the pleural cavities which aggravated by the atherosclerotic aorta causing a backflow of blood in the lungs causing pulmonary congestion.

Other ideal Diagnostic Tests/ Procedures

1. FBC- Full blood Count- An FBC, as the name suggests, is used to obtain a count of the

blood cells in the sample of blood taken. The counts from this small sample are used to estimate the levels of different blood cells within your bodys blood system. 2. Pleural Biopsy- A pleural biopsy is a procedure to remove a sample of the tissue lining the lungs and the inside of the chest wall to check for disease or infection. 3. Bronchoscopy- Bronchoscopy is a test to view the airways and diagnose lung disease. It may also be used during the treatment of some lung conditions.