NCS
Content
University of Perpetual Help System DALTA
COLLEGE OF NURSING
Molino III Bacoor, Cavite I. HEALTH HISTORY A. DEMOGRAPHIC (BIOGRAPHICAL DATA) 1. Client’s Initial: L. N. 2. Gender: Female 3. Age/ Birthdate/ Birthplace: 35/ 12.23.1975/ Bukidnon 4. Marital Status: Married 5. Nationality: Filipino 6. Religion: Catholic 7. Address: Dalla, Green Valley, San Nicolas III Bacoor, Cavite 8. Educational Background: 3rd Year College 9. Occupation: Shoe repair 10. Usual Source of Medical Care: Health Center 11. Initial Diagnosis: Presence of scar in the right lung upon chest xray 12. Final Diagnosis: Pulmunary Tuberculosis B. SOURCE AND RELIABILITY OF FORMATION • Client herself who seems reliable C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS • Chest pain for 2 hours • Restlessness • Loss of appetite D. HISTORY OF PRESENT ILLNESS 8 Critical Characteristics 1. Timing: Patient’s condition started about 6 months prior to consultation, as onset of cough, productive. 2. Location: Right lung 3. Quality: She had productive cough non-bloody with yellowish secretions. 4. Quantity: She also experience stabbing pain on her chest according to the assessment it is 6/10 and it radiates to his back. 5. Setting: Prior to consultation 6. Associated phenomena/ Factors: Type of work and crowded living space 7. Aggravating and Alleviating factors: Personal habits 8. Client’s Perception: She does not seek for any medical care from the physician because according to her it is still tolerable.
University of Perpetual Help System DALTA
COLLEGE OF NURSING
Molino III Bacoor, Cavite E. PAST MEDICAL HISTORY OR PAST HEALTH • Pediatric/ childhood/ adult illness: Measles • Injuries or accident: none • Hospitalization: none • Operation: none • Obstetric History: G5 P4 • Allergies: tuyo, eggs • Medications (Prescribed and OTC drugs): Rifampicin, Isoniacid, Pyrazinamide, Ethambutol • Medications (allergies): none • Last Examination date: 07/06/10 F. FAMILY HISTORY (FAMILY TREE or GENOGRAM/ROSTER)
54 60
B. N. G. N.
A.N. R.N. R.N. L.N. 40 38 36 26 24 22
A.N. M.N. 35 19
M.N. G.N. 33
B.N 31
E.N. 30
A.N.
J.N. 28
LEGEND: - FEMALE - MALE - PATIENT G. SOCIO- ECONOMIC FAMILY MEMBER OCCUPATION
MONTHLY INCOME
University of Perpetual Help System DALTA
COLLEGE OF NURSING
Molino III Bacoor, Cavite R. N. L. N. SHOE REPAIR SHOE REPAIR 500 400- 500
H. DEVELOPMENTAL HISTORY Generativity vs. Stagnation (Middle Adulthood, 35 to 65 years) Generativity is the concern of establishing and guiding the next generation. Socially-valued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity- a sense of productivity and accomplishment- results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation- a dissatisfaction with the relative lack of productivity. Central tasks of Middle Adulthood Express love through more than sexual contacts. Maintain healthy life patterns. Develop a sense of unity with mate. Help growing and grown children to be responsible adults. Relinquish central role in lives of grown children. Accept children's mates and friends. Create a comfortable home. Be proud of accomplishments of self and mate/spouse. Reverse roles with aging parents. Achieve mature, civic and social responsibility. Adjust to physical changes of middle age. Use leisure time creatively. Love for others I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. ROS AND PE System ROS PE SIGNIFICANCE A. General/ “Minsan nakakaramdam (+) weakness Due to respiratory Overall health status ako ng pagkahilo”, as (+) dizziness problems. verbalized by the patient. B. Integument --------(-) history of skin --------disease (-) hair loss
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University of Perpetual Help System DALTA
COLLEGE OF NURSING
Molino III Bacoor, Cavite (-) change in nail shape (-) severe headache (-) any head injury (-) eye problem (-) tinnitus (-) history of infection (-) hearing aid use (-) discharge from nares (-) tenderness (-) presence of lesions (+) black dicoloration of the enamel. (+) tooth decay (+) jaundice sclera (+) halitosis (-) stiffness (-) lumps or swelling (-) goiter (-) pain (-) nipple discharge (-) history of breast disease (+) wheezing (+)cough (+)sputum (+)varicosities (+)dizziness (+)dyspnea (+)generalized pallor
C. Head
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D. Eyes E. Ears
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F. Nose and Sinuses
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G. Mouth and Throat
“May bulok na ngipin ako pero di ko pinapabunot.”, as verbalized by the patient.
Due to improper or ineffective oral hygiene.
H. Neck
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I. Breast and Axillae
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J. Respiratory K. Cardiovascular
“Nahihirapan akong huminga” as verbalized by the patient. “May mga ugat ako sa binti ”, as verbalized by the patient.
Due to respiratory muscle fatigue. Due to insufficient oxygen in the peripheral arteries and capillary.
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Molino III Bacoor, Cavite L. Gastrointestinal “Maitim yung dumi ko na parang kulay dugo”, as verbalized by the patient. “Kulay dugo rin yung ihi ko”, as verbalized by the patient. (+)dark colored stool Due to medications given for PTB. Due to medications given for PTB.
M. Urinary
O. Musculoskeletal P. Neurologic
Q. Hematologic
R. Endocrine
(+)dark orange urine (+)UTI (+)pain in the suprapubic region “Pinupulikat ako minsan”, (+) spasticity as verbalized by the patient. --------(-) history of seizure disorder (-) paresis (-) hallucinations --------(-) excessive bruising (-) lymp node swelling (-) blood tranfusions and reactions --------(-) history of diabetic symptom (-) excessive sweating (-) tremors
Due to inadequate rest during work. ---------
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University of Perpetual Help System DALTA
COLLEGE OF NURSING
Molino III Bacoor, Cavite
J. FUNCTIONAL ASSESSMENT 1. Health perception- Health Management The patient doesn’t have complete immunization because according to her it is not available during those days and having immunization during those years are expensive and they cannot afford it. She was never been hospitalized. Does not experience any accidents. When she had a disease, she used herbal medicines like guava leaves, oregano, lagundi, etc. For her, being healthy is important. A person is healthy when she is strong, she can do what she wants and does not experience any diseases. She does not have any regular medical and dental check-ups. When she is experiencing something wrong in her body, she does not tell it promptly because according to her it is tolerable. She does not have a regular exercise, instead she cleans the house and washes the clothes of her family. The patient is malnourished. She takes a bath once a day and brushes her teeth once a day. She does use lotion, shampoo and soap. She washes her hands regularly but not always using soap. When she feels discomfort in her body she also goes to the manghihilot because it is available on their area and it is more approachable. She often forgot to cover her mouth and nose when someone sneezes and coughs in front of her. A person has a disease when she eats little amount of food, when she is weak. Health for her is important for proper functioning. Whenever she is sick, she get’s money from her children especially to the eldest, which is working abroad. She wears slippers while inside their house. She feels that her hygienic practices are adequate, and she feels clean and neat. The patient is non-smoker and she does not drink any alcoholic beverages. She denies the use any illicit drugs.
2. Self-perception According to her there is something wrong in her health and body. As a mother, she sometimes feels sad because she cannot do the previous things like going with her husband in the farm. According to her husband she is a good mother and a good wife. Her strength is her family, when there are any circumstances that involving any family member she is concerned and make some moves. She is simple.
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Molino III Bacoor, Cavite 3. ACTIVITY Feeding Bathing Toileting Bed Mobility Dressing Grooming General Mobility Legend: Legend Level 0 Level 1 Level 2 Level 3 Level 4 Activity/ Exercise pattern BEFORE HOSPITALIZATION 0 0 0 0 0 0 0 Functional Level Code Full self care Requires use of requirements or device Requires assistance or supervision from another person Requires assistance or supervision from another person or device Is dependent and does not participate DURING HOSPITALIZATION 2 0 0 0 0 0 0
4. Sleep and Rest The patient regularly sleeps at 8:00pm and wakes up at 1:00 pm. She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough. She usually sits because according to her she can breath more easily. She takes a nap in the morning from 8 am to 11 am. She feels that her sleep and rest is inadequate. She sleeps together with her husband. They have a separate room from their children. Sleeping is important to her. 5. Nutrition/ Elimination
Nutrition She loves to eat pork, fish and vegetables. She is not choosy when it comes to any cook and kind of food. She eats 3x a day. She does not eat any junk foods. She drinks 5 glasses of water a day. For her, the amount of food she consumes is adequate. She takes food supplement but it is not frequent. During snack time, she usually eats banana because it is affordable and readily available in their place. When her cough started, she is not eating the appropriate amount of food. According to her husband, she usually eats 4 spoons of rice with viand only. It is due to her cough. During her hospitalization, she is on diet as tolerated with aspiration precaution. She eats food given by the hospital. She is taking vitamin B6 and other medications.
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Molino III Bacoor, Cavite Elimination She defecates twice a week and sometimes she feels pain and difficulty. According to her the characteristic of her stool is hard, dry and colored dark brown. She feels pain at her abdomen on the hypogastric and umbilical area. She urinates 7x a day and does not feel any pain and difficulty. Previously her defecation pattern is daily, but when her condition exacerbated, it is also affected. 6. Sexuality-reproductive She is engage in sexual activity to her husband only. Presently she is still active in her sex life. She still have regular menstruation. She is aware that she will have cessation of her menstruation. She dresses appropriately, based on her gender. She is also able to express her feminine attitudes. 7. Interpersonal relationship/resources She was the fourth child in her family. She is married and they have 4 children. She is performing the trypical responsibilities of a plain house wife. Her children have a good relationship to her. She is being cared by her children who are very supportive to her. Her husband is a good husband he is a provider who does everything for the family to have food. She has a harmonious relationship with her brothers and sisters. Whenever there are any problems, they are helping each other. She can form a healthy relationship with others. She is the person who chooses her friends. She is a very quite person. She does not have any enemies. 8. Coping-stress management/tolerance pattern Whenever she has problem, she asks guidance from our Lord. She watches television as her stress management. She always listen to radio programs when she feels lonely. When she gets mad, she just keep quiet. When she experiences coughing and difficulty of breathing she just relaxes and breathes deeply. Her husband or children taps her back when she coughs. 9. Personal habits The patient is non-smoker. She does not drink any alcoholic beverages. She denies the use any illicit drugs. 10. Environmental hazards She is living in a crowded area. She is living together with her 3 children and husband. She knew all of her neighbors. She thinks that she is safe in her home. She is complaining about the lack of utilities in their neighborhood. She is living near the high-way. She is not involved in any community services. Because her job involves being exposed outside she thinks that it is not safe for her most especially during night.
University of Perpetual Help System DALTA
COLLEGE OF NURSING
Molino III Bacoor, Cavite
II. PROBLEM LIST
A. ACTUAL or ACTIVE Problem No. Problem 1 2 3 Difficulty in breathing Activity intolerance Fatigue
Date Indentified August 31, 2010 August 31, 2010 August 31, 2010 Date Identified -----------------
Date Resolved/ Remarks Resolved Unresolved Unresolved Status Unresolved Unresolved
B. HIGH RISK or POTENTIAL Problem No. Problems 1 Self care deficit in hygiene 2 Infection III. NURSING CARE PLAN
University of Perpetual Help System DALTA
COLLEGE OF NURSING
Molino III Bacoor, Cavite
IV. ANATOMY AND PATHOPHYSIOLOGY
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. Respiratory tract The respiratory tract cleans, warms, and moistens air during its trip to the lungs. The tract can be divided into an upper and a lower part. The upper part consists of the nose, nasal cavity, pharynx (throat), and larynx (voice box). The lower part consists of the trachea (windpipe), bronchi, and bronchial tree. The nose has openings to the outside that allow air to enter. Hairs inside the nose trap dirt and keep it out of the respiratory tract. The external nose leads to a large cavity within the skull, the nasal cavity. This cavity is lined with mucous membrane and fine hairs called cilia. Mucus moistens the incoming air and traps dust. The cilia move pieces of the mucus with its trapped particles to the throat, where it is spit out or swallowed. Stomach acids destroy bacteria in swallowed mucus. Blood vessels in the nose and nasal cavity release heat and warm the entering air. Air leaves the nasal cavity and enters the pharynx. From there it passes into the larynx,
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Molino III Bacoor, Cavite which is supported by a framework of cartilage (tough, white connective tissue). The larynx is covered by the epiglottis, a flap of elastic cartilage that moves up and down like a trap door. The epiglottis stays open during breathing, but closes during swallowing. This valve mechanism keeps solid particles (food) and liquids out of the trachea. If something other than air enters the trachea, it is expelled through automatic coughing. Alveoli: Tiny air-filled sacs in the lungs where the exchange of oxygen and carbon dioxide occurs between the lungs and the bloodstream. Bronchi: Two main branches of the trachea leading into the lungs. Bronchial tree: Branching, air-conducting subdivisions of the bronchi in the lungs. Diaphragm: Dome-shaped sheet of muscle located below the lungs separating the thoracic and abdominal cavities that contracts and expands to force air in and out of the lungs. Epiglottis: Flap of elastic cartilage covering the larynx that allows air to pass through the trachea while keeping solid particles and liquids out. Pleura: Membranous sac that envelops each lung and lines the thoracic cavity. Air enters the trachea in the neck. Mucous membrane lines the trachea and C-shaped cartilage rings reinforce its walls. Elastic fibers in the trachea walls allow the airways to expand and contract during breathing, while the cartilage rings prevent them from collapsing. The trachea divides behind the sternum (breastbone) to form a left and right branch, called bronchi (pronounced BRONG-key), each entering a lung. 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-oleye). The average person has a total of about 700 million gas-filled 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.
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Molino III Bacoor, Cavite This process—external respiration—causes the blood to leave the lungs laden with oxygen and cleared of carbon dioxide. When this blood reaches the cells of the body, internal respiration takes place. The oxygen diffuses or passes into the tissue fluid, and then into the cells. At the same time, carbon dioxide in the cells diffuses into the tissue fluid and then into the capillaries. The carbon dioxide-filled blood then returns to the lungs for another cycle.
Breathing Breathing exchanges gases between the outside air and the alveoli of the lungs. Lung
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Molino III Bacoor, Cavite expansion is brought about by two important muscles, the diaphragm (pronounced DIE-afram) and the intercostal muscles. The diaphragm is a dome-shaped sheet of muscle located below the lungs that separates the thoracic and abdominal cavities. The intercostal muscles are located between the ribs. Nerves from the brain send impulses to the diaphragm and intercostal muscles, stimulating them to contract or relax. When the diaphragm contracts, it moves down. The dome is flattened, and the size of the chest cavity is increased. When the intercostal muscles contract, the ribs move up and outward, which also increases the size of the chest cavity. By contracting, the diaphragm and intercostal muscles reduce the pressure inside the lungs relative to the pressure of the outside air. As a consequence, air rushes into the lungs during inhalation. During exhalation, the reverse occurs. The diaphragm relaxes and its dome curves up into the chest cavity, while the intercostal muscles relax and bring the ribs down and inward. The diminished size of the chest cavity increases the pressure in the lungs, thereby forcing air out. A healthy adult breathes in and out about 12 times per minute, but this rate changes with exercise and other factors. Total lung capacity is about 12.5 pints (6 liters). Under normal circumstances, humans inhale and exhale about one pint (475 milliliters) of air in each cycle. Only about three-quarters of this air reaches the alveoli. The rest of the air remains in the respiratory tract. Regardless of the volume of air breathed in and out, the lungs always retain about 2.5 pints (1200 milliliters) of air. This residual air keeps the alveoli and bronchioles partially filled at all times.
Precipitating Factors: • Age PATHOPHYSIOLOGY V. • Immunosuppression • Malnutrition • Systemic Infection: Diabetes Mellitus End-stage Renal Disease HIV or AIDS infection
Predisposing Factors: • Occupation ( e.g. Cobbler) • Repeated close contact w/ infected person • • Indefinite substance abuse via IV Recurrence of infection
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Molino III Bacoor, Cavite
Exposure or inhalation of infected Aerosol through droplet nuclei (exposure to infected clients by coughing, sneezing, talking)
Tubercle bacilli invasion in the apices of the Lungs or near the pleurae of the lower lobes Bronchopneumonia develops in the lung tissue (Phagocytosed tubercle bacilli are ingested by macrophages) -bacterial cell wall binds with macrophages -arrest of a phagosome which results to bacilli replication
Necrotic Degeneration occurs (production of cavities filled with cheese-like mass of tubercle bacilli, dead WBCs, necrotic lung tissue)
drainage of necrotic materials into the tracheobronchial tree (eruption of coughing, formation of lesions) PRIMARY INFECTION
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Molino III Bacoor, Cavite
Lesions may calcify (Ghon’s Complex) and form scars and may heal over a period of time Tubercle bacilli immunity develops (2 to 6 weeks after infection) (maintains in the body as long as living bacilli remains in the body) Acquired immunity leads to further growth Of bacilli and development of ACTIVE INFECTION
SIGNS AND SYMPTOMS Pulmonary Symptoms: Dyspnea Non-productive or productive cough Hemoptysis (blood tinge sputum) Chest pain that may be pleuritic or dull Chest tightness Crackles may be present on auscultation General Symptoms: • Fatigue • Anorexia • Weight loss • Low grade fever with chills • Sweats (often at night)
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With Medical Intervention
Without Medical Intervention
University of Perpetual Help System DALTA
COLLEGE OF NURSING
Molino III Bacoor, Cavite
Early detection/ diagnosis of the dse Multi-antibacterial therapy Fixed- dose therapy TB DOTS (Direct Observed Therapy) BCG vaccination
Reactivation of the tubercle bacilli (Due to repeated exposure to infected Individuals, Immunosuppression) SECONDARY INFECTION
No Recurrence
Recurrence
Severe occurrence of lesions in the lungs
Good Prognosis
Bad Prognosis
Cavitation in the lungs occurs
Active infection is spread throughout the body system (infiltration of tubercle bacilli in other organs) TB of the bones Pott’s disease Renal TB
Severe occurance of Infection (Client become clinically ill)
BAD PROGNOSIS
DEATH VI. MEDICAL – SURGICAL MANAGEMENT 1. Procedure Procedure Indication/Analysis
Nursing Responsibility
University of Perpetual Help System DALTA
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Molino III Bacoor, Cavite 1. Direct Sputum Smear Microscopy (DSSM) -Examination of the sputum under the microscope can show the presence of tuberculosis-like bacteria. Bacteria of the mycobacterium family, including atypical mycobacteria, stain positive with special dyes and are referred to as acid-fast bacteria. A sample of sputum also is usually taken and grown (cultured) in special incubators so that the tuberculosis bacteria can subsequently identified as tuberculosis or atypical tuberculosis. Nursing responsibility done before sputum collection: • Before collecting a sputum specimen the health worker should explain briefly to the pt the reason for sputum collection. Nursing responsibility done during sputum collection: • Specimen collection should be under supervision of health worker. • The pt should rinse his mouth with water before producing sputum. • Whenever possible, sputum should be collected in an open air. • Provide comfort to pt by separating him from other pt at the time of collection. • The health worker should show the pt how to cough up sputum. He should then ask the pt to cough deeply. • The health worker should make sure no one is standing in front of the pt who is trying to cough up sputum. • When the pt only cough up saliva or not enough sputum, the health worker should use ask the pt to repeat coughing until he produces enough sputum. Nursing responsibility done after sputum collection: • The health worker should place the lid on the container and firmly close it. • Put the container into a special box for transport to the laboratory. • The health worker should wash his hands thoroughly with soap and water. • The health worker should give the pt a new sputum container and make sure the pt understands that
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COLLEGE OF NURSING
Molino III Bacoor, Cavite he must spit into the container as soon as he coughs up sputum in the morning and then return it to the health center immediately. After sputum specimen is taken from the sputum container to be examined the container must be destroyed.
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2. Chest X-ray
-is a procedure that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs of the chest. The chest x-ray can reveal evidence of active tuberculosis pneumonia. Other times, the x-rays may show scarring (fibrosis) or hardening (calcification) in the lungs, suggesting that the TB is contained and inactive.
Nursing responsibility done before the procedure: • Before chest x-ray the health worker should explain briefly the procedure and the reason for doing chest x-ray Nursing responsibility done during the procedure: • Request pt to use a chest x-ray gown, and extra metallic object such as jewelry are removed from the chest and/or neck areas • Patient may be asked to breathe and hold it during the chest x-ray in order to inflate the lungs to their maximum to increase the visibility of different tissues within the chest. Nursing responsibility done after the procedure: • After the procedure the health worker is responsible in getting the results • The health worker should instruct the pt to deliver the result to a doctor to interpret the results.
2. Pharmacotherapeutics/ Medicines Generic name Indication, Dosage Classification and Frequency
Side effects and Adverse reaction
Nursing Responsibilities
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Molino III Bacoor, Cavite Rifampicin Indication: Maintenance phase treatment of all forms of pulmonary and extra pulmonary tuberculosis. For continuation phase of short course antituberculosis treatment. Dosage and Frequency: Give 1 hr before or 2 hrs after meal. 600mg tab daily GI disturbances, nausea, vomiting, diarrhea and anorexia. Shortness of breath. GI bleeding, erosive gastritis, ulcerative and eosinophilic colitis. Skin Reactions. • Asses laboratory examinations: sputum, chest x-ray before treatment Instruct client to take with meals to decrease GI symptoms; better to take on empty stomach 1 hr before meals or 2 hrs after meal, with full glass of water. Instruct client to complete full course therapy and do not skip doses. Inform client that this medication will discolor urine, stool saliva, tears, sweat and other body fluid a red-brown color. Instruct client to report any adverse effect immediately. Asses laboratory examinations: sputum, chest x-ray before treatment Give with meals to decrease GI symptoms; absorption is better when taken on empty stomach Instruct patient that compliance with doses schedule for duration is necessary to gain benefits. Caution patient in alcohol while in therapy, this may increase risk for liver damage.
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• Isoniazid Indication: Treatment of pulmonary and extra pulmonary tuberculosis. Dosageand Frequency: 300 mg tablet daily Various skin eruptions, fever, lymphadenopathy and vasculitis, hypersensitivity, nausea and vomiting, GI disturbances •
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Molino III Bacoor, Cavite • Give patient written directions on which foods to avoid while taking this medication. Asses pt condition before therapy Obtain baseline hematologic, renal and liver status and monitor regularly during therapy Monitor for drug induced adverse reaction Give with meals to decrease GI symptoms Give antiemetic if persistent vomiting occurs. Stress the importance of compliance with dosage and duration to insure therapeutic success and prevent relapse. Remind pt to also comply with follow-up schedules. Asses laboratory examinations: sputum, chest x-ray before treatment Perform visual acuity and color discrimination tests before and during therapy. Monitor for adverse reaction Give with meals to decrease GI symptoms Give antiemetic if persistent vomiting
Pyrazinamide
Indication: Treatment of active tuberculosis in adults and selected children. Dosage and Frequency: 15 to 30 mg/kg body weight. Give once a day
Dose-related hepatotoxicity, nausea, vomiting and anorexia. Thrombocytopenia. Hypersensitivity, gout.
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• Ethambutol Indication: Ethambutol is used with other antituberculous drugs in the primary treatment of pulmonary and extra pulmonary tuberculosis to suppress emergence of resistance to the other drugs used in the regimen. Retrobulbar neuritis with reduction in visual acuity, constriction of visual field, central or peripheral scotoma and green-red color blindness. •
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Molino III Bacoor, Cavite Dosage and Frequency: 15 mg/ kg body weight daily Streptomycin Indication: Used in combination with other agents for treatment of mycobacterial infections. Dosage and Frequency: 1g IM 2 or 3 times a week Allergic reactions, disturbances of vestibular function, paresthesia. occurs Stress the importance of compliance with dosage and duration to eradicate disease Obtain pt history and drug history before administration Instruct the client not to discontinue even if they feel better Advise client to take small, frequent meals, frequent mouth care, sucking lozenges, or chewing gum may help to minimize nausea, vomiting or loss of appetite.
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VII. PROGRESS NOTES Day # Day 1 August 31, 2010 Existing cues/ problems Interventions actually done Client’s response The patient is scheduled to get her medicines on August 31 2010 (Tuesday) from the health center. The patient is assessed and has presence of crackles, productive cough with sputum of yellowish in color. The patient is pale. The patient verbalized that sometimes she has body weakness and feels dizzy. She reports that she has difficulty of breathing because she keeps coughing. She also reports that she has dark colored stool. She is currently on her fourth week of regimen after diagnosed with Pulmonary Tuberculosis upon a positive scar in her lungs by chest x-ray. She was instructed to take a 6 months multi-drug therapy and she has benn complying to her treatment
VIII.
DISCHARGE PLANNING Continue Taking the Anti-TB drugs. The intensive phase is for 2 months and the maintenance phase is for 4 months. Medicines are
Medications
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Molino III Bacoor, Cavite readily available at the health center. 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. The patient may continue her work in the factory. Follow faithfully the regimen for tuberculosis, especially the medications. Have a regular sputum test, as ordered by the doctor. 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. 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. The diet should be high caloric. Always drink a lot of water. Also eat fruits 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. Always pray for the guidance of the Lord. Spiritual health affects the wellness of an individual greatly. Strengthen relationship with Lord by showing love and respect to the people around you.
Exercise/Economic Factor
Treatment Health Teaching
Out patient Followup
Diet
Spiritual/Sexual Activities IX.
SUMMARY OF CLIENT’S STATUS
August 31, 2010 upon consultation the patient asked for her weekly medicines that was our chance for our first interview with our patient. First we asked a few questions regarding her health history including her past illnesses, health status and personal information. As we observed, the patient has presence of body weakness and dizziness and we also observed that she looks pale and has difficulty of breathing with productive cough and has presence of crackles because of respiratory problems. We also observed that the patient is eager to be treated by updating her medications weekly in the health center. As a student nurse we encouraged her to report if her present condition is improving.
COLLEGE OF NURSING
Molino III Bacoor, Cavite I. HEALTH HISTORY A. DEMOGRAPHIC (BIOGRAPHICAL DATA) 1. Client’s Initial: L. N. 2. Gender: Female 3. Age/ Birthdate/ Birthplace: 35/ 12.23.1975/ Bukidnon 4. Marital Status: Married 5. Nationality: Filipino 6. Religion: Catholic 7. Address: Dalla, Green Valley, San Nicolas III Bacoor, Cavite 8. Educational Background: 3rd Year College 9. Occupation: Shoe repair 10. Usual Source of Medical Care: Health Center 11. Initial Diagnosis: Presence of scar in the right lung upon chest xray 12. Final Diagnosis: Pulmunary Tuberculosis B. SOURCE AND RELIABILITY OF FORMATION • Client herself who seems reliable C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS • Chest pain for 2 hours • Restlessness • Loss of appetite D. HISTORY OF PRESENT ILLNESS 8 Critical Characteristics 1. Timing: Patient’s condition started about 6 months prior to consultation, as onset of cough, productive. 2. Location: Right lung 3. Quality: She had productive cough non-bloody with yellowish secretions. 4. Quantity: She also experience stabbing pain on her chest according to the assessment it is 6/10 and it radiates to his back. 5. Setting: Prior to consultation 6. Associated phenomena/ Factors: Type of work and crowded living space 7. Aggravating and Alleviating factors: Personal habits 8. Client’s Perception: She does not seek for any medical care from the physician because according to her it is still tolerable.
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Molino III Bacoor, Cavite E. PAST MEDICAL HISTORY OR PAST HEALTH • Pediatric/ childhood/ adult illness: Measles • Injuries or accident: none • Hospitalization: none • Operation: none • Obstetric History: G5 P4 • Allergies: tuyo, eggs • Medications (Prescribed and OTC drugs): Rifampicin, Isoniacid, Pyrazinamide, Ethambutol • Medications (allergies): none • Last Examination date: 07/06/10 F. FAMILY HISTORY (FAMILY TREE or GENOGRAM/ROSTER)
54 60
B. N. G. N.
A.N. R.N. R.N. L.N. 40 38 36 26 24 22
A.N. M.N. 35 19
M.N. G.N. 33
B.N 31
E.N. 30
A.N.
J.N. 28
LEGEND: - FEMALE - MALE - PATIENT G. SOCIO- ECONOMIC FAMILY MEMBER OCCUPATION
MONTHLY INCOME
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Molino III Bacoor, Cavite R. N. L. N. SHOE REPAIR SHOE REPAIR 500 400- 500
H. DEVELOPMENTAL HISTORY Generativity vs. Stagnation (Middle Adulthood, 35 to 65 years) Generativity is the concern of establishing and guiding the next generation. Socially-valued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity- a sense of productivity and accomplishment- results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation- a dissatisfaction with the relative lack of productivity. Central tasks of Middle Adulthood Express love through more than sexual contacts. Maintain healthy life patterns. Develop a sense of unity with mate. Help growing and grown children to be responsible adults. Relinquish central role in lives of grown children. Accept children's mates and friends. Create a comfortable home. Be proud of accomplishments of self and mate/spouse. Reverse roles with aging parents. Achieve mature, civic and social responsibility. Adjust to physical changes of middle age. Use leisure time creatively. Love for others I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. ROS AND PE System ROS PE SIGNIFICANCE A. General/ “Minsan nakakaramdam (+) weakness Due to respiratory Overall health status ako ng pagkahilo”, as (+) dizziness problems. verbalized by the patient. B. Integument --------(-) history of skin --------disease (-) hair loss
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Molino III Bacoor, Cavite (-) change in nail shape (-) severe headache (-) any head injury (-) eye problem (-) tinnitus (-) history of infection (-) hearing aid use (-) discharge from nares (-) tenderness (-) presence of lesions (+) black dicoloration of the enamel. (+) tooth decay (+) jaundice sclera (+) halitosis (-) stiffness (-) lumps or swelling (-) goiter (-) pain (-) nipple discharge (-) history of breast disease (+) wheezing (+)cough (+)sputum (+)varicosities (+)dizziness (+)dyspnea (+)generalized pallor
C. Head
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D. Eyes E. Ears
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F. Nose and Sinuses
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G. Mouth and Throat
“May bulok na ngipin ako pero di ko pinapabunot.”, as verbalized by the patient.
Due to improper or ineffective oral hygiene.
H. Neck
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I. Breast and Axillae
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J. Respiratory K. Cardiovascular
“Nahihirapan akong huminga” as verbalized by the patient. “May mga ugat ako sa binti ”, as verbalized by the patient.
Due to respiratory muscle fatigue. Due to insufficient oxygen in the peripheral arteries and capillary.
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Molino III Bacoor, Cavite L. Gastrointestinal “Maitim yung dumi ko na parang kulay dugo”, as verbalized by the patient. “Kulay dugo rin yung ihi ko”, as verbalized by the patient. (+)dark colored stool Due to medications given for PTB. Due to medications given for PTB.
M. Urinary
O. Musculoskeletal P. Neurologic
Q. Hematologic
R. Endocrine
(+)dark orange urine (+)UTI (+)pain in the suprapubic region “Pinupulikat ako minsan”, (+) spasticity as verbalized by the patient. --------(-) history of seizure disorder (-) paresis (-) hallucinations --------(-) excessive bruising (-) lymp node swelling (-) blood tranfusions and reactions --------(-) history of diabetic symptom (-) excessive sweating (-) tremors
Due to inadequate rest during work. ---------
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Molino III Bacoor, Cavite
J. FUNCTIONAL ASSESSMENT 1. Health perception- Health Management The patient doesn’t have complete immunization because according to her it is not available during those days and having immunization during those years are expensive and they cannot afford it. She was never been hospitalized. Does not experience any accidents. When she had a disease, she used herbal medicines like guava leaves, oregano, lagundi, etc. For her, being healthy is important. A person is healthy when she is strong, she can do what she wants and does not experience any diseases. She does not have any regular medical and dental check-ups. When she is experiencing something wrong in her body, she does not tell it promptly because according to her it is tolerable. She does not have a regular exercise, instead she cleans the house and washes the clothes of her family. The patient is malnourished. She takes a bath once a day and brushes her teeth once a day. She does use lotion, shampoo and soap. She washes her hands regularly but not always using soap. When she feels discomfort in her body she also goes to the manghihilot because it is available on their area and it is more approachable. She often forgot to cover her mouth and nose when someone sneezes and coughs in front of her. A person has a disease when she eats little amount of food, when she is weak. Health for her is important for proper functioning. Whenever she is sick, she get’s money from her children especially to the eldest, which is working abroad. She wears slippers while inside their house. She feels that her hygienic practices are adequate, and she feels clean and neat. The patient is non-smoker and she does not drink any alcoholic beverages. She denies the use any illicit drugs.
2. Self-perception According to her there is something wrong in her health and body. As a mother, she sometimes feels sad because she cannot do the previous things like going with her husband in the farm. According to her husband she is a good mother and a good wife. Her strength is her family, when there are any circumstances that involving any family member she is concerned and make some moves. She is simple.
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Molino III Bacoor, Cavite 3. ACTIVITY Feeding Bathing Toileting Bed Mobility Dressing Grooming General Mobility Legend: Legend Level 0 Level 1 Level 2 Level 3 Level 4 Activity/ Exercise pattern BEFORE HOSPITALIZATION 0 0 0 0 0 0 0 Functional Level Code Full self care Requires use of requirements or device Requires assistance or supervision from another person Requires assistance or supervision from another person or device Is dependent and does not participate DURING HOSPITALIZATION 2 0 0 0 0 0 0
4. Sleep and Rest The patient regularly sleeps at 8:00pm and wakes up at 1:00 pm. She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough. She usually sits because according to her she can breath more easily. She takes a nap in the morning from 8 am to 11 am. She feels that her sleep and rest is inadequate. She sleeps together with her husband. They have a separate room from their children. Sleeping is important to her. 5. Nutrition/ Elimination
Nutrition She loves to eat pork, fish and vegetables. She is not choosy when it comes to any cook and kind of food. She eats 3x a day. She does not eat any junk foods. She drinks 5 glasses of water a day. For her, the amount of food she consumes is adequate. She takes food supplement but it is not frequent. During snack time, she usually eats banana because it is affordable and readily available in their place. When her cough started, she is not eating the appropriate amount of food. According to her husband, she usually eats 4 spoons of rice with viand only. It is due to her cough. During her hospitalization, she is on diet as tolerated with aspiration precaution. She eats food given by the hospital. She is taking vitamin B6 and other medications.
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Molino III Bacoor, Cavite Elimination She defecates twice a week and sometimes she feels pain and difficulty. According to her the characteristic of her stool is hard, dry and colored dark brown. She feels pain at her abdomen on the hypogastric and umbilical area. She urinates 7x a day and does not feel any pain and difficulty. Previously her defecation pattern is daily, but when her condition exacerbated, it is also affected. 6. Sexuality-reproductive She is engage in sexual activity to her husband only. Presently she is still active in her sex life. She still have regular menstruation. She is aware that she will have cessation of her menstruation. She dresses appropriately, based on her gender. She is also able to express her feminine attitudes. 7. Interpersonal relationship/resources She was the fourth child in her family. She is married and they have 4 children. She is performing the trypical responsibilities of a plain house wife. Her children have a good relationship to her. She is being cared by her children who are very supportive to her. Her husband is a good husband he is a provider who does everything for the family to have food. She has a harmonious relationship with her brothers and sisters. Whenever there are any problems, they are helping each other. She can form a healthy relationship with others. She is the person who chooses her friends. She is a very quite person. She does not have any enemies. 8. Coping-stress management/tolerance pattern Whenever she has problem, she asks guidance from our Lord. She watches television as her stress management. She always listen to radio programs when she feels lonely. When she gets mad, she just keep quiet. When she experiences coughing and difficulty of breathing she just relaxes and breathes deeply. Her husband or children taps her back when she coughs. 9. Personal habits The patient is non-smoker. She does not drink any alcoholic beverages. She denies the use any illicit drugs. 10. Environmental hazards She is living in a crowded area. She is living together with her 3 children and husband. She knew all of her neighbors. She thinks that she is safe in her home. She is complaining about the lack of utilities in their neighborhood. She is living near the high-way. She is not involved in any community services. Because her job involves being exposed outside she thinks that it is not safe for her most especially during night.
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Molino III Bacoor, Cavite
II. PROBLEM LIST
A. ACTUAL or ACTIVE Problem No. Problem 1 2 3 Difficulty in breathing Activity intolerance Fatigue
Date Indentified August 31, 2010 August 31, 2010 August 31, 2010 Date Identified -----------------
Date Resolved/ Remarks Resolved Unresolved Unresolved Status Unresolved Unresolved
B. HIGH RISK or POTENTIAL Problem No. Problems 1 Self care deficit in hygiene 2 Infection III. NURSING CARE PLAN
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Molino III Bacoor, Cavite
IV. ANATOMY AND PATHOPHYSIOLOGY
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. Respiratory tract The respiratory tract cleans, warms, and moistens air during its trip to the lungs. The tract can be divided into an upper and a lower part. The upper part consists of the nose, nasal cavity, pharynx (throat), and larynx (voice box). The lower part consists of the trachea (windpipe), bronchi, and bronchial tree. The nose has openings to the outside that allow air to enter. Hairs inside the nose trap dirt and keep it out of the respiratory tract. The external nose leads to a large cavity within the skull, the nasal cavity. This cavity is lined with mucous membrane and fine hairs called cilia. Mucus moistens the incoming air and traps dust. The cilia move pieces of the mucus with its trapped particles to the throat, where it is spit out or swallowed. Stomach acids destroy bacteria in swallowed mucus. Blood vessels in the nose and nasal cavity release heat and warm the entering air. Air leaves the nasal cavity and enters the pharynx. From there it passes into the larynx,
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Molino III Bacoor, Cavite which is supported by a framework of cartilage (tough, white connective tissue). The larynx is covered by the epiglottis, a flap of elastic cartilage that moves up and down like a trap door. The epiglottis stays open during breathing, but closes during swallowing. This valve mechanism keeps solid particles (food) and liquids out of the trachea. If something other than air enters the trachea, it is expelled through automatic coughing. Alveoli: Tiny air-filled sacs in the lungs where the exchange of oxygen and carbon dioxide occurs between the lungs and the bloodstream. Bronchi: Two main branches of the trachea leading into the lungs. Bronchial tree: Branching, air-conducting subdivisions of the bronchi in the lungs. Diaphragm: Dome-shaped sheet of muscle located below the lungs separating the thoracic and abdominal cavities that contracts and expands to force air in and out of the lungs. Epiglottis: Flap of elastic cartilage covering the larynx that allows air to pass through the trachea while keeping solid particles and liquids out. Pleura: Membranous sac that envelops each lung and lines the thoracic cavity. Air enters the trachea in the neck. Mucous membrane lines the trachea and C-shaped cartilage rings reinforce its walls. Elastic fibers in the trachea walls allow the airways to expand and contract during breathing, while the cartilage rings prevent them from collapsing. The trachea divides behind the sternum (breastbone) to form a left and right branch, called bronchi (pronounced BRONG-key), each entering a lung. 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-oleye). The average person has a total of about 700 million gas-filled 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.
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Molino III Bacoor, Cavite This process—external respiration—causes the blood to leave the lungs laden with oxygen and cleared of carbon dioxide. When this blood reaches the cells of the body, internal respiration takes place. The oxygen diffuses or passes into the tissue fluid, and then into the cells. At the same time, carbon dioxide in the cells diffuses into the tissue fluid and then into the capillaries. The carbon dioxide-filled blood then returns to the lungs for another cycle.
Breathing Breathing exchanges gases between the outside air and the alveoli of the lungs. Lung
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Molino III Bacoor, Cavite expansion is brought about by two important muscles, the diaphragm (pronounced DIE-afram) and the intercostal muscles. The diaphragm is a dome-shaped sheet of muscle located below the lungs that separates the thoracic and abdominal cavities. The intercostal muscles are located between the ribs. Nerves from the brain send impulses to the diaphragm and intercostal muscles, stimulating them to contract or relax. When the diaphragm contracts, it moves down. The dome is flattened, and the size of the chest cavity is increased. When the intercostal muscles contract, the ribs move up and outward, which also increases the size of the chest cavity. By contracting, the diaphragm and intercostal muscles reduce the pressure inside the lungs relative to the pressure of the outside air. As a consequence, air rushes into the lungs during inhalation. During exhalation, the reverse occurs. The diaphragm relaxes and its dome curves up into the chest cavity, while the intercostal muscles relax and bring the ribs down and inward. The diminished size of the chest cavity increases the pressure in the lungs, thereby forcing air out. A healthy adult breathes in and out about 12 times per minute, but this rate changes with exercise and other factors. Total lung capacity is about 12.5 pints (6 liters). Under normal circumstances, humans inhale and exhale about one pint (475 milliliters) of air in each cycle. Only about three-quarters of this air reaches the alveoli. The rest of the air remains in the respiratory tract. Regardless of the volume of air breathed in and out, the lungs always retain about 2.5 pints (1200 milliliters) of air. This residual air keeps the alveoli and bronchioles partially filled at all times.
Precipitating Factors: • Age PATHOPHYSIOLOGY V. • Immunosuppression • Malnutrition • Systemic Infection: Diabetes Mellitus End-stage Renal Disease HIV or AIDS infection
Predisposing Factors: • Occupation ( e.g. Cobbler) • Repeated close contact w/ infected person • • Indefinite substance abuse via IV Recurrence of infection
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Molino III Bacoor, Cavite
Exposure or inhalation of infected Aerosol through droplet nuclei (exposure to infected clients by coughing, sneezing, talking)
Tubercle bacilli invasion in the apices of the Lungs or near the pleurae of the lower lobes Bronchopneumonia develops in the lung tissue (Phagocytosed tubercle bacilli are ingested by macrophages) -bacterial cell wall binds with macrophages -arrest of a phagosome which results to bacilli replication
Necrotic Degeneration occurs (production of cavities filled with cheese-like mass of tubercle bacilli, dead WBCs, necrotic lung tissue)
drainage of necrotic materials into the tracheobronchial tree (eruption of coughing, formation of lesions) PRIMARY INFECTION
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Molino III Bacoor, Cavite
Lesions may calcify (Ghon’s Complex) and form scars and may heal over a period of time Tubercle bacilli immunity develops (2 to 6 weeks after infection) (maintains in the body as long as living bacilli remains in the body) Acquired immunity leads to further growth Of bacilli and development of ACTIVE INFECTION
SIGNS AND SYMPTOMS Pulmonary Symptoms: Dyspnea Non-productive or productive cough Hemoptysis (blood tinge sputum) Chest pain that may be pleuritic or dull Chest tightness Crackles may be present on auscultation General Symptoms: • Fatigue • Anorexia • Weight loss • Low grade fever with chills • Sweats (often at night)
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With Medical Intervention
Without Medical Intervention
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Molino III Bacoor, Cavite
Early detection/ diagnosis of the dse Multi-antibacterial therapy Fixed- dose therapy TB DOTS (Direct Observed Therapy) BCG vaccination
Reactivation of the tubercle bacilli (Due to repeated exposure to infected Individuals, Immunosuppression) SECONDARY INFECTION
No Recurrence
Recurrence
Severe occurrence of lesions in the lungs
Good Prognosis
Bad Prognosis
Cavitation in the lungs occurs
Active infection is spread throughout the body system (infiltration of tubercle bacilli in other organs) TB of the bones Pott’s disease Renal TB
Severe occurance of Infection (Client become clinically ill)
BAD PROGNOSIS
DEATH VI. MEDICAL – SURGICAL MANAGEMENT 1. Procedure Procedure Indication/Analysis
Nursing Responsibility
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Molino III Bacoor, Cavite 1. Direct Sputum Smear Microscopy (DSSM) -Examination of the sputum under the microscope can show the presence of tuberculosis-like bacteria. Bacteria of the mycobacterium family, including atypical mycobacteria, stain positive with special dyes and are referred to as acid-fast bacteria. A sample of sputum also is usually taken and grown (cultured) in special incubators so that the tuberculosis bacteria can subsequently identified as tuberculosis or atypical tuberculosis. Nursing responsibility done before sputum collection: • Before collecting a sputum specimen the health worker should explain briefly to the pt the reason for sputum collection. Nursing responsibility done during sputum collection: • Specimen collection should be under supervision of health worker. • The pt should rinse his mouth with water before producing sputum. • Whenever possible, sputum should be collected in an open air. • Provide comfort to pt by separating him from other pt at the time of collection. • The health worker should show the pt how to cough up sputum. He should then ask the pt to cough deeply. • The health worker should make sure no one is standing in front of the pt who is trying to cough up sputum. • When the pt only cough up saliva or not enough sputum, the health worker should use ask the pt to repeat coughing until he produces enough sputum. Nursing responsibility done after sputum collection: • The health worker should place the lid on the container and firmly close it. • Put the container into a special box for transport to the laboratory. • The health worker should wash his hands thoroughly with soap and water. • The health worker should give the pt a new sputum container and make sure the pt understands that
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Molino III Bacoor, Cavite he must spit into the container as soon as he coughs up sputum in the morning and then return it to the health center immediately. After sputum specimen is taken from the sputum container to be examined the container must be destroyed.
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2. Chest X-ray
-is a procedure that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs of the chest. The chest x-ray can reveal evidence of active tuberculosis pneumonia. Other times, the x-rays may show scarring (fibrosis) or hardening (calcification) in the lungs, suggesting that the TB is contained and inactive.
Nursing responsibility done before the procedure: • Before chest x-ray the health worker should explain briefly the procedure and the reason for doing chest x-ray Nursing responsibility done during the procedure: • Request pt to use a chest x-ray gown, and extra metallic object such as jewelry are removed from the chest and/or neck areas • Patient may be asked to breathe and hold it during the chest x-ray in order to inflate the lungs to their maximum to increase the visibility of different tissues within the chest. Nursing responsibility done after the procedure: • After the procedure the health worker is responsible in getting the results • The health worker should instruct the pt to deliver the result to a doctor to interpret the results.
2. Pharmacotherapeutics/ Medicines Generic name Indication, Dosage Classification and Frequency
Side effects and Adverse reaction
Nursing Responsibilities
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Molino III Bacoor, Cavite Rifampicin Indication: Maintenance phase treatment of all forms of pulmonary and extra pulmonary tuberculosis. For continuation phase of short course antituberculosis treatment. Dosage and Frequency: Give 1 hr before or 2 hrs after meal. 600mg tab daily GI disturbances, nausea, vomiting, diarrhea and anorexia. Shortness of breath. GI bleeding, erosive gastritis, ulcerative and eosinophilic colitis. Skin Reactions. • Asses laboratory examinations: sputum, chest x-ray before treatment Instruct client to take with meals to decrease GI symptoms; better to take on empty stomach 1 hr before meals or 2 hrs after meal, with full glass of water. Instruct client to complete full course therapy and do not skip doses. Inform client that this medication will discolor urine, stool saliva, tears, sweat and other body fluid a red-brown color. Instruct client to report any adverse effect immediately. Asses laboratory examinations: sputum, chest x-ray before treatment Give with meals to decrease GI symptoms; absorption is better when taken on empty stomach Instruct patient that compliance with doses schedule for duration is necessary to gain benefits. Caution patient in alcohol while in therapy, this may increase risk for liver damage.
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• Isoniazid Indication: Treatment of pulmonary and extra pulmonary tuberculosis. Dosageand Frequency: 300 mg tablet daily Various skin eruptions, fever, lymphadenopathy and vasculitis, hypersensitivity, nausea and vomiting, GI disturbances •
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Molino III Bacoor, Cavite • Give patient written directions on which foods to avoid while taking this medication. Asses pt condition before therapy Obtain baseline hematologic, renal and liver status and monitor regularly during therapy Monitor for drug induced adverse reaction Give with meals to decrease GI symptoms Give antiemetic if persistent vomiting occurs. Stress the importance of compliance with dosage and duration to insure therapeutic success and prevent relapse. Remind pt to also comply with follow-up schedules. Asses laboratory examinations: sputum, chest x-ray before treatment Perform visual acuity and color discrimination tests before and during therapy. Monitor for adverse reaction Give with meals to decrease GI symptoms Give antiemetic if persistent vomiting
Pyrazinamide
Indication: Treatment of active tuberculosis in adults and selected children. Dosage and Frequency: 15 to 30 mg/kg body weight. Give once a day
Dose-related hepatotoxicity, nausea, vomiting and anorexia. Thrombocytopenia. Hypersensitivity, gout.
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• Ethambutol Indication: Ethambutol is used with other antituberculous drugs in the primary treatment of pulmonary and extra pulmonary tuberculosis to suppress emergence of resistance to the other drugs used in the regimen. Retrobulbar neuritis with reduction in visual acuity, constriction of visual field, central or peripheral scotoma and green-red color blindness. •
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Molino III Bacoor, Cavite Dosage and Frequency: 15 mg/ kg body weight daily Streptomycin Indication: Used in combination with other agents for treatment of mycobacterial infections. Dosage and Frequency: 1g IM 2 or 3 times a week Allergic reactions, disturbances of vestibular function, paresthesia. occurs Stress the importance of compliance with dosage and duration to eradicate disease Obtain pt history and drug history before administration Instruct the client not to discontinue even if they feel better Advise client to take small, frequent meals, frequent mouth care, sucking lozenges, or chewing gum may help to minimize nausea, vomiting or loss of appetite.
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VII. PROGRESS NOTES Day # Day 1 August 31, 2010 Existing cues/ problems Interventions actually done Client’s response The patient is scheduled to get her medicines on August 31 2010 (Tuesday) from the health center. The patient is assessed and has presence of crackles, productive cough with sputum of yellowish in color. The patient is pale. The patient verbalized that sometimes she has body weakness and feels dizzy. She reports that she has difficulty of breathing because she keeps coughing. She also reports that she has dark colored stool. She is currently on her fourth week of regimen after diagnosed with Pulmonary Tuberculosis upon a positive scar in her lungs by chest x-ray. She was instructed to take a 6 months multi-drug therapy and she has benn complying to her treatment
VIII.
DISCHARGE PLANNING Continue Taking the Anti-TB drugs. The intensive phase is for 2 months and the maintenance phase is for 4 months. Medicines are
Medications
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Molino III Bacoor, Cavite readily available at the health center. 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. The patient may continue her work in the factory. Follow faithfully the regimen for tuberculosis, especially the medications. Have a regular sputum test, as ordered by the doctor. 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. 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. The diet should be high caloric. Always drink a lot of water. Also eat fruits 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. Always pray for the guidance of the Lord. Spiritual health affects the wellness of an individual greatly. Strengthen relationship with Lord by showing love and respect to the people around you.
Exercise/Economic Factor
Treatment Health Teaching
Out patient Followup
Diet
Spiritual/Sexual Activities IX.
SUMMARY OF CLIENT’S STATUS
August 31, 2010 upon consultation the patient asked for her weekly medicines that was our chance for our first interview with our patient. First we asked a few questions regarding her health history including her past illnesses, health status and personal information. As we observed, the patient has presence of body weakness and dizziness and we also observed that she looks pale and has difficulty of breathing with productive cough and has presence of crackles because of respiratory problems. We also observed that the patient is eager to be treated by updating her medications weekly in the health center. As a student nurse we encouraged her to report if her present condition is improving.
