Overview of Disease

Tuberculosis is a contagious infection caused by an airborne bacterium.

Mycobacterium tuberculosis.

Tuberculosis usually affects the lungs, although it can attack almost any organ
in the body. Other mycobacteria (such as Mycobacterium bovis or Mycobacterium
africanum) occasionally can cause a similar disease.
Tuberculosis has been a serious public health problem for a long time. In the
1800s, the disease was responsible for more than 30% of all deaths in Europe. With
the advent of antituberculosis antibiotics in the 1940s, the battle against TB seemed to
be won. Unfortunately – because of factors such as inadequate public health
resources, reduced immune response due to AIDS, the development of drug
resistance, and extreme poverty in many parts of the world – tuberculosis continues to
be a deadly disease. Worldwide, there are 8 million new cases of symptomatic
tuberculosis and 3 million deaths from the disease every year. It is believed that one
third of all the people in the world have a dormant (latent) tuberculosis infection,
although only about 5 to 10% progress to active tuberculosis disease.
In the United States and other developed countries, tuberculosis has been
more common among older people, whereas it is a disease of young adults in poorer
countries. Of the cases reported in the United States in 2000, 22% involved people
older than 65. There were more cases among older people because they were more
likely to have acquired the infection in an era when tuberculosis was more common.
As the body’s immune system weakens with age, dormant bacteria become
reactivated. Fortunately, the incidence of tuberculosis among older people is
declining because each generation entering old age has a lower rate of latent
infection.
Because tuberculosis has existed in Europe longer than anywhere else, people
in European descent are somewhat more resistant to the disease than people whose
ancestors lived in parts of the world where tuberculosis was introduced more recently,
thus, in the United States; tuberculosis is more common among blacks, Native
Americans, certain other minorities, and immigrants from non-European countries.
Additionally, people in these groups tend to be poorer, live in crowded conditions,
and have less access to medical care – all conditions that are conductive to the spread
of tuberculosis.
 PATIENT’S DEMOGRAPHIC DATA

Patient’s Initial: RJP

Address: #17 Road 7 North Daanghari Bicutan, Taguig

Age: 22 Birth date: October 12, 1987 Birthplace: Manila

Nationality: Filipino Religion: Roman Catholic

Civil Status: Single # of Children: N/A

Educational Attainment: Highschool graduate Occupation: Unemployed

ADMISSION DATA:

Chief of Complaint: Difficulty of breathing, Hemoptysis

Date Admission: June 23, 2010

Ward: Male Room # 318

Probable Diagnosis: PTB II t/c CAP

Final Diagnosis: PTB II

Attending Physician: Dr. Edgar Rabe

III. NURSING HISTORY

A. History of Present Illness

1 month prior to confinement, the patient had an on and off nonproductive

cough and is experiencing occasional vomiting. He has a history of tuberculosis and
recovered from the disease, so he hasn’t given much thought to what he was feeling
and only take cough syrup whenever he feels uncomfortable. The patient underwent
several chest X-rays and other laboratories, and results considered that there is CAP
vs. PTB. 3 weeks prior to confinement, his doctor advised him to take Fixcom 4 for
one month, but on the morning of the day of his confinement he suffered from a fever
of 37.9o C and hemoptysis which prompted him to go to the hospital.

B. Past Medical History

The patient has no illness apart from having PTB for a year but recovered
from it before getting hospitalized again.

C. Family History

His parents and siblings are all healthy. Apart from the patient which
occasionally gets sick because of his weak immunity.

D. Social History

RJP according to himself is a friendly person and is always outside their house
along with his “barkada’s” often walking around their town. He also has a history of
drinking alcohol and smoking for six years. The place where they live is a
compressed area with houses that have minimal distance to each other.

F. Occupational History

RJP is currently unemployed but from time to time he gets his so called
“sideline” by helping his mother sell barbecue on their barangay.

G. Developmental History

RJP grew up with no problems regarding his physical and mental

development. He also availed all the possible immunizations like BCG, HPV, TT,
DPT and OPV when he was an infant.
IV. PHYSICAL ASSESSMENT (HEAD TO TOE)

BODY PART TECHNIQUE FINDINGS REMARKS

Head

Skull Inspection Symmetrically Normal

round, proportional
to body size
Palpation no tenderness noted Normal
Lighter in color Normal
Scalp Inspection than the
complexion, moist
and oily, no scars
noted, no lesions
Palpation No tenderness nor Normal
masses
Black, evenly Normal
Hair Inspection distributed and
covers the whole
scalp
Equally round and Normal
Face Inspection smooth, dry
Palpation No tenderness Normal
noted
Eyelids Inspection Eyelid skin intact Normal

Eyebrows Inspection eyebrow hair Normal

evenly distributed
Eyelashes Inspection hair intact Normal

Palpebral fissure Inspection measures about Normal

10mm vertically
and 30 mm
horizontally
Conjunctiva Inspection Pinkish in color Normal

Sclera Inspection White and clear Normal

Iris Inspection proportional to the Normal

size of the eye,
round and
symmetrical
Soft Palate Inspection Pinkish, smooth Normal
and moist
Hard Palate Inspection Slightly pinkish Normal

Tonsils Inspection At the center, Normal

symmetrical, and
freely moveable
Voice Low-tone and clear Normal
in speech
Neck Inspection proportional to the Normal
size of the body &
head, symmetrical
and straight
Palpation No palpable lumps, Normal
masses or areas of
tenderness
Inspection Chest contour is Abnormal
Anterior Thorax asymmetrical,
exertional
Palpation no masses, no Normal
tender areas
Percussion Dull sound Normal
Auscultation rales Abnormal

Inspection Chest contour is Abnormal

Posterior Thorax asymmetrical,
exertional
Palpation no masses, no Normal
tender areas
Percussion Dull sound Normal
Auscultation rales Abnormal

PMI Auscultation Palpable on the 5th Normal

ICS
Breast Inspection Symmetrical, dark Normal
pink nipples
Palpation No cracks and Normal
discharges
Inspection Abdominal skin is Normal
Abdomen unblemished
Auscultation Bowel sounds Normal
present
Percussion Tympanytic Normal
Palpation Soft with no Normal
palpable mass and
tenderness

Upper Extremities
Arms Inspection can be moved in Normal
different range of
motion with
relative ease.
Palpation No palpable mass Normal
and tenderness
Palms Inspection Pinkish Normal
Palpation Warm, soft, and Normal
elastic
Fingers Inspection 5 fingers in both Normal
hands

Lower Extremities
Legs Inspection can be moved in Normal
different range of
motion with
relative ease.
 Palpation No palpable mass Normal
and tenderness
Dorsal Surface Inspection Smooth with pink Normal
nail beds
Sole Inspection Smooth with Normal
creases
Toes Inspection Can be moved in Normal
different range of
motion, 5 fingers
on both feet
Palpation No palpable mass Normal
and tenderness
noted
Genitalia Inspection Penis is Normal
circumcised

V. PATTERNS OF FUNCTIONING
BEFORE DURING
AREAS HOSPITALIZATION HOSPITALIZATION

A. Respiration

B. Circulation

C. Food and Fluid

Intake

D. Elimination

E. Rest and Sleep

F. Pain and
Discomfort

G. Personal Hygiene

H. Exercise

I. Coping with Stress

J. Religious Life

K. Sensory and
Communication
 Skills

L. Developmental
Task

M. Health Supervision

VI. LABORATORY RESULT

PROCEDURE REFERENCE FINDINGS REMARKS

VALUE
Chest X-ray Hazy nodular Consider miliary
densities are noted TB, pneumonia
in both lungs. A with consolidation
homogenous right upper lobe,
density with minimal pleural
cavitary image is effusion right.
noted in the right
upper lobe. The
right CNS is
blunted.
HgB M – 130 - 180 128 Decreased
HcT M – 0.42 – 0.54 0.43 Normal
RBC M – 4.6 – 6.2 5.7 Normal
WBC M – 5.0 12.1 Increased
Segmenters M – 0.55 – 0.65 0.85 Increased
Lymphocytes M – 0.15 – 0.35 0.11 Decreased

VII. ANATOMY AND PHYSIOLOGY OF INVOLVED ORGAN (BRIEF ONLY)

VIII. PATHOPHYSIOLOGY OF DISEASE PROCESS

IX. DRUG STUDY

Generi Bran Classificati Dosag Mechanis Indicatio Contraindicati Side Nursing

c d on e m of ns on Effect Implicatio
name name Action s n

XI. Analysis of Disease Process

(from Book) (Actual Patient)
Signs and Symptoms Signs and Symptoms
Causes Causes
 XII. IDENTFIED NURSING PROBLEM

Date identified Nursing Diagnosis Date Resolved

X. NURSING CARE PLAN

Cues Nursing Nursing Goal/Objectiv Nursing Rationale Evaluatio
Subjectiv Objectiv Diagnosi Backgroun e Interventio of the n
e e s d n Nursing
Interventio
n

XI. DISCHARGE PLANNING (interdependent)

Medication
Continue taking the AntiTB drugs. The intensive phase is for 2 months and the
maintenance phase is for 4 months. Medicines are readily available at the health
center.

Exercise
Practice deep breathing exercise and coughing exercises. Resume previous activities.
Prevent extraneous work. Have a regular physical exercise like brisk walking for 30
minutes daily. For financial insufficiency, there are government drug stores available.

Treatment
Follow faithfully the regimen for tuberculosis, especially the medications. Have a
regular sputum test, as ordered by the doctor.

Health Teaching
You should practice hand washing regularly. Always cover the mouth and the nose
when exposed to person who coughs or sneezes. You should not spit anywhere,
instead spit in a single container to prevent transfer of M. Tuberculosis.

Office visit/ outpatient

Always have a regular check up at your nearest health center, at least once a week to
monitor the progress of the treatment. The client should report immediately to the
physician if there is difficulty of breathing, there is productive cough more than 5
days and there is chest pain and experiencing fatigue.

Diet
The diet should be high caloric. Always drink a lot of water. Also eat fruit s and
vegetables. Don’t escape meals. If there are any food supplements available, consult
it with the doctor. Eat vitamin C rich food to strengthen immune systems.

S igns and symptoms

XII. BIBLIOGRAPHY