A Case Study of

Pulmonary Tuberculosis
In Partial fulfillment of the requirements in NCM 104

Prepared By:

chelle

BSN IV-B

October 17, 2009

 I. Introduction

A. Background of the study

This whole case study is about to discussed Pulmonary Tuberculosis (TB)

and few of Pneumothorax and Hydrothorax. This case will tackle about the
disease, patient’s health and of course nursing intervention.

Tuberculosis (abbreviated TB for tubercle bacillus or Tuberculosis) is

a common and often deadly infectious disease caused by mycobacteria, in
humans mainly Mycobacterium tuberculosis. Tuberculosis usually attacks the
lungs (as pulmonary TB) but can also affect the central nervous system, the
lymphatic system, the circulatory system, the genitourinary system, the
gastrointestinal system, bones, joints, and even the skin. Other mycobacteria
such as Mycobacterium bovis, Mycobacterium africanum, Mycobacterium
canetti, and Mycobacterium microti also cause tuberculosis, but these
species are less common in humans.

Tuberculosis is spread through the air, when people who have the
disease cough, sneeze, or spit. Most infections in human beings will result in
asymptomatic, latent infection, and about one in ten latent infections will
eventually progress to active disease, which, if left untreated, kills more than
half of its victims. The classic symptoms of tuberculosis are a chronic cough
with blood-tinged sputum, fever, night sweats, and weight loss. Infection of
other organs causes a wide range of symptoms.

Demographic incidence

Tuberculosis (TB) is a deadly disease. It is the world’s No. 1 cause of

death around the world; about 3 million persons die of TB every year. It is
one of the 10 top killer diseases in the Philippines; 75 Filipinos die of TB
every day.
 Pneumothorax, or collapsed lung, is a potential medical emergency
caused by accumulation of air or gas in the pleural cavity, occurring as a
result of disease or injury, or spontaneously.

• Kind: Closed Pneumothorax – Air escapes in pleural space from a puncture

or tear in an internal respiratory structure such as bronchus, bronchioles,
and alveoli.
• Classification: Spontaneous – the cause is “Unknown”, could be result of
another disease such as COPD, PTB and Cancer. Chest wall is intact;
blebs/bulla is rapture causing collapse lungs.

A hydrothorax is a condition that results from serous fluid

accumulating in the pleural cavity.

B. Objective

General

The general objective of this case study is to broaden our knowledge

about the disease and develop skills on how to render the best possible care
to a patient suffering from Pulmonary Tuberculosis.

Specific

☺ To be able to define Pulmonary Tuberculosis as well as on how it is

acquired, factors, signs and symptoms.

☺ To be able to know the pathophysiology of Pulmonary Tuberculosis.

☺ To be able to know the other problems that the client is suffering right
now not only PTB but also Pneumothorax and Hydrothorax

☺ To gain more information about patient’s condition.

☺ To apply skills learned in the classrooms to actual handling and caring

of a patient who suffered from Pulmonary Tuberculosis.
 ☺ To determine the possible nursing intervention that will be a great help
in patient’s prognosis.

☺ To be able to give the appropriate health teaching and better

understanding of the disease to the patient, family and significant
others.

C. Scope and delimitation

The scope of this study will focus on Pulmonary Tuberculosis with a few
discussions of pneumothorax and hydrothorax. The study covers the
background of the disease, the anatomy, pathology, mode of transmission,
pathophysiology and as well as its complications.

All information needed to come up with this case study was taken from
patient, patient’s family (mother and sister), patient’s chart, laboratory
result, physical assessment, books and internet.

D. Theoretical Framework

“FLORENCE NIGHTINGALE ENVIRONMENTAL THEORY”

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Nutritio Ventilati

ENVIRO MR.
ADL
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Cleanline
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Beddi
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Light
 Florence Nightingale was born to a wealthy and intellectual family. She
was known as the Lady with the Lamp. She believed she was “called by God
to help others … to improve the well being of mankind”

Nightingale is viewed as the mother of modern nursing. She

synthesized information gathered in many of her life experiences to assist
her in the development of modern nursing. Her contribution to the nursing
profession was her “Environmental Theory” in which the nurse’s role is to
place the client in the best position for nature to act upon him, thus
encouraging healing.

Nightingale viewed the manipulation of the physical environment as a

major component of nursing care. She identified ventilation and warmth,
light, noise, variety, bed and bedding, cleanliness of the rooms and walls,
and nutrition as major areas of the environment the nurse could control.
When one or more aspects of the environment are out of balance, the client
must use increased energy to counter the environmental stress. These
stresses drain the client of energy needed for healing. These aspects of
physical environment are also influenced by the social and psychological
environment of the individual.

I as a student nurse and part of the medical field, has the role of
providing nursing care with the help of the institutions and personnel involve
to cure the illness and lower down the factors causing the patient’s disease
with the help of Nightingale’s Environmental Theory.
 II.Clinical summary

A. General data

Name: Mr. ADL

Age: 24 years old

Religion: Roman Catholic

Civil Status: Single

Occupation: Car washer

Nationality: Filipino

Ethnic Group: Ilonggo

Admitting Diagnosis: Pulmonary Tuberculosis, Pneumohyrothorax Right

Sources of Information: Patient, Patient chart and the Significant

Others (Mother and the sister)

Reliability: 90% Reliable

B. Chief complaint
 The patient complained of difficulty of breathing.

C. History of present illness

The information that I gathered are second hand as they came from
the patient mother and sister. Due to unknown reason, the patient
refused to be interviewed even though based on my observation; he has a
capability to answer my questions.

Last two months, the family observed Mr. ADL is loosing weight and
decrease of appetite but instead of eating foods he his more on vices.
Then his condition became worsened according to family’s observation.

A month prior to admission, the patient condition became more at it

worst and his cough became productive with intermittent spots of blood in
the sputum upon coughing. He also starting to have night sweat started
becoming sluggish and spending lots of time sleeping. He was advice by
the family to have a check-up and visit the nearest hospital or clinic but
he refuse everything that his family’s concerned, as verbalized by Mr.
ADL’s sister.

Based on the statement of his mother, two days prior to admission Mr.
ADL experience body weakness, fatigue, and on the day of admission last
August 21, 2009 in Rizal Provincial Hospital, suddenly he was complaining
of difficulty of breathing, one hour after he ate his lunch.

D. Past medical history

Referring to the statements made by his sister, Mr. ADL was diagnosed
with Pulmonary Tuberculosis (PTB) last 2004, 6 years ago. He entered a
rehabilitation program sponsored by the local government in Cavite that
will provide the beneficiates with 100% coverage on the six months
duration in curing the disease. The six months duration in curing the
 disease became successful, he was cured by the medication given by the
sponsored but due to vices like smoking and active drinking of liquor the
disease from the past became active again.

By 2005 the patient has finger clubbing and through the course of my
interview, it was confirmed that at early age, my patient was suspected of
heart problem; “Mahina daw po ang puso niya. Lahat din naman kami,
normal na sa amin ang mababa ang dugo (blood pressure) mga 90/70”,
as verbalized by the patient’s sister per word.

E. Familial history

Last 2002, 8 years ago when his father died from heart attack. I
observed that Mr. ADL has a clubbing finger, through the course of
interview it was confirm that all of the siblings have a heart problem.

Then two of his uncle died from respiratory diseases, one is from
Tuberculosis and another is from lung cancer. His sister also said that it
was Mr. ADL twice to be confined in a hospital with a serious condition.

F. Psychosocial health

1. Psychosocial Health

a. Coping Pattern

Patient used silence; he is making an observation to the student nurse

who is assigned to him.

b. Interaction Pattern
 The patient ignores my kind interview due to unknown reasons but he
cooperated when I obtain Vital Signs, afternoon care, giving
medications, and physical assessment.

c. Cognitive Pattern

According to the mother, Mr. ADL knows already his condition because
he already suffered it before, last 2004, 6 years ago. But this time it is
more complicated.

d. Self Concept

In my observation, the patient looks shy. He just mind his own self
maybe because he is still in pain due to Chest tube thoracostomy
attached on his right chest.

e. Emotional Pattern

The patient looks sad and weak maybe because of the pain that he is
experiencing right now and the disease that he is suffering.

2. Socio-Cultural Health

a. Cultural Pattern

The patient was evidently proud of his ethnicity during their family’s
conversation.

b. Significant Relationship

According to the Mother, she doesn’t have an idea about sexual

activity of Mr. ADL; she only knew that Mr. ADL is single and no
girlfriend as of now.

c. Recreation Pattern
 Mr. ADL plays basketball with his friends; they also participated in any
championship as one team in their barangay, this is good for
recreation. He also has a good voice, according to his sister.

d. Economic

Mr. ADL is a car washer. He is working since 2006, 4 years ago, week
days; it is near to their house, and earning 150 pesos per day. He
shares some of his earnings to his mother as one of their resources of
foods.

3. Spiritual Health

a. Religious Beliefs

Mr. ADL is a Roman Catholic, sometimes he visit the church, one ride of
jeep from their house, twice a month.

b. Values and valuing

Mr. ADL is close to his mother. He lives with his mother from the time
he was born to the time he is where right now. All good values that he
has was educated by his mother but during his adolescence stage he
became abusive in his body, he became active with many kinds of
vices that are influenced by his friends, these is the reason why he got
the disease Tuberculosis.
G. Review of system

The data gathered are all coming from the mother as it was the patient
subjective complaint.

SYSTEM
General Generalized body weakness
Skin Dry
Head
Eyes & Ears
Nose Runny nose, with discharges
Throat & Mouth Dry mouth
Neck
Breast
Respiratory Difficulty of breathing, dyspnea upon
exertion. Cough
CVS Dyspnea upon exertion and chest
pain
GIT Constipated at times, defecate every
other day.
GUT
Extremities Joint pain
Neurologic Weakness
Hematologic
Endocrine Excessive night sweating
Psychiatric Depression, Ignores kind interview

H. Physical assessment

a. General appearance/survey:

Patient appeared weak looking but was somehow coherent in a high

fowlers position due to CTT attach to his right chest. Mr. ADL ignores my kind
interview but he is willing to cooperate when it comes in taking vital signs,
physical assessment and giving medication which is important. The patient’s
skin was dry especially on the lower extremities. IVF of D5NM 1L + 1 amp of
Moriavit at 50cc level was attached to his right hand.

b. Measurement

FIDINGS NORMAL ANALYSIS/

VALUES INTERPRETATION
(Ht, wt) Height: 5’5” BMI BMI below normal as a
Weight: 101 lbs result of malnutrition

Vital Signs Temp: 36.0 C Temp: 37 C With some abnormal

PR: 90 bpm PR: 60-100 bpm findings in the
RR: 29 bpm RR: 16-20 bpm respiratory rate.
BP: 100/70 BP: 120/80 Increase RR; difficulty
mmHg mmHg of breathing (decrease
Oxygen supply in the
body)
c. Head to toe Assessment

BODY PARTS NORMAL ACTUAL ANALYSIS/

FINDINGS FINDINGS INTERPRETATI
ON
A. HEAD
a. Skull Rounded Normoceph Normal findings
(normocephali alic
c, with frontal,
parietal and
occipital
prominences)

b. Hair Evenly Typical hair type

distributed; Evenly of men
thick hair; distributed
silky resilient
hair; no
infestation or
infection;
variable
amount of
c. Face body hair Normal findings
 Symmetric
Symmetric facial
facial features, features
palpebral
fissures equal
d. Eye/vision in size,
4.1 Eyeball symmetric Normal findings
nasolabial
folds Round,
4.2 Lid margins uniform in Normal findings
Shape is size
round; size
equal Close
symmetrical
Protects eyes,
4.3 Conjunctiva anteriorly Undernourished,
meet at the lack of vitamins
medial and
lateral corners Smooth and
of eye. pale

4.4 Sclera Delicate Normal findings

membrane;
covers part of
the outer Appears
4.5 Pupils surface of the white Normal findings
eyeball

Outermost
tunic, thick Normal
white pupil
connective constriction
tissue.
4.6 Eyebrow, lashes, color, Normal findings
symmetry, quality of hair, Pupils
placement constrict when
looking at
4.7 Eye movement in all near objects, Normal findings
directions pupils Hair evenly
converge distributed,
when object is intact skin
moved
towards the Equal
nose movement

Hair evenly
 distributed,
intact skin

Equal
movement
B. VISION TESTING
a. Visual field When looking Client can Normal
straight ahead see from his peripheral vision
clients can see periphery
objects in
periphery

b. Visual acuity Able to read Able to read Normal visual

newspaper newspaper findings
C. EARS
a. Pinna Same color as Same color Normal ear
facial skin, as facial features
pinna recoils skin, pinna
after it is recoils after
folded it is folded

b. External canal Wet and

Dry ear wax sticking Normal findings
grayish-tan cerumen
color or sticky with
wet cerumen transparent
in various color
shades of
brown/ pearly
gray color;
c. Hearing acuity semitranspare
nt Responds to Normal findings
moderately
Responds to loud voice
moderately tone
loud voice
tone
D. NOSE Symmetric, No (+) dyspnea,
normal deformity, patient have
breathing, (+) cough which
able to difficulty of reflex is not the
identify breathing. only way to
familiar smell With runny protect our
nose airways which
causes patient
to have runny
 nose.
E. MOUTH/LIPS
a. Gums Pink gums; Dark gums Gums darkened
moist firm due to smoking
texture history
b. Teeth Yellowish
32 adult teeth with few Needs dental
smooth, white cavities and work
yellowish some
shiny tooth missing
c. Tongue enamel teeth

Central Central No remarkable

position, pale position, findings
d. Palate-hard/soft in color pale in color

Pale in color No remarkable

e. Oropharynx/ Tonsil Pink and findings
smooth; freely
movable Pale No remarkable
posterior findings
Pink and wall
smooth
posterior wall
F. CHEECKS Hollow in Indicates
appearance malnutrition,
due to weight
loss
G. NECK Lymph nodes Lymph Normal findings
freely movable nodes freely
movable
H. CHEST Quiet rhythmic (+) Presence of
a. Anterior and effortless difficulty of crackles caused
b. Posterior respirations; breathing, by fluid often
full symmetric with associated with
excursions abnormal inflammation or
sound in infection of the
the right alveoli.
lower lobe Indicates
respiratory
problems such
us TB,
Pneumohydroth
Localized orax
pain around No air leak on
 thoracosto drainage
I. HEART Full and my site. system:
symmetric manageable
J. BREAST Full and incision pain.
symmetric
Normal findings

K. ABDOMEN Flat, rounded Flat, Client is not well

(convex) or scaphoidal nourished.
scaphoids in shape It is also due to
weight loss.
L. UPPER EXTREMETIES Equal in size Equal in Client is not well
on both sides size but nourished
of the body; muscular
no muscle atrophy
atrophy; evident. Struggling
normally firm; Unable to movements due
smooth move freely to wounds,
coordinated due to pain incision pain.
movements in incision
site.
M. LOWER EXTREMETIES Equal in sixe With Client is not well
on both sides muscular nourished
of the body; atrophy
no muscle evident. Weakness and
atrophy; Occationally pain hinder
normally firm; stands up client from
smooth for short actively moving
coordinated time. (2 around.
movements days post-
op)
I. Activities of daily living

Before During Analysis/

Hospitalization Hospitalization Interpretation
a. Fluid & Skipping meals Moderate Due to
Nutrition most of the time, decrease of the medication given
according to the appetite; can as side effects
significant others. consume about ½ such as;
Mr. ADL is more of the foods Combivent and
on vices. given. Rifampicin, there
is a decrease of
His fluid appetite.
preferences are
water, softdrinks Diet as tolerated The pt was
and liquor. was advised to trained to take
Mr. ADL DAT diet to
Mr. ADL drinks 3- sustain his
4 glass of water a nutritional needs.
day and can
consume Liquor
of 3-4 beer a day.

He is more on
bread in the
morning;
b. Elimination vegetables and
fish most of their
meals.
Usually voids 2-4
Mr. ADL usually times a day.
voids large
amount of urine, Mr. ADL There is a
c. Safety, 5-7 x a day. defecates every decrease bowel
Activity & Defecates at other day. movement due to
Exercise least once a day. decrease
appetite.
There is no
Doing his job as a exercise at all Patient’s daily
car washer was because of CTT exercise is limited
his form of attached on his because of body
d. Hygiene & exercise abdomen. He weakness and
Comfort everyday. habitually sits on CTT attach on his
bed during abdomen.
confinement.
Dependence
Restricted on related to
The patient takes bed; the patient restricted
e. Rest & a bath once a day can’t take a bath mobility after
Sleep and brushes his due to CTT done surgical
teeth twice a day. in his right. All procedure.
hygienic activities
J. Laboratory / Diagnostic Exam

a. Hematology report August 21,

2009

Test Results Normal Value Analysis

Hemoglobin 110 g/L 140 – 170 g/L Decrease
Insufficient
oxygen
circulating in the
bloodstream.
Indicates Anemia
due to blood loss
after surgery.
Hematocrit 0.33 0.40 – 0.50 Decrease
Insufficient
oxygen
circulating in the
bloodstream.
Indicates Anemia
due to blood loss
after surgery.
WBC 15.2 x 10 5.0 – 10.0 x 10 Increase
Leukocytosis
Indicates
infection
Neutrophils 0.78 0.45 – 0.65 Increase
Acute bacterial
infection
Lymphocytes 0.21 0.25 – 0.40 Decrease
low absolutely
lymphocyte
concentration,
associated with
increase rates of
infection
Monocytes 0.01 0.02 – 0.06 Decrease
Depleted in
overwhelming
bacterial infection
Platelets 320 150 - 450 Normal
 b. Chest X-ray August 21,
2009

Impression: Pulmonary Tuberculosis (PTB)

Right sided Pneumohydrothorax

c. Urinalysis August 21, 2009

Color: Yellow
Transparency: S/I Fubid

Chemical Strips

Reaction: 5.2
Specific Gravity: 1.025 (above normal) – dehydration
and contamination
Albumin: Trace

Microscopic

WBC 8-12
RBC 1-3
Epithelial Cells Rare
Mucus treads Moderate
Amorphous Urates Plenty
d. RT Hemithorax August 22, 2009

Ultrasound done on the right hemithorax, there is a significant fluid in

the right lower hemithorax. Minimal fluid is seen with leculations noted of
about 36cc. Echoes noted within probably due to air.

Impression: Minimal leculated hydrothorax, right

e. Urinalysis August 22, 2009

Color: Yellowish brown

Consistency: Soft
Microscopic: No Ova, parasite seen
WBC 4-8
RBC 0-1
Bacteria Plenty – bacterial infection
f. Radiological Report August 23,
2009

Impression: Pulmonary Tuberculosis, Left

Pneumohydrothorax, Right
K. Surgical procedure

Mr. ADL has a fluid (hydrothorax) in his right lung, but when Chest
Tube Thoracostomy was performed last August 22, 2009, there was no fluid
extracted, the fluid was noted in the right lung.

Chest Tube Thoracostomy

• Returns (-) pressure to the internal pleural space
• Remove abnormal accumulation of air
• Serves as lung while healing is ongoing.
The insertion of chest tube permits removal of the air or bloody fluid and
allows re-expansion of the lungs and restoration of the normal negative
pressure in the pleural space. Because air rises, a chest tube inserted to
remove air is usually placed anteriorly through the 2nd ICS. A chest tube
inserted to remove fluids is placed posteriorly in the 8th and 9th ICS because
fluid tends to flow to the bottom of the pleural space.

Chest Drainage Container

A waterseal at the end of a chest tube is essential to allow air to escape

through the tube but prevent air from traveling back up the tube and into the
pleural space. The waterseal drainage system is placed below the level of
the patient’s chest, taking advantage of the force or gravity to promote
drainage and prevent backflow of bottle contents into the pleural space.
L. Final diagnosis

• PTB with Pneumothorax and Hydrothorax, Right

M. Course in the ward

August 21, 2009
2:00pm – 10:00pm
• Admitted a 24 years old male accompanied by relatives with a
complained of difficulty of breathing.
• Vital signs are taken and recorded with a BP: 100/70 mmHg, HR: 81
bpm, RR: 35 bpm
• Seen and examined by Dra. Magtoto
• Consent signed and secured
• Tuberculin skin test done; due at 3:30 pm
• IVF of D5NM 1L + 1 ampule of Lysmix inserted and regulated with 31
gtts/min
• Laboratory requested by the attending physician such as; Urine
analysis, Ultrasound of right lung, BUN and Creatinine, and chest X-ray
• Transferred to Charity Medical Ward, bed 22
• Endorsed

August 22, 2009

2:00pm – 10:00pm
• Received on bed with an IVF of D5NM 1L + 1 ampule of Lysmix @
600ml level
• Conscious and coherent
• Vital signs are taken and recorded with blood pressure of 100/70
mmHg
 • A febrile 36.5
• NPO was advice
2:30pm
• Consent signed and secured
3:00pm
• Undergone CTT @ right lung
• Vital signs recheck
• Needs attended
• Endorsed

August 23, 2009

2:00pm – 10:00pm
• Received on bed with an IVF of D5NM 1L + 1 ampule of Moriavit X 8
hours @ consuming level
• Vital signs taken and recorded with Blood Pressure of 100/70 mmHg
4:00pm
• Cefuroxime 200mg TIV after negative skin test
6:00pm
• Vital signs recheck with no significance finding
• Needs attended
• Endorsed

August 24, 2009

2:00pm – 10:00pm
• Received on bed with an IVF of 1L @ 400cc level
• Vital signs taken and recorded BP: 90/60 mmHg, PR: 90 bpm, RR: 29
bpm and Temperature: 36.6 C
• With abnormal RR: 29 bpm
• Diet as tolerated maintained
• Due medication given and recorded
4:00pm
• Cefuroxime 200mg TIV after negative skin test
7:00pm
• Rifampicin 1 tablet before dinner
• Vital signs recheck with no significance finding
• Needs attended
• Endorsed
August 25, 2009
2:00pm – 10:00pm
• Received on bed alert, coherent, cooperative.
• With an IVF of D5NM 1L + 1 ampule of Moriavit @ 700cc level and
regulated with 31 gtts/min on the right hand
• Vital signs taken and recorded
• Afternoon care rendered
• Health teaching done
• Medication given
• Needs attended
• No other complaints
• Endorsed

III. Clinical discussion of the disease

A. Anatomy and physiology
UPPER RESPIRATORY TRACT

Respiration is defined in two ways. In common usage, respiration refers

to the act of breathing, or inhaling and exhaling. Biologically speaking,
respiration strictly means the uptake of oxygen by an organism, its use in
the tissues, and the release of carbon dioxide. By either definition,
respiration has two main functions: to supply the cells of the body with the
oxygen needed for metabolism and to remove carbon dioxide formed as a
waste product from metabolism. This lesson describes the components of the
upper respiratory tract.

The upper respiratory tract conducts air from outside the body to the
lower respiratory tract and helps protect the body from irritating substances.
The upper respiratory tract consists of the following structures:

The nasal cavity, mouth, pharynx, piglottis, larynx, and upper trachea;
the oesophagus leads to the digestive tract.

One of the features of both the upper and lower respiratory tracts is
the mucociliary apparatus that protects the airways from irritating
substances, and is composed of the ciliated cells and mucus-producing
glands in the nasal epithelium. The glands produce a layer of mucus that
traps unwanted particles as they are inhaled. These are swept toward the
posterior pharynx, from where they are swallowed, spat out, sneezed, or
blown out.
 Air passes through each of the structures of the upper respiratory tract
on its way to the lower respiratory tract. When a person at rest inhales, air
enters via the nose and mouth. The nasal cavity filters, warms, and
humidifies air. The pharynx or throat is a tube like structure that connects
the back of the nasal cavity and mouth to the larynx, a passageway for air,
and the esophagus, a passageway for food. The pharynx serves as a
common hallway for the respiratory and digestive tracts, allowing both air
and food to pass through before entering the appropriate passageways.

The pharynx contains a specialised flap-like structure called the

epiglottis that lowers over the larynx to prevent the inhalation of food and
liquid into the lower respiratory tract.

The larynx, or voice box, is a unique structure that contains the vocal
cords, which are essential for human speech. Small and triangular in shape,
the larynx extends from the epiglottis to the trachea. The larynx helps
control movement of the epiglottis. In addition, the larynx has specialised
muscular folds that close it off and also prevent food, foreign objects, and
secretions such as saliva from entering the lower respiratory tract.

LOWER RESPIRATORY TRACT

The lower respiratory tract begins with the trachea, which is just below
the larynx. The trachea, or windpipe, is a hollow, flexible, but sturdy air tube
that contains C-shaped cartilage in its walls. The inner portion of the trachea
is called the lumen.

The first branching point of the respiratory tree occurs at the lower end
of the trachea, which divides into two larger airways of the lower respiratory
tract called the right bronchus and left bronchus. The wall of each bronchus
contains substantial amounts of cartilage that help keep the airway open.
Each bronchus enters a lung at a site called the hilum. The bronchi branch
sequentially into secondary bronchi and tertiary bronchi.

The tertiary bronchi branch into the bronchioles. The bronchioles

branch several times until they arrive at the terminal bronchioles, each of
which subsequently branches into two or more respiratory bronchioles.

The respiratory bronchiole leads into alveolar ducts and alveoli. The
alveoli are bubble-like, elastic, thin-walled structures that are responsible for
the lungs’ most vital function: the exchange of oxygen and carbon dioxide.

Each structure of the lower respiratory tract, beginning with the

trachea, divides into smaller branches. This branching pattern occurs
multiple times, creating multiple branches. In this way, the lower respiratory
tract resembles an “upside-down” tree that begins with one trachea “trunk”
and ends with more than 250 million alveoli “leaves”. Because of this
resemblance, the lower respiratory tract is often referred to as the
respiratory tree.

IV. Nursing problem list

• Ineffective Airway Clearance

• Ineffective Breathing Pattern

• Risk for Infection

• Imbalanced Nutrition; less than Body Requirements

• Activity Intolerance

• Impaired Physical Mobility

• Anxiety

Nursing Priority:

1. Ineffective Airway Clearance

2. Risk for infection

3. Impaired Physical Mobility

 VI. Drug Study

Generic Name: CEFUROXIME 200 mg TIV q8 hours ANST (-)

Brand Name: CEFTIN
Classification Action Indication Adverse Effect Nursing
Consideration
2ND generation A 2nd generation Treatment of susceptible Allergic reaction, oral Ask the patient if he
cephalosporin cephalosporin that infection due to group B candidiasis, mild has a history of
binds to bacterial cell streptococcus, E. coli, H. diarrhea, mild allergies to drugs,
membranes and influenza etc. abdominal cramping. particularly to
inhibits cell wall cephalosporin and
synthesis. penicillin.

Generic Name: IPRATROPIUM BROMIDE q4 hours

Brand Name: COMBIVENT, DOUNEB
Classification Action Indication Adverse Effect Nursing
Consideration
Anti-cholinergic An anti-cholinergic Maintenance treatment of Hypotension, Monitor Vital signs
bronchodilator that blocks the action bronchospasm due to insomnia, metallic or Monitor intake and
of acetylcholine at chronic obstruction unpleasant taste, output
parasympathetic sites pulmonary disease palpitations, urine
in bronchial smooth (COPD), bronchitis, reaction.
muscles. emphysema, asthma.

Generic Name: RIFAMPICIN 2 Tablets before lunch and 1 tablet before dinner
Brand Name: MYRIN-P FORTE
Classification Action Indication Adverse Effect Nursing
Consideration
Antituberculosis Inhibits RNA synthesis, Initial phase treatment and Disorder of the Explain to the patient
decreases tubercle retreatment of all forms of blood and lymphatic to expect a orange
bacilli replication TB in category I and II system, immune color of urine.
patients caused by system, metabolism
susceptible strains of and nutrition, CNS, Monitor I & O.
mycobacterium. eye, GI, skin and
tissues, renal, fever,
dryness of mouth.
Generic Name: TRAMADOL 50 mg
Brand Name: ULTRAM
Classification Action Indication Adverse Effect Nursing
Consideration
Analgesic, An analgesic that binds Uses for management of CNS: dizziness, Monitor vital signs
centrally-acting to mu-opoid receptors moderate to moderately vertigo, anxiety, sleep especially Blood
and inhibits reuptake severe pain. disorder, migraine. pressure.
of norepinephrine and GI: nausea and
vomiting, constipation,
serotonin. Reduces the Monitor input and
abdominal pain,
intensity of pain anorexia.
output.
stimuli reaching OTHERS: rash,
sensory nerve ending. sweating, Assist with ambulation
hypotension, urinary if dizziness and vertigo
retention. occurs.

Drug: LYSMIX 20 ml / amp TID

Classification Contents Indication Dossage
Parenteral nutritional Per amp- L-lysine Nutritional supplements Adult: 1 amp BID – TID
products monohydrochloride 20mg, L- Lysmix 20 ml x 5’s
Multivitamins with minerals histamin monoHCl 4mg, dl-
used as dietary methionine 10mg, thiamine
HCl (Vit. B1) 1mg, riboflavin
supplements
(Vit. B2) 100mcg, pyridoxine
HCl (Vit. B6) 100mcg, taurine
4mg, dextrose 100mg.

Generic Name: AMINO ACID 20ml/ Ampule TIV q8 hrs

Brand Name: MORIAVIT
Classification Action Indication Adverse Effect Nursing
Intervention
Calorics (Nutritional Provides a substrate Total Parenteral CNS: Fever Monitor body
Drug) for protein synthesis Nutrition GI: Flushing temperature every 4
or increases GU: Osmotic dieresis hours.
conservation of Metabolic:
existing body protein. electrolytes Obtain baseline
imbalance, weight electrolyte, glucose,
gain BUN, calcium and
Musculoskeletal: phosphorus levels
Osteoporosis before giving drugs.
 VII. Discharge Plan (METHODS)

M- Medications

Medications should be taken as ordered and prescribed by the

physician to avoid complications and help mange the condition of the
patient. There are a lot of main anti-Tuberculosis medications such us:
Isoniazid, Fifampicin, Ethambutol and Pyrazinamide.

E- Exercise

• Instruct the patient to have a time for deep breathing exercise

everyday for several times at home to helps achieved maximal lung
expansion and for relaxation.

• Start with exercises that you are already comfortable doing. Starting
slowly makes it less likely that you will injure yourself.

• Immediately stop any activities that might causes undue fatigue,

increased shortness of breath or chest pain.

T- Treatment

• Remind the importance of taking the medication in the right time and
dose.

• Sleep in a room with good ventilation.

• Limit your activity to avoid fatigue. Frequent rest is advice.

• Maintained wound integrity on the surgical site.

H- Health Teachings

• Advise to take the medication on time and with the right dosage.

• Semi-fowlers position is advice most of the time for breathing

relaxation.
 • Avoid close contact with others until the doctor finds it Okay.

• Advise the client to turn your head when coughing. Keep tissues with
you and cover your mouth when you cough then throws the tissues
used in the plastic bag.

• Keep your hands clean. Maintain proper hygiene.

• Isolate techniques is one of the best way to prevent the speared of

the bacteria; separation of dining ware.

• Advise the relatives to clean the environment regularly since it is one

of the factor that contribute to the speared of bacteria.

• Discuss to the client and significant others the cardinal signs of

infection such as; redness, heat, induration, swelling and separation
of drainage.

O- Out- patient follow- up

Most of the treatment to cure Pulmonary Tuberculosis can be given at

home but must be taken as explained by the health care worker. The family
has the responsibility to check the status of the patient and the progress of
it.

D- Diet

• Diet as tolerated is advice by the attending physician, to sustain his

nutritional needs.
• High protein diet for tissue repair - meat and green leafy vegetables.

S- Spiritual practice

Mr. ADL’s religion is Catholic, encourage the patient pray daily, go to

church regularly and increase his faith with God Almighty.