Mindanao State University Iligan Institute of Technology COLLEGE OF NURSING

Pulmonary Tuberculosis with Severe Malnutrition

A case presentation

DEMOGRAPHIC DATA Name: Patient D Address: P-3 Canaway, Iligan City Age: 14 years old Sex: Male Status: Child Religion: Roman Catholic

HEALTH HISTORY
Chief complaint/s:Difficulty of Breathing complaint/s: Impression/Admitting Diagnosis:(1) T/C PTB, active (2) Malnutrition, Severe Diagnosis: History of Present Illness: (location, onset, character, intensity, duration, Illness: aggravation and alleviation, associated symptoms, previous treatment and result, social and vocational responsibilities). responsibilities). 7 years PTA, patient had been experiencing productive cough every now and then which lasts for a month and intermittent low to moderate grade fever. fever. Patient had not sought consultation and no medications were taken. One year taken. PTA, patient started to have night sweats and is gradually losing weight in spite of proper diet. Patient sought consultation and was prescribed diet. Salbutamol and Cefaclor which caused short-term relief of cough. One month shortcough. PTA, patient suffered body weakness, easy fatigability, somnolence, and shortness of breath which caused absences from school. Patient stayed at school. home and slept most of the time. Morning PTA, patient experienced DOB time. which prompted admission. admission.

History of Past illness:(previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illness, allergies, medication, habits, birth and development history, nutrition for pedia). One year PTA, patient sought consultation at GTLMH due to chronic cough and was prescribed with Salbutamol and Cefaclor to be taken for 6 mos. Patient s immunization status was completed when he was 1 y.o. Patient was born full term with birth weight of 7 lbs

Heath Habits

1. Tobacco 1. Alcohol 1. OTC drugs/nonprescription drugs y Cefaclor y Salbutamol

Frequen Amount Period cy N/A N/A N/A N/A N/A N/A PRN When difficulty of breathi ng is felt.

Family History with Genogram

Cancer ___ Diabetes ___ Asthma  Hypertension ___ Cardiac disease ___ Mental disorders ___ Others ___

Patient s Perception of Present Illness: Kapoy. Sakit. as verbalized by the patient. Hospital Environment: Patient nodded when asked if the hospital environment Summary of Interaction The patient is feeling drowsy and weak and cannot hear well. He does not respond to most questions and it was his mother who provided most of the information. The SO though was responsive and cooperative.

Vital Signs Temperature: __________ Pulse: __________ Respiration: __________ Blood Pressure:__________

Height: __________ Weight:__________ Observation: _________________________________________

1. General Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour. Facial features are Symmetrical and palpebral fissure equal in size, nasolabial folds are symmetrical. Hair is Evenly distributed with no patches of hair loss; thick hair. Silky, smooth and resilient. Pinkish conjunctiva with presence of capillaries. Pupils are 3mm in diameter; 2. HEENT equally round and reactive to light and accommodation. Ears are symmetrical. Nose is symmetrical and straight. Nasal septum intact and in midline. Lips are Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse lips. Tongue is Central position; pink color; smooth tongue base with prominent veins. Gag reflex is present. Skin is warm to touch. Afebrile at . pt has good skin turgor and is not 3. Integumentary diaphoretic. Skin has uniform light brownish color. Hair distribution is even. Patient has Difficulty of breathing. Has O2 inhalation at . Has crackles sounds on the upper thorax & lower thorax. Has a anteroposterior to transverse 4. Respiratory diameter ratio of 1:2, elliptical in shape and symmetrical chest. Has crackles heard on the anterior and middle part of right and left lungs. Diminished lung sound on the posterior right lung.

Has full and rapid pulsation. bpm/minute. Sounds on the aortic and pulmonic areas; has a lub sound on the apex and dub sounds on the tricuspid area. 5. Cardiovascular Blood pressure is mm Hg. PMI is at 5th ICS at midclavicular line. Has round abdomen. No enlargement of the spleen and liver seen. Has a symmetrical abdominal contour. Has no 6. Digestive blood vessels visible. Has normal bowel sounds. Abdominal movements noted when inhaling. 7. Excretory

Extremities are Proportionate to the body; even in both sides. Has no fasciculation and tremors. Weak muscle tone. 8. Musculoskelet No edema, no pain when moved. Weak muscle strength. al No swelling, no warmth, no redness, no pain, no crepitus of joints. Capable of ROM and has muscle strength of +4 in all extremities.

9. Nervous

Patient is Alert, Oriented to person, time and place. Coherent. Able to identify the scent of the alcohol. (+) Facial symmetry. Present gag reflex, able to swallow and able to idebtify the taste of the food. Can shrug shoulders against resistance and can turn the head fro right to right. Able to protrude the tongue and move it side to side.

10.Endocrine

11.Reproductiv Patient is male. Circumcised. Has swollen and e tender scrotum.

SUMMARY OF IVF #1 D5LR 1L #2 D5NM +1amp Moriamin S2 (ANST) #5 D5NM 1L SUMMARY OF MEDICATION
Medication Salbutamol 2mg tab TID Salbutamol nebulizer 20 u q 4hrs Clarithromycin 250/5mL BID Azithromycin 500g tab OD Furosemide 20 mg IVTT q 12H Hydrocortisone 85 mg IVTT q 6H Cloxacillin 500 mg IVTT q 6 Streptomycin 350 mg IM q other day Rifampicin 200mg/5mL per breakfast Tramadol 250 q IVTT now then q 12 H Ketorolac 30mg IVTT q 6H prn Cefepime 1g IVTT q 12 H ANST (-) Zinc 20mg tab OD Paracetamol 250g /5mL PO every 4hrs for fever Remarks Given and tolerated Given and tolerated Given Given and tolerated Given Given Given and tolerated Given Given and tolerated Given and tolerated Given and tolerated Given and tolerated Given and tolerated Given Nursing Intervention

REFER TO DRUG STUDY

LABORATORY AND DIAGNOSTIC PROCEDURE

PROCEDURE INDICATION Find lung conditions such as pneumonia, lung cancer, chronic obstructive pulmonary disease (COPD), collapsed lung (pneumothorax ), or cystic fibrosis and monitor treatment for these conditions. See if a tube, catheter, or other medical device has been placed in the proper position in an airway, the heart, blood vessels of the chest, or the stomach. NORMAL VALUE RESULT IMPLICATIONS NURSING RESPONSIBILITIES

Chest X-ray Radiologic Exam

The poorly taken PTB, F.A. both lungs, chest exam active partial 1. Instruct patient to reveals heart, pulmonary atelectasis, remove all forms of jewelries aorta, & trachea Left. Slight pulmonary are deviated to emphysema, Right. 2. Pregnant women, particularly those in the first or second the left. Chronic Pneumo-hydrothorax, Left. trimester, should not have chest parenchymal x rays unless absolutely infiltrates with necessary. If the exam is ordered, huge cavity at the women who are, or could Right & partial possibly be, pregnant must wear collapse of the a protective lead apron, with the Left lung. full coverage adjusted for the Pneumodirection of the x-ray beam. hydrothorax at the Because the procedure involves Left lung field. radiation, care should always be Right hemitaken to avoid overexposure, diaphragm particularly for children. flattened & However, the amount of radiation blunted sinuses; from one chest x ray procedure is obliterated & minimal. elevated. Bony thorax not unusual.

ANATOMY OF RESPIRATORY SYSTEM

Respiration is the process by which living organisms take in oxygen and release carbon dioxide. The human respiratory system, working in conjunction with the circulatory system, supplies oxygen to the body's cells, removing carbon dioxide in the process. The exchange of these gases occurs across cell membranes both in the lungs (external respiration) and in the body tissues (internal respiration). Breathing, or pulmonary ventilation, describes the process of inhaling and exhaling air. The human respiratory system consists of the respiratory tract and the lungs.

The lungs The lungs are two cone-shaped organs located in the chest or thoracic cavity. The heart separates them. The right lung is somewhat larger than the left. A sac, called the pleura, surrounds and protects the lungs. One layer of the pleura attaches to the wall of the thoracic cavity and the other layer encloses the lungs. A fluid between the two membrane layers reduces friction and allows smooth movement of the lungs during breathing. The lungs are divided into lobes, each one of which receives its own bronchial branch. Inside the lungs, the bronchi subdivide repeatedly into smaller airways. Eventually they form tiny branches called terminal bronchioles. Terminal bronchioles have a diameter of about 0.02 inch (0.5 millimeter). This branching network within the lungs is called the bronchial tree. The terminal bronchioles enter cup-shaped air sacs called alveoli (pronounced al-VEE-o-leye). The average person has a total of about 700 million gasfilled alveoli in the lungs. These provide an enormous surface area for gas exchange. A network of capillaries (tiny blood vessels) surrounds each alveoli. As blood passes through these vessels and air fills the alveoli, the exchange of gases takes place: oxygen passes from the alveoli into the capillaries while carbon dioxide passes from the capillaries into the alveoli.

PATHOPHYSIOLOGY
High Risk Factors: 1Old Age 2Infants 3Children 4Low Socio-Economic Status 5Drug Addicts 6HIV Positive 7Severely Malnourished 8Health Care Workers Etiological Agent: Environmental Factors: Mycobacterium tuberculosis Mode of Transmission: Droplets Nuclei 1High-Risk Communities 2Low income Communities 3Health Care Facilities

Mode of Entry: Respiratory Tract Lungs (Alveoli)

Diagnostic Procedures: 1Medical History 2Physical Examination 3Chest Radiography 4Mantoux tuberculin skin test 5Microbiological smears and cultures

Signs and Symptoms 1Fever 10. Anxiety 2Fatigue 11. Low Self-Esteem 3Anorexia 12. Elevated WBC 4Hemoptysis 5Productive Cough 6Night Sweats 7Pallor 8Chest Pain 9Dyspnea

Treatment

Death

1Anti-TB Drugs 2Surgery

Cure

DRUG STUDY PARACETAMOL 250 g/5mL PO q 4 hours parents to consult prescriber before giving drug to children younger than age 2. 2. Advise patients or parents that drug is only for shortterm use. 3. Advise patient or caregiver that many OTC products contain paracetamol. 4. Warn patient that high doses or unsupervised long-term use can cause liver damage. 1. Tell Clarithromycin 250/5ml BID 1. Culture infection before therapy 2. Monitor px for anticipated response 3. Administer w/out regard to meals; administer with food if GI upset occur

Furosemide 20 mg IVTT Q 12 x 4 doses with BP precaution 1. Administer with food or milk to prevent GI upset 2. Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP responds 3. Give early in the day so that increased urination will not disturb sleep 4. Avoid IV use if oral use is at all possible 5. Do not mix parenteral sol n with higly acidic solutions with pH below 3.5 6. Discard diluted sol n after 24 hours 7. Measure and record weight to monitor fluid changes 8. Arrange for potassium-rich diet or supplemental potassium as needed

Hydrocortisone 85 mg IVTT q 6 1. Give daily before 9am to mimic normal peak diurnal corticosteroid levels and minimize HPA suppression 2. Space multiple doses evenly throughout the day 3. Use minimal doses for minimal duration to minimize S/E 4. Taper doses when discontinuing highdose or long-term therapy 5. Arrange for inc dosage when px is subject to unusual stress 6. Ensure that adequate amount of Ca+ is taken if prolonged administration of steroids 7. Do not give live virus vaccines with immunosuppressive doses of the drug 8. Provide antacids between meals to help avoid peptic ulcer

Isoniazid 200g/tsp 5ml OD x 6mos 1. Give on an empty stomach, 1hr before or 2hrs after meals, may be given with food if GI upset occurs 2. Give in a single daily dose. Reserve parenteral dose for px unable to take oral medications 3. Decrease foods containing tyramine or histamine in px s diet 4. Consult with physician and arrange for daily pyridoxine in diabetic, alcoholic, or malnourished px s 5. Discontinue drug, and consult with physician if sings of hypersensitivity occurs 6. Monitor liver enzymes monthly; risk for serious fatal hepatitis

Pyrazinamide 250g/tsp 5ml TID x 2mos 1. Administer only in conjunction with other antituberculotic 2. Administer once a day 3. Arrange for ff-up of LFTs (AST, ALT) prior to and every 2-4 weeks during therapy 4. Discontinue drug if liver 5. Damage or hyperuricemia in conjunction with acute gouty arthritis occurs

SALBUTAMOL 2mg tab 1. Assess lung sounds, PR and BP before drug administration and during peak of medication. 2. Observe fore paradoxical spasm and withhold medication and notify physician if condition occurs. 3. Administer PO medications with meals to minimize gastric irritation. 4. Extended-release tablet should be swallowed-whole. It should not be crushed or chewed. 5. If administering medication through inhalation, allow at least 1 minute between inhalation of aerosolmedication. 6. Advise the patient to rinse mouth with water after each inhalation to minimize dry mouth. 7. Inform the patient that Albuterol may cause an unusual or bad taste.

AZITHROMYCIN 500g tab, OD 1. Culture site of infection before therapy. 2. Administer on an empty stomach--1 hr before or 2 3 hr after meals. Food affects the absorption of this drug.

ZINC 20mg 1 tab, PO, OD 1. Check levels of trace elements in patients who have received TPN for 2 months or longer. Give supplement, if ordered. Report low levels of thee elements. 2. Normal level is 88 to 112 mcg/dl zinc. 3.Solutions of trace elements are compounded by pharmacist for addition to TPN solutions according to various formulas. 4. Explain need for zinc administration to patient and family. 5. Tell patient to report signs of hypersensitivity promptly. 6. Inform patient and family that trace elements are normally received from dietary intake that, when patient begins eating well, supplements won t be needed.

CLOXACILLIN 500mg, IVTT, q 6 1. Probenecid (Benemid) increases the effects of cloxacillin. These drugs may be used together for this purpose; however, be sure your doctor is aware if you are taking probenecid. You may need a lower dose of cloxacillin. 2. Cloxacillin is best absorbed when administered on an empty stomach, preferably 1 to 2 hours before meals. 3. Frequent blood level determinations and dosage adjustments when necessary are advisable in these patients. 4. Take all of the cloxacillin that has been prescribed for the patient even if he/she begins to feel better.

RIFAMPICIN 200mg/5ml per breakfast x 6mos 1. Teach client to take drug in a single daily dose. Take on an empty stomach, 1 hr before or 2 hrs after meals. 2. Inform client to take this drug regularly; avoid missing any doses; do not discontinue this drug without consulting thehealth care provider. 3. Tell client to have periodic medical checkups, including eye examinations and blood test, to evaluate the drug effects. 4. Inform client that he may experience the drug s side effects (especially the red colored secretion) 5. Instruct client to see his physician if he experience fever, chills, muscle and bone pain, excessive tiredness or weakness, loss of appetite, N/V, yellowing of eyes/skin, unusual bleeding or bruising, skin rash or itching. 6. Instruct client to remove contact lenses as they may discolor

LEFEPIME 1g IVTT q 12 ANST (-) 1. Administer IV over approximately 30 mins. 2. Dilute vials with 50-100cc of compatible IV fluid. 3. Parenteral drugs should be inspected visually for particulate matter before administration. 4. If IM, inject IM prep deeply into large muscle groups. 5. Do not share this medication with others.

TRAMADOL 250mg ivtt now then q wehrs x 3 doses Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. Assess BP & RR before and periodically during administration. Respiratory depression has not occurred with recommended doses. Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects. Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously received opioids for more than 1 wk; may cause opioid withdrawal symptoms. Monitor patient for seizures. May occur within recommended dose range. Risk increased with higher doses and inpatients taking antidepressants (SSRIs, tricyclics, or Mao inhibitors), opioid analgesics, or other durgs that decrese the seizure threshold. Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse some, but not all, of the symptoms of overdose. Treatment should be symptomatic and supportive. Maintain adequate respiratory exchange. Encourage patient to cough and breathe deeply every 2 hr to prevent atelactasis and pneumonia.

KETOROLAC 30mg IVTT now then q 6hrs prn for pain 1. Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria. 2. Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. 3. Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy. 4. Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. 5. Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur. 6. Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another.

MEDICAL MANAGEMENTS IDEAL

2 factors making drug therapy less than ideal - Drug toxicity. - Tendency of tubercle bacilli to develop drug resistance. Combined therapy ( 6 or more months) - Decreases drug resistance. - Increases tuberculostatic action of the drugs - Lessens toxic drug reactions - Drugs Isoniazide (INH), Rifampin (RMP), Pyrazinamide(PZA), Ethambutol(EMB), Streptomycin(SM). Screening test :Tuberculin test (Mantoux test) 0.1 ml of PPD is injected intradermally into the dorsal aspect of the forearm. Test read within 48-72 hours. Assess for erythema and induration. Diameter of induration (> 10mm)determines infection, read in millimeteres. Positive reaction indicates client : Has developed an immune response to bacillus. Does not indicate active TB or current infection. Body tissues are sensitive to tuberculin. Needs further evaluation.

ACTUAL
12/12/2012 y y y y y y y 1. 2. 3. y y y y Pls admit at pedia isolation Secure content to care High CHON high calorie diet TPR q 4hours IVF: D5LR 1L @ 15gtts/min LABS CBC, platelet =CXR-PAR U/A MEDS: Paracetamol250/5ml; 5ml q 4hours Cefuroxime 500mg IVTT q 8 hours ANST Salbutamol Nebulizate 1 nebule q 6hours + 2 units NSS Monitor I&O q shift O2 inhalate @ 2L/min Moderate high back rest IVF TF: D5NM @ 15gtts/min

MEDICAL MANAGEMENTS IDEAL ACTUAL 12-14-11 y CXR film or official reading y For anti TB meds once proven with CXR y Continue meds y IVTTF D5NM @SR y For referral to DOTS y Try referral to dietary TCQ = 2600cal/kg CHO=1200 cal CHON = 360 cal FATS = 840 cal

Diagnostic tests 3 consecutive early morning sputum sent for (AFB)acid-fast bacillus smear and culture. Chest Xray Fiberoptic bronchoscopy, gastric lavage, gastric aspiration.

MEDICAL MANAGEMENTS IDEAL ACTUAL 2400 cal/ kg Divided into 3 meals 3 snacks INH 200g/kg 5.00 OD x 6months Rifampicin 200g/kg 5.00 for breakfast x 6months Pyrazinamide 250 g/kg 5.0 TID x 2months

y y y

12-15-11 y y Continue meds TF: D5NM + 1amp @17 gtts/min

MEDICAL MANAGEMENTS IDEAL

12/18/11 y y Pls refer xray film to Sangge re: Pneumo hydrothorax Continue meds

ACTUAL

12/19/11 y y y Continue meds Platelet count FT: D5NM @ 17gtts/ min

12/20/11 y y y y Still for CTT insertion Streptomycin 350 mg IM q after day ANST For chest physiotherapy Cefepime 1 g IVTTq 12hours ANST

MEDICAL MANAGEMENTS IDEAL

y y y

ACTUAL
Cefuroxime once Cefepime is started Continue other meds IVFTF: D5NM @ 17gtss/min

12/21/11 y y Follow up CTT materials Follow up streptomycin

12/26/11 y y y y y Still on CTT Repeat CXR Monitor vital signs q 30 mins, x 2hours q hourly x 2hours until stable, chart please Ketorolac 30 mg IVTT then q 6hours prn for pain For deep breathing exercise daily

MEDICAL MANAGEMENTS MEDICAL MANAGEMENTS IDEAL 12/27/11 y y y y Continue meds Follow up repeat CXR result D5LR Repeat CBC platelet ACTUAL

12/28/11 y y Pls. facilitate streptomycin c/o DOTS Continue deep breathing exercise

1/1/12 y y y Refer to surgery for possible CTT removal Continue meds IVF to IV D5NM

MEDICAL MANAGEMENTS MEDICAL MANAGEMENTS IDEAL 1/3/12 y y Follow up CTT removal For CTT repositioning and reinsertion ACTUAL

1/4/12 y y y Post chest tube removal CXR AP now Tramadol 25g IM now then q 12hours x 3 doses

1/5/12 y Pls give Cefepime regularly refer if not given regularly refer to DSWD for medication

MEDICAL MANAGEMENTS MEDICAL MANAGEMENTS IDEAL

1/9/12 y y y y y y Follow up CXR taken Clarithromycin 250/5ml 2-5ml BID c/o DSWD May use Azithromycin 500mg tab tab OD if clarithromycin is not available Please nebulized Salbu + Ipra Salbutamol 2mg tab, 1 tab TID Refer to DSWD

ACTUAL

1/10/12 y y May use available Clarithromycin 125 mg/5ml; 5ml FT D5NM

1/11/12 y y y y y y y MGH Clarithromycin 125mg/5ml; 5.0ml 2x of ___ provide for 10 day course c/o DSWD Salbutamol tab; tab 3x g Contain bacteria therapy 5pm: Hold MGH Continue 10 meds

MEDICAL MANAGEMENTS MEDICAL MANAGEMENTS IDEAL

1/12/12 y y Facilitate O2 tank at home Continue meds

ACTUAL

1/14/12 y y y y y Continue meds IVFTF D5NM Please win off from O2 O2 inhalation prn only Repeat CXR-AP tomorrow

1/15/12 y y y Refer to surgery dept (scrotal swelling) Furosemide 20mg IVTT q 1hour x 4 doses with BP precaution Follow D5IMB at SR

SURGICAL MANAGEMENTS IDEAL The surgical treatment of tuberculosis is confined to the management of multi-drug resistant TB. Lobectomy. Lobectomy is performed normally during a thoracotomy. An incision is made in the lateral aspect of the chest, and ribs may be removed or spread apart to allow the surgeon access to the lung. Pre op Interventions: 1. Improve air clearance. 2. Educate the patient. 3. Relieve anxiety. ACTUAL Chest Tube Thoracostomy Date: December 26, 2011 Pre op DX: Pleural Effusion, Left Pre op Interventions: 1. Assess the patient for pneumothorax, hemothorax, and the occurrence of respiratory distress. 2. Obtain patient s chest xray, ultrasound or fluoroscopic localization. 3. Assemble the drainage system. 4. Reassure the patient and explain the steps to be carried out during the procedure.

SURGICAL MANAGEMENTS IDEAL Post op Interventions: 1. Vital signs are checked frequently. 2. Oxygen is administered via cannula, mask or ventilator as long as necessary. 3. Fluids are given at a low hourly rate to prevent fluid overload and pulmonary edema. 4. Careful positioning of the patient is important, bed may elevated 30 to 45 degrees. 5. Turning from back to operated side, but not completely to the un-operated side to prevent mediastinal shifting. 6. Pain medications are administered. Encourage splinting of the incision site. 7. Breathing exercises and spirometry are resumed to facilitate lung ventilation. ACTUAL 1. Tell the patient he may feel a needle prick and slight pressure during the administration of anesthesia. 2. Get the patient ready by positioning him for an intercostal nerve block or as preferred by the physician Intra op Interventions: 1. Skin preparation is done, anesthetized thereafter. 2. An exploratory needle is inserted. 3. IntraCath catheter is inserted through the needle into the pleural space. The needle is removed and the catheter is pushed several centimetres into the pleural space.

SURGICAL MANAGEMENTS IDEAL Dressings are assess for fresh bleeding. Assess for signs of complications such as cyanosis, dyspnea and acute chest pain. Pneumonectomy. A surgical procedure to remove a lung. Pre op Interventions: 1. Improve air clearance. 2. Educate the patient. 3. Relieve anxiety. 4. Post op Interventions: 5. Vital signs are checked frequently. 6. Oxygen is administered via cannula, mask or ventilator as long as necessary. 7. Fluids are given at a low hourly rate to prevent fluid overload and pulmonary edema. ACTUAL 4. The catheter is taped into the skin. 5. The catheter is attached to a connecting tube to the drainage system. Post op Interventions: 1. Observe the drainage for blood or air. 2. There should be a free fluctuation in the tube on respiration. 3. Secure a follow-up chest x-ray. 4. Look for bleeding, infection, leakage of air and fluid around the tube.

SURGICAL MANAGEMENTS IDEAL Careful positioning of the patient is important, bed may elevated 30 to 45 degrees. Turning from back to operated side, but not completely to the un-operated side to prevent mediastinal shifting. Pain medications are administered. Encourage splinting of the incision site. Breathing exercises and spirometry are resumed to facilitate lung ventilation. Dressings are assess for fresh bleeding. Assess for signs of complications such as cyanosis, dyspnea and acute chest pain. ACTUAL

NURSING MANAGEMENTS IDEAL

Risk for infection 1. Monitor sputum for changes indicating infection 2. Monitor vital signs 3. Teach patient and family the purpose and techniques for infection control such as hand washing, patient covering mouth when coughs, maintaining isolation if necessary 4. Teach patient the purpose, importance and how to take medications as prescribed consistently over the long term therapy. Deficient knowledge 1. Determine who will be the learner, patient or family 2. Assess ability to learn 3. Identify any existing misconceptions about the material to learn 4. Assist the learner to integrate the information into daily life 5. Give clear thorough explanations and demonstrations

ACTUAL Imbalanced Nutrition 1. Document pt s nutritional status on admission, noting skin turgor, current weight and degree of weight loss, integrity of oral mucosa, ability/inability to swallow, presence of bowel tones, history of nausea/vomiting or diarrhea. 2. Monitor I and O. 3. Encourage and provide for frequent rest periods. 4. Provide oral care before and after respiratory treatments. 5. Encourage small, frequent meals with foods high in protein and carbohydrates. 6. Encourage SO to bring foods from home to share meals with patient unless contraindicated.

NURSING MANAGEMENTS IDEAL Noncompliance 1. Determine if there has been past noncompliance and the reasons 2. Ask to see prescription drugs periodically and count the remaining pills 3. If economics are a reason for noncompliance, explore community resources 4. Increase the amount of supervision provided, follow up visits, phone calls, etc. ACTUAL Pain 1. Monitor vital signs. 2. Assess degree and characteristics of pain. 3. Maintain bed rest during acute phase. 4. Maintain upright position. 5. Administer medications, as prescribed. 6. Provide comfort measures (back rubs) 7. Encourage relaxation/breathing exercises. 8. Offer frequent oral hygiene. 9. Instruct and assist patient in chest splinting techniques during coughing episodes

NURSING MANAGEMENTS
IDEAL Ineffective therapeutic regimen management 1. Assess prior efforts to follow regimen 2. Assess patient's perceptions of their health problem 3. Assess other factors that may affect success in a negative way 4. Inform patient of the benefits of conforming with the regimen 5. Concentrate on the behaviors that will make the most difference to the therapeutic effect 6. Include family, support system in teachings and explanations 7. Instruct patient on the importance of ordering refills of medications several days ahead of running out. ACTUAL Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs 1. Assess client s level of understanding. 2. Discuss ways on how to prevent transmission of the disease like covering mouth when coughing, sneezing and use of disposable tissues to contain respiratory secretions and proper handwashing. 3. Discuss simple pathophysiology of the disease process including signs and symptoms. 4. Discuss simple measures to avoid development of TB like avoiding exposure to infection and avoiding exposure to secondary smoke. 5. Regarding medications discuss the action , dose, timing, side effects of all medications. 6. Emphasize importance of long term therapy. 7. Discuss importance of good ventilation, well balanced nutritious diet , adequate rest and fluid intake of 3-4 l/day

NURSING MANAGEMENTS IDEAL Activity intolerance 1. Assess patient's level of mobility 2. Observe and document response to activity 3. Assess emotional response to change in physical status 4. Anticipate patient's needs to accommodate 5. Teach energy conservation techniques 6. Refer to community resources as needed ACTUAL Ineffective airway 1. Obtain vital signs of the patient. 2. Observe for respiratory rate and rhythm; presence of nasal flaring; and use of accessory muscles when breathing like the diaphragm and coastal muscles. 3. Perform the Blanch Test. 4. Auscultate the lungs to note any lung sounds. 5. Independent- Facilitative: 6. Perform Chest physiotherapy. 7. Suction secretion as needed. 8. Increase the amount of oral fluid intake as ordered by the doctor. 9. Administer bronchodilators as ordered. 10. Elevate the head of the bed. 11. Position the head in the midline of the body.

NURSING MANAGEMENTS IDEAL Ineffective airway clearance 1. Auscultate lungs for wheezing, decreased breath sounds, coarse sounds 2. Use universal precautions if secretions are purulent even before culture reports 3. Assess cough for effectiveness and productivity 4. Note sputum amount, color, odor, consistency 5. Send sputum specimens for culture as prescribed or prn 6. Institute appropriate isolation precautions if cultures are positive 7. Use humidity to help losen sputum 8. Administer medications, noting effectiveness and side effects 9. Teach effective deep breathing and coughing techniques ACTUAL Activity intolerance 1. -Determine cause of activity intolerance and determine whether cause is physical, psychological, or motivational. 2. Assess client daily for appropriateness of activity and bed rest orders. 3. Monitor and record client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. 4. Encourage client to gradually increase activity, allowing client to assist with positioning, transferring, and self-care as possible. 5. Obtain any necessary assistive devices or equipment needed before ambulating client (e.g., walkers, canes, crutches, portable oxygen).

NURSING CARE PLAN

Identified Problem: Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to lack of appetite because of prolonged cough and mucus
production as evidenced by decreased BMI.

CUES Subjective: Wala kaayu siyay gana mukaon tungod sa iyang ubo. Mga 6 ra ka hungit dayun dli na siya ganahan mukaon. As verbalized by SO. Objective: - The patient weight is 31.5 kilograms. - Poor muscle tone. - Appears weak. - Minimal subcutaneous fat.

OBJECTIVES INTERVENTIONS Short Term Objective: 1. Document pt s nutritional Within 8 hrs of duty, pt will be status on admission, noting able to initiate skin turgor, current weight behaviors/lifestyle changes to and degree of weight loss, regain and/or to maintain integrity of oral mucosa, appropriate weight. ability/inability to swallow, Long Term Objective: presence of bowel tones, After 3 days of duty, pt will be history of nausea/vomiting or able to demonstrate diarrhea. 2. Monitor I and O. progressive weight gain 3. Encourage and provide for toward goal and be free of frequent rest periods. signs of malnutrition. 4. Provide oral care before and after respiratory treatments. 5. Encourage small, frequent meals with foods high in protein and carbohydrates. 6. Encourage SO to bring foods from home to share meals with patient unless contraindicated.

1.

2.

3.

4.

5.

6.

RATIONALE Useful in identifying degree of problem and appropriate choice of interventions. Useful in measuring effectiveness of nutritional and fluid support. Helps conserve energy, especially when metabolic requirements are increased by fever. Reduces bad taste left from sputum or medications used for respiratory treatments that can stimulate the vomiting center. Maximizes nutrient intake without undue fatigue/energy expenditure from eating large meals, and reduces gastric irritation. Creates a more normal social environment during mealtime, and helps meet personal, cultural preferences.

EVALUATION STO: Outcome met. After 8 hrs of duty, pt and SO was able to initiate behaviors/lifestyle changes to regain and maintain appropriate weight such as having small, frequent meals with foods high in CHON and carbohydrates. LTO: Outcome partially met. After 3 days of duty, pt was able to demonstrate progressive weight gain toward goal and be free of signs of malnutrition as manifested by increased gradual increase in appetite and having small frequent meals during the day.

NURSING CARE PLAN Identified Problem: Pain Nursing Diagnosis: Pain r/t
CUES Subjective: Patient verbalized, Sakit ang akong dughan samot na kung mag-ubo ko. Objective: y P coughing y Q dull and burning y R nonradiating y S 9 out of 10 (most painful) when coughing, 8 of 10 when not coughing y T sustained and exacerbated by coughing y Vital signs: T: 36.6 HR: 114 RR: 32 OBJECTIVES Short Term Objective: Within 8 hours of duty, patient will report a decrease of pain from a scale of 9 to 3 out of 10. Long Term Objective: Within 3 days of duty, patient will be free from pain. INTERVENTIONS RATIONALE 1. Monitor vital signs. 1. Changes in HR of BP may 2. Assess degree and indicate that patient is experiencing pain. characteristics of pain. 2. Chest pain, usually present 3. Maintain bed rest during to some degree with acute phase. pneumonia. 4. Maintain upright position. 3. Reduces discomfort 5. Administer medications, as associated with muscle prescribed. contraction and movement. 6. Provide comfort measures 4. Encourages venous return to (back rubs) facilitate circulation. 7. Encourage 5. Relieves pain and decreases relaxation/breathing muscle tension. exercises. 8. Offer frequent oral hygiene. 6. Nonanalgesic measures 9. Instruct and assist patient in administered with a gentle touch can lessen discomfort chest splinting techniques and augment therapeutic during coughing episodes. effects of analgesics. 7. Lessen discomfort and augment therapeutic effects of analgesia. 8. Mouth breathing and oxygen therapy can irritate and dry out mucous membranes, potentiating general discomfort. 9. Aids in control of chest discomfort while enhancing effectiveness of cough effort. EVALUATION STO: Outcome met. Patient reported a decrease in pain from a scale of 9 to 3. LTO: Outcome not met. Patient still reports pain.

NURSING CARE PLAN Identified Problem: Nursing Diagnosis: Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs
CUES Subjective: Pt verbalized, Nah wa jud ko kabalo asa ni gikang sakita. Maayo pa kaha ko ani?. Objective: y Insufficient healthcare knowledge and practices. y Lack of knowledge regarding treatment regimens and prevention. y Lack of understanding regarding the disease process. OBJECTIVES Short Term Objective: Within 8 hours of duty, patient will be able to verbalize understanding of condition, disease process and treatment. Long Term Objective: Within 3 days of duty, patient will be able to initiate necessary lifestyle changes and participate in treatment regimen. INTERVENTIONS 1. Assess clients level of understanding. 2. Discuss ways on how to prevent transmission of the disease like covering mouth when coughing, sneezing and use of disposable tissues to contain respiratory secretions and proper handwashing. 3. Discuss simple pathophysiology of the disease process including signs and symptoms. 4. Discuss simple measures to avoid development of TB like avoiding exposure to infection and avoiding exposure to secondary smoke. 5. Regarding medications discuss the action , dose, timing, side effects of all medications. 6. Emphasize importance of long term therapy. 7. Discuss importance of good ventilation, well balanced nutritious diet , adequate rest and fluid intake of 3-4 l/day RATIONALE 1. Facilitates planning of preoperative teaching program and identifies content needs. 2. To know how to prevent spread of the disease 3. To understand the manifestations of signs and symptoms 4. To know how to prevent further development of PTB. 5. To prevent overdosage or any complications caused by medication errors 6. Abrupt stopping of the therapy may cause exacerbation of the disease or fatal complications. 7. To maintain good health. EVALUATION STO: Outcome met. Patient verbalized understanding of condition, disease process and treatment. LTO: Outcome met. Patient initiated necessary lifestyle changes and participate in treatment regimen.

NURSING CARE PLAN Identified Problem: Nursing Diagnosis: Ineffective airway clearance related to retained secretions in the respiratory tract secondary to bacterial infection as evidenced by crackles upon auscultation.
OBJECTIVES Short term: Subjective Cues: After 8 hours the - Patient verbalized, client will be able to Dugay nako giubo. Gahi mobilize his igawas ang plema. secretions through at Objective Cues: least 4 interventions done by the nurse - Presence of Long term: adventitious breath sound (Crackles) upon Within 3 days of nursing intervention, auscultation. -The patient is coughing the patient will be able to maintain without phlegm. patent airway through - Oriented the mobilization of - GCS E4V5M6 secretions as - T: 36.6 evidenced by HR: 114 productive cough. RR: 32 - Difficulty vocalizing - Has hallow eyes. - Bluish nail beds. ASSESSMENT NURSING INTERVENTION 1. Obtain vital signs of the patient. 2. Observe for respiratory rate and rhythm; presence of nasal flaring; and use of accessory muscles when breathing like the diaphragm and coastal muscles. 3. Perform the Blanch Test. 4. Auscultate the lungs to note any lung sounds. 5. Independent- Facilitative: 6. Perform Chest physiotherapy. 7. Suction secretion as needed. 8. Increase the amount of oral fluid intake as ordered by the doctor. 9. Administer bronchodilators as ordered. 10. Elevate the head of the bed. 11. Position the head in the midline of the body. 1. RATIONALE Health status is regulated through homeostatic mechanisms. A change in V/S might indicate health change. (Taylor et.al, FON 5th ed. Page 523) Nasal flaring and use of accessory muscles indicates increased effort is required for breathing. Blanch test reflects the adequacy of o2 circulation in the periphery. Crackles are intermittent sounds that occur when air moves through airway that contain fluids. (Taylor et.al, FON 5th ed. Tapping the chest can loosen the secretions. Suction removes secretions through the use of a strong pressure. EVALUATION Short term: Outcome partially met. After 8 hours of rendering care, patient was able to mobilize secretions as evidenced by expectorating phlegm three times with an estimate of 1 tablespoon. Long term: Outcome partially met. After 3 days of nursing intervention, the patient will be able to maintain patent airway through the mobilization of secretions as evidenced by productive cough but still in O2 inhalation.

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7. Current data indicates that fluid restriction may actually reduce blood volume and decrease cerebral circulation. The lack of volume causes the blood to be thick and sluggish and may decrease the mobilization of nutrition and toxins out of the circulation. Patient should be maintained in a euvolemic state rather than a fluid-restricted state. 8. They act on the respiratory tract, it opens narrowed airways. 9. For maximal lung expansion that will improve oxygen delivery. 10. Position changes allow free movement of the diaphragm and expansion of the chest wall

Identified Problem: Nursing Diagnosis: Activity intolerance related to inadequate oxygen supply as evidenced by easy fatigability
CUES Subjective: Pt verbalized weakness and fatigue, and cannot tolerate walking and standing. Objective: Abnormal heart rate in response to activity; RR-120 Exertional discomfort or dyspnea OBJECTIVES INTERVENTIONS Short Term Objective: 1. -Determine cause of Within 8 hrs of rendering activity intolerance and nursing care, pt will be able determine whether cause to use identified techniques is physical, psychological, to enhance activity or motivational. tolerance. 2. Assess client daily for Long Term Objective: appropriateness of activity After 3 days of duty, pt will and bed rest orders. be able to demonstrate a 3. Monitor and record client's decrease in physiological ability to tolerate activity: signs of intolerance. note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. 4. Encourage client to gradually increase activity, allowing client to assist with positioning, transferring, and self-care as possible. 5. Obtain any necessary assistive devices or equipment needed before ambulating client (e.g., walkers, canes, crutches, portable oxygen). 6. Work with client to set mutual goals that increase activity levels. 7. Allow for periods of rest before and after planned exertion periods RATIONALE - Determining the cause of a disease can help direct appropriate interventions. - Inappropriate prolonged bed rest orders may contribute to activity intolerance. -To ascertain client s level of activity that can be tolerated. - Decreases the perception of the client as incapable and frail. - Assistive devices can increase mobility by helping the client overcome limitations. - Assistive devices can increase mobility by helping the client overcome limitations. - Rest periods decrease oxygen consumption EVALUATION STO: Outcome met. After 8 hrs of duty, pt was able to use identified techniques to enhance activity level such as identifying activities that are tolerable to the patient, having adequate rest periods and use of assistance when ambulating. LTO: Outcome partially met. After 3 days of duty, pt was able to demonstrate a decrease in physiological signs of intolerance such as normalization of heart rate when attempting activity, no changes in skin color, and no use of accessory muscles before and after activity.

DISCHARGE PLAN Patients Name: Patient XXX

Nature: Home per request Px is ambulatory and has improved health condition

Medication

Inform SO to continue intake of prescribed drugs of the physician to the client in proper time and proper dosage. Inform the SO not to stop the intake of antibiotics prescribed before due date even the signs and symptoms does not appear. Inform the SO regarding the action, dose, timing, side effects of all medications. Instruct SO to report side-effects. Emphasize importance of long term therapy.

Exercise

Instruct SO to let the client play with supervised guidance. Inform SO to increase fluid intake, increase intake foods high in calories and increase intake of foods rich in vitamins. Inform SO that breast milk is best to keep the baby healthy. Instruct pt to increase fluid intake 3-4 l/day. Teach SO proper handwashing. Inform pt to avoid playing in danger zones like road, especially high ways where accidents are more prone. Maintain proper hygiene to avoid infection. Cover mouth when coughing, sneezing. Use disposable tissues to contain respiratory secretions Emphasize importance of good ventilation, well balanced nutritious diet. Promote adequate rest. Instruct pt to avoid exposure to secondary smoke. Instruct SO to visit physician if symptoms or condition is not relieved through home medication or management.

Diet

Health Teachinga

Schedule for Next Visit

Spiritual

Instruct patient to pray to God and thank him for the life and to ask forgiveness for the committed sins. And to ask protection and guidance. Encourage SO to maintain cleanliness in the environment to avoid acquiring infection. Instruct SO to remove hazardous materials in the surroundings to prevent unwanted accidents. Instruct pt to avoid exposure to secondary smoke. Refer to the nearest hospital or clinic if symptoms or condition persists.

Lifestyle

Referral