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Introduction
As it was written and said by the many, disease and illness have plagued
human race since ancient time. Through years, people were full of queries and
speculations that why some individuals become sick physically weak while
other remain healthy. Why a condition turns out to a severe one? Why an organ
complicates another at a later time? From that, people became more curious on
how it can affect the body and how it can be cured.
Various disease and illness exist nowadays, just like on this case that the
researchers studied. Through its complexity they were puzzled on, how can
these bacteria affects the body? What manifestation and complications may
arise? This brings their attention to focus. From this study, they can then fully
understand the cause, its schematic flow and how it can alter a persons body.
Pulmonary Tuberculosis, a chronic sub-acute or acute respiratory disease
commonly affecting the lungs characterized by the formation of tubercles in the
tissue which tend to undergo cessation, necrosis and calcification. It is also
known as a poor mans disease or consumption disease. The causative agent in
this disease is Mycobacterium tuberculosis, a rod shaped bacteria that has
plagued humans since the Neolithic times. The bacteria usually attack the lungs,but they can also damage other parts of the body. TB spreads through the air
when a person with TB on the lungs or throat coughs, sneezes or talks.
If left untreated, each person with active TB disease will infect an average
of 10 to 15 people every year. But people infected with TB bacilli will not
necessarily become sick, only if the immune system " walls off " the TB bacilli
which, protected by a thick waxy coat, can lie dormant for years. When the
immune system is weakened, the chances of becoming sick are greater.
Global and Regional Incidence
Tuberculosis continues to be a major health problem worldwide. In 2008,
the World Health Organization (WHO) estimated that the largest number of new
TB cases occurred in the South-East Asia Region, which accounted for 35% of
incident cases globally. However, the estimated incidence rate in sub-Saharan
Africa is nearly twice that of the South-East Asia Region with over 350 cases per
100, 000 populations.
An estimated 1.7 million people died from TB in 2009. The highest number
of deaths was in the Africa Region. More than 90% of TB cases occur in
developing nations that have poor hygiene and health-care resources, and high
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numbers of people infected with HIV. The highest case rates occur in non-white
males over 30 years of age and non-white females over 60.
National and Regional Incidence
TB is one of the top 10 leading cause of morbidity and mortality rates in
the country. In 2007, the Philippines recorded over 86,000 TB cases based on
the 2009 World Health Organization Report but the trend is increasing as for this
year, it is estimated that 133 people out of 100, 000 population has TB.
Cebu, Philippines - has the highest number of cases of tuberculosis in the
region while Central Visayas is included in the top 10 regions nationwide with the
highest incidence rate of TB cases.
The Philippines ranks 9th worldwide in the incidence of the ordinary TB
disease which can easily be treated. And remember, a new infection occurs
every second.
Risk Factors for TB:
Low socioeconomic status
Homelessness Alcoholism
HIV patient
Weakened immune system
Crowded living conditions
Person who frequently travel to place with high incidence rate
Health-care workers
Ethical Consideration
Oral informed consent was obtained from the patient and her significant
others for the case discussion and physical assessment. The study was
approved by the Clinical Instructor and the staff of CUMC Station 4.
Study Design and Data Collection
Interview was conducted and answered by the patient and her significant
others.
Rationale for Choosing the Case
The researchers decided to choose this case because they wanted to:
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Acquire more knowledge about Pulmonary Tuberculosis.
Know the factors why and how the patient was affected by PTB.
Use the acquired knowledge in promoting awareness to the people (to
seek for medical care in order to prevent the progression of the disease).
Significance of the Study
This study will help the nursing profession by providing information about
the proper management and care for PTB patient. It will also educate the people
to seek medical care in order to prevent PTB.
It will increase awareness about the importance of having a healthy
lifestyle and clean environment. And will also elaborate the inter relatedness of
lifestyle habits, environment and acquiring Pulmonary Tuberculosis.
Objectives
After the completion of this study, the researchers will have been able to:
Perform the thorough assessment and implementation of care to a PTB
patient.
Review the background of the disease and the signs and symptoms.
Reassess the risk factors, the diagnostic procedures and the needed
medical treatment.
Formulate nursing care plan based on the nursing process.
Perform the needed nursing care and intervention to better the health of
the patient.
Provide information about the disease: occurrence and contributing
factors.
Give health teachings and the importance of family involvement to better
the health of the patient.
Scope and Limitations of the Study
This study is focused on the nursing aspect of care to those patients who
have Pulmonary Tuberculosis. This study will only be used in the nursing
profession.
The researchers only focused their attention on medications, diagnostics,
nursing care plan, pathophysiology and discharge planning.
This study is not limited to PTB patients only, but it is also for all people
who are interested in PTB. We are more focused on primary preventions through
health teachings because primary prevention is the true prevention.
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Authors Contributions
The group did their interview and physical assessment last January 04,
2011. Discussion and interpolations was raised. Each of the authors was given
assignments and submitted their drafts. And final brain-storming was
scheduled.
Conceptual Frameworks
This study is anchored on these following theories:
Abraham Maslow's Hierarchy of Needs
Maslow's hierarchy of needs is often portrayed in the shape of a pyramid,
with the largest and most fundamental levels of needs at the bottom, and the
need forself-actualization at the top.
Florence Nightingales Environmental Theory
The act of utilizing the environment of the patient to assist in his recovery
Focuses on changing and manipulating the environment in order to put the
patient in the best possible conditions for nature to act. Identified 5 environmentalfactors: fresh air, pure water, efficient drainage, cleanliness/sanitation and
light/direct sunlight. Considered a clean, well-ventilated, quiet environment
essential for recovery.
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Deficiencies in these 5 factors produce illness or lack of health, but with a
nurturing environment, the body could repair itself.
SITUATION
Man needs care, has capacity to
mend
Health altered condition
Environment inefficient drainage,
poor sanitation
Nursing holistic approach
ACTION
- Attended physiologic needs (e.g.
supplement air, adequate water,
etc.)
- Medication regimen
- Provided with clean, quiet and well
ventilated environment
- Nursing care and intervention
This model will help the researchers to compare and contrast their
findings based on the patients condition and how those needs being attended.
Conclusion
Findings from our study indicate that knowledge and awareness of PTB
are still unsatisfactory in Filipino population.
Gender issues should be considered in promoting patients' health-care.
Results of this study are derived from Patient X, but could be discussed also in
relation to other similar condition.
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Clients Profile
A. Demographic Data
This is a case of Patient X, a 17-year-old single female and a Roman Catholic
affiliate residing at Opol, Misamis Oriental. Admitted at Capitol University Medical
City last January 2, 2011 at 5:30pm Station 4; room 421.
B. Vital Signs
The client has the following vital signs and physical exam during the series of
Vital Signs E.R. Admission
assessment
1st week of
assessment
2nd week of
assessment
Blood Pressure
(lying)
150/60 mmHg 100/60 mmHg 100/70 mmHg
Respiratory rate 37cpm 36cpm 34cpm
Pulse rate 120bpm 108bpm 102bpm
Temperature
(Axillary)
37.5 C 39.6 C 36.5 C
O2 saturation 92% 98% 99%
C. Health Perception Assessment:
1. Health Perception and Health Management (Pertinent Clinical History
and Physical examination, Chief complaint, History of Present Illness,
Previous Hospitalization/ Surgeries, other health problems and things done to
manage health)
Chief complaint:
Cough/Fever
History of present illness:
Condition started since 4 months prior to admission as onset ofhard and
productive cough with yellowish phlegm, no shortness of breath, sought
consultation at community health center and sputum test was done. A result of
negative PTB and was given a medication (unremembered brand) for cough,
regimen was not completed due to financial stability and the condition was
getting well.
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Mouth:
Patients lips and gums was pale, tongue is midline with complete teeth.
Pharynx:
Tonsils are not inflamed.
Neck:
Trachea is midline.
Skin:
General color of the patient is pale, with rough texture, with poor skin
turgor, and temperature was warm.
Week 2 (January 11, 2011)
The patient takes in 5-6 glasses of water a day. The client eats 3 meals in
a day with fair appetite and a combination of 1 cup of rice with different viand,
served with DAT with strict aspiration precaution. Upon assessment, the client
had pale skin and body nourishment was maintained. She has an ongoing
intravenous fluid of PLR1L regulated at 20gtts/min, infusing well at the left arm.
Mouth:Patients lips, gums and mucosa were pale; tongue is midline with
complete teeth.
Pharynx:
Tonsils are not inflamed.
Neck:
Trachea is midline.
Skin:
General color of the patient is pallor, still with rough texture, with poor skin
turgorand temperature on normal range.
3. ELIMINATION PATTERN
Week 1 (January 4, 2011)
Patient X has a normal elimination pattern. She defecates once a day or
every other day with moderate amount, formed light brown in color. No
discomforts in the usual bowel pattern.
There was no problem in control upon urination. She urinates 4-5 times a
day with yellowish colored urine for about 150 200cc per urination.
Week 2 (January 11, 2011)
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This week the patient defecated 4 times per week with soft brown stool in
moderate amount. No discomforts in the usual bowel pattern.
There was no problem in control upon urination. She urinates 3-5 times a
day with yellowish colored urine for about 150 200cc per urination.
4. ACTIVITY AND EXERCISE PATTERN
Week 1 (January 4, 2011)
According to the SO the patient has a sedentary lifestyle, her leisure
activities include watching television and listening to music.
Cardiovascular Status:
There was no signs of chest pain, point of maximal impulse best
appreciated at 5th ICS left midclavicular line, heart sounds were distinct and
regular in intervals. Peripheral pulses were symmetrical with Capillary refill time
of 2 seconds.
Respiratory Status:
Breathing Pattern is irregular with 31 cycles per minute, asymmetrical lung
expansion at right lung field; rales at right lung field are heard upon auscultation,with productive cough, plenty of yellowish sputum. The patient is on Oxygen
inhalation regulated at 2 LMP via nasal cannula.
Activities of daily living:
The patient is in assist with person to Feeding, bathing, dressing,
grooming, meal preparations, cleaning, laundry, toileting, bed mobility, chair/toilet
transfer, ambulation and in active-passive R.O.M. The reasons for ADL/mobility
limitations are due to weakness in the lower extremities as well as due to IVF line
connected to the patient.
Week 2 (January 11, 2011)
Cardiovascular Status:
There was no signs of chest pain, point of maximal impulse best
appreciated at 5th ICS left midclavicular line, heart sounds were distinct and
regular in intervals. Peripheral pulses were symmetrical with Capillary refill time
of 2 seconds.
Respiratory Status:
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Breathing Pattern is irregularwith 34 cycles per minute, asymmetrical lung
expansion at right lung field, rales are minimally heard upon auscultation, with
less productive cough of yellowish sputum. Oxygen inhalation was removed.
Activities of daily living:
The patient is in assist with person to Feeding, bathing, dressing,
grooming, meal preparations, cleaning, laundry, toileting, bed mobility, chair/toilet
transfer, ambulation and in active-passive R.O.M. The reasons for ADL/mobility
limitations are due to weakness in the lower extremities as well as due to IVF line
connected to the patient.
5. COGNITIVE- PERCEPTUAL PATTERN
Week 1 (January 4, 2011)
The client was conscious and oriented to time/person/place. The patients
capillary refill is 2-3 seconds.
The client was calm and relaxed. The clients primary language is Bisaya
and she dropped out of school during her 1st year in high school due to illness.
Week 2 (January 11, 2011)The client was conscious and oriented to time/person/place. The patients
capillary refill is 2 seconds.
The client was calm in emotional state. The clients primary language is
Bisaya and she dropped out of school during her 1st year in high school due to
illness.
6. SLEEP-REST PATTERN
Week 1 (January 4, 2011)
When she was not yet admitted, her usual sleep/rest pattern was 6-8hours
a day. The longest time for her to rest is eight hours. And now that she is sick,
she normally rest for about 4-6hours which is inadequate on her body needs as
verbalized by the patient. Relieving the cough with medication as prescribed and
providing calm environment was one of the ways to make the patient rest.
Week 2 (January 11, 2011)
There was already an improvement of the clients sleep and rest pattern
patient can sleep for 6-8 hours according to the SO. Relieving the cough with
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medication as prescribed and providing calm environment was one of the ways
to make the patient rest.
7. SELF- PERCEPTION AND SELF-CONCEPT PATTERN
Week 1 (January 4, 2011)
Luyahan ug kapoi pud, as patient described herself was worried with her
conditio . The patient feels the she reduced weight since illness/ hospitalization.
The clients non-verbal actions showed minimal self expression.
Week 2 (January 11, 2011)
Okay, raman ako pamati, as verbalized the patient. The patient feels
good and positive that she will be well. The Clients non-verbal behavior showed
that she was eager to participate in achieving health goals.
8. SEXUALITY REPRODUCTIVE PATTERN
Week 1 and Week 2 (January 4&11, 2011)
The patient has irregular menstrual pattern. Her Last Menstrual Period
(LMP) was October 2010, 2 months delayed. No history of birth control use. No
monthly self breast exam. Breasts are bilaterally equal; surfaces are smooth withno lesions, tenderness and masses.
9. COPING-STRESS TOLERANCE PATTERN
Week 1 (January 4, 2011)
The financial difficulty was one of the clients stresses other than her
illness.
Week 2 (January 11, 2011)
The financial difficulty was one of the clients stressors other than her
illness. She usually managed stress by doing diversional activities such as
watching TV and listening to music. She finds time with herself in her room to
relax and rest. She uses her family and friends as her support groups and they
are very helpful emotionally.
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11. VALUE-BELIEF PATTTERN
Week 1 (January 4, 2011)
The client is a Roman Catholic affiliate; believes that faith and miracle was
very vital in her life. Hospitalization does not interfere, visit prayer meeting was
done.
Week 2 (January 11, 2011)
The client is a Roman Catholic; hospitalization would not interfere in any
medical intervention.
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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, the mouth, the pharynx, the epiglottis, the larynx, and the
upper trachea. The oesophagus leads to the digestive tract.
One of the features of both the upper and lower respiratory tracts is themucociliary 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
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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 specialized 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 specialized muscular foldsthat close it off and also prevent food, foreign objects, and secretions such as
saliva from entering 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
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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.
THE LUNGS
The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity.
There are two lungs that occupy a significant portion of this cavity.
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The diaphragm is a broad, dome-shaped muscle that separates the
thoracic and abdominal cavities and generates most of the work of breathing.
The inter-costal muscles, located between the ribs, also aid in respiration. The
internal intercostal muscles lie close to the lungs and are covered by the external
intercostal muscles.
The lungs are cone-shaped organs that are soft, spongy and normally
pink. The lungs cannot expand or contract on their own, but their softness allows
them to change shape in response to breathing. The lungs rely on expansion and
contraction of the thoracic cavity to actually generate inhalation and exhalation.
This process requires contraction of the diaphragm.
To facilitate the movements associated with respiration, each lung is
enclosed by the pleura, a membrane consisting of two layers, the parietal pleura
and the visceral pleura.
The parietal pleura comprise the outer layer and are attached to the chest
wall. The visceral pleura are directly attached to the outer surface of each lung.
The two pleural layers are separated by a normally tiny space called the pleural
cavity. A thin film of serous or watery fluid called pleural fluid lines and lubricatesthe pleural cavity. This fluid prevents friction and holds the pleural surfaces
together during inhalation and exhalation.
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I. Pathophysiology
Mycobacterium Tuberculosis
Small airborne
Droplet spread
Subsequentphagocytosis by
macrophages
Predisposing factors:
Age
Heredity
Precipitating factors:
Repeated contact
with infected
persons
Part of low
income
population(lack
of medical care)
Low Body
weight (37 kg)
Environment
Infectious droplet settle throughout
airways and majority are trapped in
the upper parts of the airway
Successful control of
infection
Bacterial cell
division still
Inhallation
of particles
Progression of active
disease(Primary progressive
TB
Bacteria in droplets
that bypass
mucocilliary systemand reach alveoli
NOTE:
Outcome isdetermined by
quality of host
defense andm cobacteria
Complement system
also performsphagocytosis(Protein
C3
Binds to cell wall and
enhances recognition of
mycobacterium bymacro ha es
Rapidly surrounded
and engulfed bymacrophages
Production of protolytic enzymes
and cytokines by macrophages in
an attempt to control bacteria
DX: (+)
tuberculin skin
test
Cytokines attracts T
lymphocytes to the
site(synthesized T cells)
Microorganisms continue to
grow until cell-mediated
immune response is fully
Constitutescell mediated
Immunity
Formation of granulomas
around the M. Tuberculosisorganism
Limits replication
Spread Of
mycobacteria
Arrest of phagosome
Bacilli
replication
Low grade
Fever
Weight
loss
AnorexiaSleep
Hyperhid
rosis
>Paracetamol
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Acquired immunity leads to further
growth of bacilli and devpt. Of
active infection
Drainage of necrotic materials into thetrachiobronchial tree(eruption of
coughing,formation of lesions ) Primary
infection
Bronchopneumonia develops in the
lung tissue (Phagocytosed tubercle
bacilli are ingested by macrophages)
General:
Anorexia
Vomitting
Weight loss
Low grade fever
with chills(39.6C)
Bacterial cell wall binds
with macrophages
Necrotic degeneration occurs(production of
cavities filled with cheese like mass of tuberclebacilli, dead WBCs, necrotic lung tissue)
Tubercle bacilli immunity develops(2-6 weeks after infection). Maintains
in the body as long as living bacilli
remains in the body.
As infection progresses in
which immune response wasnot capable of destroying it
Pulmonary:
Dyspnea (31-34
CPM)
productive cough
with yellowish
phlegm)
Hemoptysis(blood
Lesions may calcify (GhonsComplex ) and forms scars and
may heal over period of time.
Signs and Symptoms:
Productive
cough
Mucus
consolidation
Dyspnea
Rales
Rupture of alveolar-capillary beds
Hemoptysis
>Fluimucil
>Combivent
>Benadryl
>Ceftriaxone
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With medical Treatment:
Early detection and
diagnosis of case
Multi-antibacterial
Therapy
Without Medical treatment :
Reactivation of
tubercle bacilli(due
to repeatedexposure to infected
individuals,
immunosuppression
)
NO reccurence Recurrence
Good
Prognosis
Bad
Prognosis
LEGEND:
INFECTION
PROCESS
IMMUNOLO
GIC
PROCESS OF
LUNGS and
Treatment
Medications
NOTES ANDEXPLANATI
ONS
SYMPTOMS
PRESENTED
BY PATIENT
WHILE
ASSESSMEN
T
Continuation at
next page
>Fixcom>Peprasan
>Levoflaxacin
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Laboratory and Diagnostics
X-ray
An X-ray is a quick, painless test that produces images of the structures
inside your body particularly your bones. X-ray beams can pass through your
body, but they are absorbed in different amounts depending on the density of the
material they pass through. The air in your lungs shows up as black. Fat and
muscle look like varying shades of gray.
CHEST X-RAY PA (December 28, 2010 at COMC)
Nodule hazed densities altered in both lungs more in the Right partially
obscuring the bilateral cardiac margins.
Heart is not enlarged.
Aorta is not dilated.
Diaphragm and both costrophrenic sulci are intact.
The rest of the visualized chest structures are unremarkable.
Impression:
PTB, far advanced, bilateral
CHEST X-RAY (January 5, 2011 at CUMC)
Reticulo nodular densities are seen in both lungs, more confluent on the
Right.
Heart is within normal limits in size.
Aorta is not dilated.
Diaphragm and sulci are intact.
The rest of the visualized chest structures are unremarkable.
Impression:
Pulmonary Tuberculosis VS. Pneumonia Bilateral
CHEST X-RAY (January 9, 2010 at CUMC)
Follow up study since 1/5/11 shows no significant interval change in the
previously noted reticulo nodular densities in both lungs, more confluent
on the Right.
Heart is within normal limits in size.
Aorta is not dilated.
Diaphragm and sulci are intact.
The rest of the visualized chest structures are unremarkable.
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Impression:
To consider Pulmonary Tuberculosis Bilateral. Please correlate clinically.
Complete Blood Count
A complete blood count (CBC), also known as full blood count (FBC) or
full blood exam (FBE) or blood panel, is a test requested by a doctor or other
medical professional that gives information about the cells in a patient's blood. A
lab technician (diploma holder) or technologist (bachelor holder) performs the
requested testing and provides the requesting Medical Professional with the
results of the CBC. A CBC is also known as a "hemogram".
COMPLETE BLOOD COUNT (January 2, 2011)
TEST RESULT REFERENCE INDICATION INTERPRETATION
WBC 16,7005,000-10,000
Cell/mm
Determines anyinflammation andinfection.
Result is above thenormal range whichindicates presenceinfection.
RBC 4.184.2-5.010^6/L
Determines thepresence ofbleeding.
Result is belownormal range, thusindicating presenceof bleeding.
Hemoglobin 10.711.7-14.5
g/dL
Usually done to a pt.with renal disease to
determine if thekidneys ability toreleaseerythropoietin factoris already affected
Result is below thenormal range, thus
the patientexperiencedbleeding causinganemia.
Hematocrit 32.034.1-44.3
gm%
Used to measureRBC number andvolume. It is anintegral part of theevaluation of anemicpatients.
Result is below thenormal range thus,showing anemia anddue to blood loss.
MCV 70.6 80.0-96.0 fL
Determines anychronic bacterialinfection or viralinfection.
Result is below thenormal range ,implicatingpresence of infection
MCH 21.9 27.0-31.0 pg
Determines anychronic bacterialinfection or viralinfection.
Result is below thenormal range,implicatingpresence of infection
MCHC 31.132.0-36.0
g/dL
Determines anychronic bacterialinfection or viral
infection.
Result is below thenormal range,implicating
presence of infection
Lymphocyte 17.0 18-45 %
Determines anychronic bacterialinfection or viralinfection.
Result is below thenormal range,implicatingpresence of infection
Segmenters 81.0 45-70 % Determines anychronic bacterial
The result is abovethe normal range.
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infection or viralinfection.
Indicates presenceof infection.
Monocyte 1.0 4-8 %
Determines anyacute bacterialinfection.
Result is below thenormal range,implicating
presence of infection
Eosinophil 1.0 2-3 %
Determines anyacute bacterialinfection.
Result is below thenormal range,implicatingpresence of infection
Platelet 566,000174,000-390,00010^3/L
To diagnose and/ormonitor bleeding andclotting disorders.
Results above thenormal range,implicating tendencyof acute infection.
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COMPLETE BLOOD COUNT (January 5, 2011)
TEST RESULT REFERENCE INDICATION INTERPRETATION
WBC 19,0005,000-10,000
Cell/mm
Determines anyinflammation andinfection.
Result is above thenormal range whichindicates presence
infection.
RBC 3.334.2-5.010^6/L
Determines thepresence of bleeding.
Result is belownormal range, thusindicating presenceof bleeding.
Hemoglobin 8.211.7-14.5
g/dL
Usually done to a pt.with renal disease todetermine if thekidneys ability torelease erythropoietinfactor is alreadyaffected
Result is below thenormal range, thusthe patientexperiencedbleeding causinganemia.
Hematocrit 25.034.1-44.3
gm%
Used to measure RBCnumber and volume. Itis an integral part ofthe evaluation ofanemic patients.
Result is below thenormal range thus,showing anemiaand due to bloodloss.
MCV 70.1 80.0-96.0 fL
Determines anychronic bacterialinfection or viralinfection.
Result is below thenormal range,implicatingpresence ofinfection
MCH 22.9 27.0-31.0 pg
Determines anychronic bacterialinfection or viralinfection.
Result is below thenormal range,implicatingpresence ofinfection
MCHC 32.2 32.0-36.0 g/dL
Determines anychronic bacterialinfection or viralinfection.
Result is normalrange. Indicatingabsence ofbacterial infection.
Lymphocyte 16.0 18-45 %
Determines any
chronic bacterialinfection or viralinfection.
Result is below the
normal range,implicatingpresence ofinfection
Segmenters 82.0 45-70 %
Determines anychronic bacterialinfection or viralinfection.
The result is abovethe normal range.Indicates presenceof infection.
Monocyte 1.0 4-8 %
Determines any acutebacterial infection.
Result is below thenormal range,implicating
presence ofinfection
Eosinophil 1.0 2-3 %
Determines any acutebacterial infection.
Result is below thenormal range,implicatingpresence ofinfection
Platelet 635,000 174,000- To diagnose and/or Results above the
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390,00010^3/L
monitor bleeding andclotting disorders.
normal range,implicatingtendency of acuteinfection.
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COMPLETE BLOOD COUNT (January 6, 2011)
TEST RESULT REFERENCE INDICATION INTERPRETATION
WBC 23,2005,000-10,000
Cell/mm
Determines anyinflammation andinfection.
Result is above thenormal range whichindicates presence
infection.
RBC 3.574.2-5.010^6/L
Determines thepresence of bleeding.
Result is belownormal range, thusindicating presenceof bleeding.
Hemoglobin 9.711.7-14.5
g/dL
Usually done to a pt.with renal disease todetermine if thekidneys ability torelease erythropoietinfactor is already
affected
Result is below thenormal range, thusthe patientexperiencedbleeding causinganemia.
Hematocrit 29.034.1-44.3
gm%
Used to measure RBCnumber and volume. Itis an integral part ofthe evaluation ofanemic patients.
Result is below thenormal range thus,showing anemiaand due to bloodloss.
MCV 69.9 80.0-96.0 fL
Determines any acutebacterial infection.
Result is below thenormal range,implicatingpresence ofinfection
MCH 22.4 27.0-31.0 pg
Determines any acutebacterial infection.
Result is below thenormal range,implicatingpresence ofinfection
MCHC 32.1 32.0-36.0 g/dL
Determines any acutebacterial infection.
Result is normal.Indicating absenceof bacterialinfection.
Lymphocyte 15.0 18-45 %
Determines anychronic bacterial
infection or viralinfection.
Result is below thenormal range,
implicatingpresence ofinfection
Segmenters 81.0 45-70 %
Determines anychronic bacterialinfection or viralinfection.
The result is abovethe normal range.Indicates presenceof infection.
Monocyte 2.0 4-8 %
Determines any acutebacterial infection.
Result is below thenormal range,implicatingpresence of
infection
Eosinophil 2.0 2-3 %
Determines any acutebacterial infection.
Result is normal.Indicating absenceof bacterialinfection.
Platelet 675,000 174,000-390,000
To diagnose and/ormonitor bleeding and
Results above thenormal range,
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10^3/L
clotting disorders. implicatingtendency of acuteinfection.
COMPLETE BLOOD COUNT (January 7, 2011)
TEST RESULT REFERENCE INDICATION INTERPRETATION
WBC 22,1005,000-10,000
Cell/mm
Determines anyinflammation andinfection.
Result is above thenormal range whichindicates presenceinfection.
RBC 3.974.2-5.010^6/L
Determines thepresence of bleeding.
Result is belownormal range, thusindicating presence
of bleeding.
Hemoglobin 10.711.7-14.5
g/dL
Usually done to a pt.with renal disease todetermine if thekidneys ability torelease erythropoietinfactor is alreadyaffected
Result is below thenormal range, thusthe patientexperiencedbleeding causinganemia.
Hematocrit 32.034.1-44.3
gm%
Used to measure RBCnumber and volume. Itis an integral part of
the evaluation ofanemic patients.
Result is below thenormal range thus,showing anemia
and due to bloodloss.
MCV 74.0 80.0-96.0 fL
Determines anychronic bacterialinfection or viralinfection.
Result is below thenormal range,implicatingpresence ofinfection
MCH 23.7 27.0-31.0 pg
Determines anychronic bacterialinfection or viralinfection.
Result is below thenormal range,implicatingpresence of
infection
MCHC 32.1 32.0-36.0 g/dL
Determines anychronic bacterialinfection or viralinfection.
Result is normal.Indicating absenceof bacterialinfection.
Lymphocyte 19.0 18-45 %
Determines anychronic bacterialinfection or viralinfection.
Result is normal.Indicating absenceof bacterialinfection.
Segmenters 76.0 45-70 %
Determines anychronic bacterial
infection or viralinfection.
The result is abovethe normal range.
Indicates presenceof infection.
Monocyte 4.0 4-8 %
Determines any acutebacterial infection.
Result is normal.Indicating absenceof bacterialinfection.
Eosinophil 1.0 2-3 % Determines any Result is below the
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chronic bacterialinfection or viralinfection.
normal range,implicatingpresence ofinfection
Platelet 657,000174,000-390,00010^3/L
To diagnose and/or
monitor bleeding andclotting disorders.
Results above the
normal range,implicatingtendency of acuteinfection.
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COMPLETE BLOOD COUNT (January 8, 2011)
TEST RESULT REFERENCE INDICATION INTERPRETATION
WBC 23,5005,000-10,000
Cell/mm
Determines anyinflammation andinfection.
Result is above thenormal range whichindicates presence
infection.
RBC 4.034.2-5.010^6/L
Determines thepresence of bleeding.
Result is belownormal range, thusindicating presenceof bleeding.
Hemoglobin 10.811.7-14.5
g/dL
Usually done to a pt.with renal disease todetermine if thekidneys ability torelease erythropoietinfactor is already
affected
Result is below thenormal range, thusthe patientexperiencedbleeding causinganemia.
Hematocrit 32.034.1-44.3
gm%
Used to measure RBCnumber and volume. Itis an integral part ofthe evaluation ofanemic patients.
Result is below thenormal range thus,showing anemiaand due to bloodloss.
MCV 74.5 80.0-96.0 fL
Determines any acutebacterial infection.
Result is below thenormal range,implicatingpresence ofinfection
MCH 24.0 27.0-31.0 pg
Determines any acutebacterial infection.
Result is below thenormal range,implicatingpresence ofinfection
MCHC 32.2 32.0-36.0 g/dL
Determines any acutebacterial infection.
Result is normal.Indicating absenceof bacterialinfection.
Lymphocyte 24.0 18-45 %
Determines anychronic bacterial
infection or viralinfection.
Result is normal.Indicating absence
of bacterialinfection.
Segmenters 72.0 45-70 %
Determines anychronic bacterialinfection or viralinfection.
The result is abovethe normal range.Indicates presenceof infection.
Monocyte 2.0 4-8 %
Determines any acutebacterial infection.
Result is below thenormal range,implicatingpresence ofinfection
Eosinophil 2.0 2-3 %Determines any acutebacterial infection.
Result is normal.Indicating absenceof bacterialinfection.
Platelet 728,000 174,000-390,00010^3/L
To diagnose and/ormonitor bleeding andclotting disorders.
Results above thenormal range,implicating
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tendency of acuteinfection.
HEMATOLOGY
January 2, 2011
ABO TYPING B Rh+
Blood Chemistry Test
Blood Chemistry is needed to assess a wide range of conditions and the
function of organs. It also a test to check electrolytes, the minerals that help keep
the bodys fluid level in balance, and are necessary to help the muscles, heart,
and other organs work properly. This also helps assess kidney function and
blood sugar, and other substances in the blood.
CLINICAL CHEMISTRY
January 2, 2011
Test Result Reference
Creatinine 0.70 0.60-1.30 mg/dL
SGPT 25.10 10-40 Iu/LSodium 125.50 135-148 mmol/L
Potassium 3.07 3.5-5.3 mmol/L
Interpretation: The result of the Potassium and Sodium are slightly decreased.
So the patient is hypokalemic and hyponatremic, a condition in which the
concentration of potassium and sodium in the blood is low
January 5, 2011
Test Result ReferenceUric Acid 4.60 2.6-7.2
Sodium 129.90 135-148 mmol/L
Potassium 3.95 3.5-5.3 mmol/L
Interpretation: The result of the Sodium is still decreased but compared to
previous laboratory result (01/02/11); it has increased by 0.88. Still the patient is
hyponatremic.
January 6, 2010
Test Result Reference
FBS 104.00 75-115
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Interpretation: The FBS result is within normal range.
January 8, 2011
Test Result Reference
Potassium 4.25 3.5-5.3 mmol/LInterpretation: The Potassium is within normal Range.
AFB Stain
AFB smears and cultures are used to determine whether you have an
active Mycobacterium tuberculosis infection, an infection due to another member
of the Mycobacterium family, orTB-like symptoms due to another cause. They
are used to help determine whether the TB is confined to the lungs (pulmonary)
or has spread to organs outside the lungs (extrapulmonary). AFB cultures can be
used to monitor the effectiveness of treatment and can help determine when a
patient is no longer infectious.
AFB STAIN REPORT
January 3, 2010 January 6, 2011
Result
Interpretation
Result Grading No of fields
examine
More than 10 AFB/oil immersion field Positive 3+ 20
1-10 AFB 10 AFB/oil immersion field Positive 2+ 5010-99 AFB in 100 oil immersion field Positive 1+ 100
1-9 AFB in 100 oil immersion field Scanty Record
actual #
200
No AFB in 100 oil immersion field Negative 0 100
January 6, 2011
Specimen sputum
Result No microorganism seen
Polymorphonuclear cells few
Epithelial cells few
Positive
Grade 3+
Specimen Sputum
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CULTURE REPORT (January 7, 2011)
Preliminary Report
Findings: No growth after 2 days of incubation
Urinalysis
A physical, microscopic, or chemical examination of urine. The specimen
is physically examined for color, turbidity, and specific gravity. Then it is spun in a
centrifuge to allow collection of a small amount of sediment, which is examined
microscopically for blood cells, casts, crystals, pus, and bacteria. Chemical
analysis may be performed to measure the pH and to identify and measure the
levels of ketones, sugar, protein, blood components, and many other substances.
URINALYSIS (January 3, 2011)
Color Orange
Transparency Hazy
Reaction 6.0
Sp gravity 1.015Sugar negative
Protein trace
PUS cell 3-6 cells/HFP
RBC 0-2 cells/HPF
EPITHELIAL CELLS
Squamous epithelial moderate
Bacteria moderate
MUCUOS THREADS few
Fecalysis
Fecalysis is also known as stool analysis. It refers to a series of laboratory
tests done on fecal samples to analyze the condition of a person's digestive tract
in general. Among other things, a fecalysis is performed to check for the
presence of any reducing substances such as white blood cells (WBCs), sugars,
or bile and signs of poor absorption as well as screen for colon cancer.
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FECALYSIS (January 3, 2011)
Consistency soft
Color dark brown
RBC
Pus cells
Ascaris
Hook worm
Amoeba No Parasite seen
Trichuris
Fat globules
Bacteria
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Nursing Care Management
ASSESSMENT DATA(Subjective and Objective
Cues)
NURSING DIAGNOSIS(Problem and Etiology)
GOALS ANDOBJECTIVES
NURSING INTERVENTIONS ANDRATIONALE
EVALUATION
Subjective:Galisod ko ug ginhawatungod sa akong ubo, asverbalized by the patient.
Objective/s:
Productive cough noted,yellowish in color
RR= 31 cpm, tachypnea(16-24cpm)
O2 saturation= 98%
With O2 inhalation vianasal cannula at 2LPM
Lab:
CXRAY = Dec. 28, 2010@COMC
CXRAY = Jan. 5, 2011@CUMC
Impression: PTB Far advanced bilateral
(Right lung)
Ineffective AirwayClearance related toaccumulation ofsecretions at the rightlower field of the lungs.
Short term:Within 15 minutes ofNursing Care andinterventions, patient will:
Maintain orimproved airwaypatency.
Expectorate/clearsecretions readily.
Long term:Within 1-2 daysof Nursing Care andinterventions, patient will:
improve oxygenexchange.
INDEPENDENT:1. Auscultate breath sounds andassess air movement.R: to ascertain status and noteprogress.2. Position head midline with flexionappropriate for age/condition.R: to open or maintain openairway in at-rest or compromisedindividual.3. Elevate head of the bed/ changeposition every 2hours.R: to take advantage of gravitydecreasing pressure on thediaphragm and enhancingdrainage of ventilation to differentlung segments.4. Encourage deep-breathing andcoughing exercises.
R: to promote lung expansion.5. Increase fluid intake to at least2000 ml/day within level of cardiac
After 30 minutes ofNursing Care andinterventions, GOALWAS PARTIALLYMET, patient was ableto maintain airwaypatency andexpectorate/ clearsecretions readily.
After 2-3 days ofNursing Care andinterventions, GOALWAS MET, patientwas:
Able to improveoxygen exchang asevidenced by removal
of 02 supplementationlast Jan. 9, 2011.
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tolerance; encourage/provide warmversus cold liquids as appropriate.R: to help liquefy secretions.6. Monitor vital signs, noting bloodpressure/pulse changes.R: to note any changes/complications.
7. Encourage and provideopportunities for rest; limit activities
to level of respiratory tolerance.R: to prevent and lessen fatigue.
COLLABORATIVE:1. Give expectorant/bronchodilatorsas ordered (Combivent neb. + 1ccNSS, Nebulization every 8 hours).R: to treat underlying conditions.
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NURSING CARE MANAGEMENT
ASSESSMENT DATA(Subjective and Objective
Cues)
NURSINGDIAGNOSIS
(Problem andEtiology)
GOALS ANDOBJECTIVES
NURSING INTERVENTIONS ANDRATIONALE
EVALUATION
SUBJECTIVE:Dili naku gaka-hurot akongpagkaon, wala koi gana, asverbalized by the patient.
OBJECTIVES:
Weight= 37.5 kg(17/Female ; normal 39-41kg)BMI= 17.9)
Height= 147 cm
BMI= 17.9 (NormalBMI: 18.5 24.5)
Pale conjunctiva and mucusmembrane
inability to consume fullshare of food
IVF: PLR@20gtts/min
LAB: Clinical chemistry:Jan 2,2011
Na = 125.50 Below normalrange(135-148mmol/L)K = 3.07: Below normal
Imbalanced Nutrition:less than bodyrequirements relatedto lack of interest in
food.
Short term:Within 8 hours of NursingCare and interventions,patient will:
Regain normalappetite
Increase foodintake.
Long term:Within 2 weeks ofNursing Care andInterventions, patient will:
Demonstrateprogressive weightgain toward goal.
Displaynormalization oflaboratory values.
IINDEPENDENT:1. Assess the weight; Followingprotocol in weighing a patientR: to establish baseline
parameters.2. Ascertain understanding ofindividual nutritional needsR: to determine informationalneeds of the client.3. Discuss eating habits, includingfood preferences,intolerance/aversions.R: to appeal to clientslikes/dislikes.
After 8 hours of NursingCare and interventions,GOAL WAS MET, patientwas able to improve
appetite and consumed fullshare of food.
After 2 weeks of NursingCare and interventions,GOAL PARTIALLY MET,
Patient was able togain weight of450gm(Stillunderweight18.35Kg, Normal:18.5Kg Female 17years old)
LAB: ClinicalchemistryJan 5,2011 Na levelfrom 125.50 to
129.90 increase by4.4mmol/L
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range(3.5-5.3mmol/L) K level from 3.07 to3.95 increase by0.88mmol/L
NURSING CARE MANAGEMENT
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ASSESSMENT DATA(Subjective andObjective Cues)
NURSINGDIAGNOSIS
(Problem andEtiology)
GOALS ANDOBJECTIVES
NURSING INTERVENTIONS ANDRATIONALE
EVALUATION
SUBJECTIVE:Gapamugnaw ko, medyolabad akong ulo, initakong paminaw sa lawasas verbalized by the
patient.
OBJECTIVE:
Febrile; Temp=39.6C
Flushed skin ; warm totouch
Tachypnea RR =31cpm(Normal 16 24cpm)
Tachcardia =108bpm(Normal 60 100bpm)
Hyperthermia relatedto disease process.
Short term:Within 30 to 60 minutes ofnursing care andinterventions the patient willbe able to:
Maintain coretemperature withinnormal range andlower bodytemperature from39.6C-36.5C.
Demonstratebehaviors to monitorand promotenormothermia.
Long term:Within 2-3days nursing careand interventions the patientwill be able to:
Be free of
INDEPENDENT:1. Vital signs taken and recordR: to note any changes and/orcomplications and as baseline.2. Perform TSB to lower down Body
temperature to normal: (36.5 37.5C)3. Maintain bed rest.R: to reduce metabolic demands/oxygen consumption4. Provide adequate sleep.R: to regain back body strength.5. Provide adequate fluid intake.R: to prevent dehydration.
COLLABORATIVE:1. Administer medications, as indicated,such as antipyretics and antibiotics (forinfection).R: to treat underlying cause.
After 1hour of nursing careand interventions, patientstemperature was loweredfrom 39.6 to 36.9 degreeCelsius and demonstrated
behaviors to monitor andpromote normothermia.GOAL WAS MET
After 2-3days nursing careand interventions, thepatient able to:
Free fromcomplications andfree from seizures
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complications suchas infection.
Be free of seizureactivity.
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R: to promote muscle tone
NURSING CARE MANAGEMENT
ASSESSMENT DATA(Subjective and Objective
Cues)
NURSING DIAGNOSIS(Problem and Etiology)
GOALS ANDOBJECTIVES
NURSING INTERVENTIONS ANDRATIONALE
EVALUATION
SUBJECTIVE: Gakaulaw ko sa akong
sakit as verbalized bypatient.
OBJECTIVES:
Developmental changes
Functional impairment
Physical illness
Delayed educationalattainment: Drop out fromschool during 1st year in
highschool.
Situational low selfesteem related to socialrole changes.
Long term:Within 2weeks ofnursing care andintervention the patientwill be able to:
Acknowledgefactors that leadto possibility offeelings of lowself esteem.
Verbalize view asworthwhile,important personwho functionswellinterpersonally
Demonstrate selfconfidence bysetting realistic
INDEPENDENT:1. Assess nonverbal body language.R: incongruencies betweenverbal/nonverbal communicationsrequire clarification.2. Identify previous adaptations toillness/disruptive events in life.R: May be predictive of currentoutcome.3. Ascertain sense of control. Clienthas over self and situation todetermine clients trust to self.4. Identify the strength of the clientR: to reinforce self-view5. Encourage verbalization offeelings.R: to promote positive sense of
self.
COLLABORATIVE:
After 2 weeks of nursingcare and intervention,GOAL WASPARTIALLY MET, thepatient was be able to:
Acknowledgedfactors that leadto possibility offeelings of lowself esteem.
Verbalized viewas worthwhile,important personwho functionswellinterpersonally.
Demonstratedself confidenceby setting
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goals and activelyparticipating in lifesituation.
1. Promote attendance in therapy orinvolvement of familyR: to provide appropriate supportto client.
realistic goalsand activelyparticipating inlife situation.
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Identify/use availableresources.
participation in planning and evaluatingprocess.R: enhances commitment to plan,optimizing outcomes.
Identify/use availableresources.
NURSING CARE MANAGEMENT
ASSESSMENT DATA(Subjective and Objective
Cues)
NURSING DIAGNOSIS(Problem and Etiology)
GOALS ANDOBJECTIVES
NURSING INTERVENTIONS ANDRATIONALE
EVALUATION
SUBJECTIVE:Galisud ko ug ginhawa sahay,tungod sa akong plemas asverbalized by the patient.
OBJECTIVE:
Tachypnea; RR= 31cpm
Productive cough noted
Abnormal skin color (pale)
Impaired gas exchangerelated to retainedbronchial secretions.
Short term:Within 5-10 minutes ofnursing care andintervention the patientwill be able to:
Maintain airwaypatency.
Long term:Within 1-2days nursingcare and interventionsthe patient will be ableto:
Demonstrate
improvedventilation and
INDEPENDENT:1. Monitor vital signs and cardiacrhythm.R: to note any changes and/orcomplications.2. Note respiratory rate, depth,pursed-lip breathing; and areas ofpallor/cyanosis; for example,peripheral (nailbeds).R: to assess respiratoryinsufficiency.3. Elevate head of bed/position clientappropriately; provide airwayadjuncts, as indicated.
R: to maintain airway.4. Maintain adequate intake andoutput, but avoid fluid overload.
After 5-10 minutes ofnursing care andintervention, patientmaintained airwaypatency as evidencedby RR=30cpm. GOALWAS PARTIALLYMET.
After 1-2days nursingcare and interventionsthe patient able to:
Demonstrateimproved
ventilation andadequateoxygenation
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adequateoxygenationwithin clientsnormal limits andabsence ofsymptoms ofrespiratorydistress.
Participate intreatmentregimen (e.g.,
breathingexercises,effectivecoughing, anduse of oxygen)within level ofability/ situation.
R: for mobilization of secretions.5. Provide adequate rest and limitactivities to within client tolerance.Promote calm/ restful environment.R: helps limit oxygen needs/consumption.6. Provide psychological support,active-listen questions/concernsR: to reduce anxiety.7. Keep environmentallergen/pollutant free
R: to reduce irritant effect of dustand chemicals on airways.8. Emphasize the importance ofnutritionR: in improving stamina andreducing the work of breathing.
COLLABORATIVE:1. Encourage frequent positionchanges and deep breathing/coughing exercises.R: Promotes optimal chestexpansion and drainage ofsecretions.2. Administer medications, asindicated (e.g. bronchodilators)R: to treat underlying conditions.
3. Provide supplemental oxygen asindicated by laboratory results andclient symptoms/situation.
within clientsnormal limitsand absence ofsymptoms ofrespiratorydistress.
Participate intreatmentregimen (e.g.,breathingexercises,
effectivecoughing, anduse of oxygen)within level ofability/ situation.
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R: to improve respiratory function/oxygen-carrying capacity.
NURSING CARE MANAGEMENT
ASSESSMENT DATA(Subjective and Objective
Cues)
NURSING DIAGNOSIS(Problem and Etiology)
GOALS ANDOBJECTIVES
NURSING INTERVENTIONS ANDRATIONALE
EVALUATION
RISK FACTORS:
Febrile; Temp= 39.6C
Lowered resistance/suppressed inflammatoryresponse
Productive cough noted
Somnolence (lethargy)
Infection related toinadequate primarydefenses (decreasedciliary action/stasis ofsecretions).
Short term:Within 30minutes to 1hour of nursing care andintervention the patientwill be able to:
Maintain coretemperaturewithin normalrange.
Be afebrile.
Long term:Within 2-3days ofnursing care andintervention the patientwill be able to:
Verbalizeunderstanding of
INDEPENDENT:1. Vital signs taken and recorded.R: to note any changes and/orcomplications.2. Stress proper hand hygiene by allcaregivers betweentherapies/clients.R: a first-line of defense againsthealthcare-associated infections(HAI).3. Provide for respiratory isolation,as indicated.R: reduces risk of cross-contamination.4. Encourage early ambulation, deepbreathing, coughing exercises, and
position changes.R: for mobilization of secretionsand prevention of aspiration/
After 30minutes to 1hour of nursing care andintervention, the patientmaintained a coretemperature withinnormal range, and wasafebrile as evidenced bybody temperature of36.9C. GOAL WASMET.
After 2-3days of nursingcare and intervention,GOAL WAS MET, thepatient able to:
Verbalize
understanding ofindividualcausative/ risk
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individualcausative/ riskfactor(s).
Identifyinterventions toprevent/ reducerisk of infection.
respiratory infections.5. Maintain adequate hydration.R: to avoid bladder distention/urinary stasis.
COLLABORATIVE:1. Administer/ monitor medicationregimen and note clients response.R: to determine effectiveness oftherapy/ presence of side effects.2. Emphasize necessity of taking
antivirals/ antibiotics, as directed(e.g., dosage and length of therapy).R: premature discontinuation oftreatment when client begins tofeel well may result in return ofinfection and potentates drug-resistant strains.
factor(s).
Identifyinterventions toprevent/ reducerisk of infection.
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NURSING CARE MANAGEMENT
ASSESSMENT DATA(Subjective and Objective
Cues)
NURSING DIAGNOSIS(Problem and
Etiology)
GOALS ANDOBJECTIVES
NURSING INTERVENTIONSAND RATIONALE
EVALUATION
SUBJECTIVE:
Lisud e-ginhawa, asverbalized by the patient.
OBJECTIVES:
RR= 36 cpm
Pallor noted
with O2 inhalation of 2 LMPvi nasal cannula
productive cough noted withyellowish in color.
Ineffective Breathing
Pattern related toimbalance betweenoxygen supply anddemand.
Short term:
Within 2-3 hours ofNursing Care andinterventions, patient will:
Establish a normaland effectiverespiratory pattern.
INDEPENDENT:
1. Auscultate chest, notingpresence and character of breathsounds, presence of secretions.R: Note any changes/complications.2. Elevate HOB as appropriate.R: to promote physiological/psychological ease of maximalinspiration.3. Encourage slower/deeperrespirations, use of purse-liptechnique, and so on.R: to assist the client in takingcontrol of the situation.4. Maintain a calm attitude whiledealing with the client and SO/s.R: to limit the level of anxiety.
5. Assist the client in the use ofrelaxation techniques andencourage position of comfort.
After 2-3 hours of
Nursing Care andinterventions, GOALWAS MET, patient wasable to established anormal and effectiverespiratory pattern.
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R: Promotes optimal chestexpansion and drainage ofsecretions.6. Assist client to learn breathingexercise; diaphragmatic,abdominal breathing, inspiratoryresistive, as pursed-lip asindicated.
7. Encourage adequate restperiods between activities to
prevent fatigue.R: to meet increased metabolicdemands.
COLLABORATIVE::1. Administer oxygen at lowestconcentration indicated forunderlying pulmonary conditionand respiratory distress: O2inhalation regulated at 2 LPM vianasal cannula.R: to offset increased oxygendemandsand consumption.
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NURSING CARE MANAGEMENT
ASSESSMENT DATA(Subjective and Objective
Cues)
NURSINGDIAGNOSIS
(Problem andEtiology)
GOALS ANDOBJECTIVES
NURSING INTERVENTIONS ANDRATIONALE
EVALUATION
SUBJECTIVE:Mag mata-mata ko usahay, diliko maka tulog dali sa akongubo, as verbalized by thepatient.
OBJECTIVE:
inadequate hours of sleep:
Before admission: 6 8hours
During admission: 4 6hou
Disturbed SleepPattern related topresence of coughand fever.
Long term:Within 8 hours ofNursing Care andinterventions, patientwill:
Achievesoptimalamounts ofsleep asevidenced byrestedappearance,verbalizationof feelingrested, andimprovement
in sleeppattern.
INDEPENDENT:1. Observe and/or obtain feedback fromclient and SO/s regarding usual bedtime,rituals/routines, number of hours of sleep,time of arising and environmental needs,to determine usual sleep pattern andprovide comparative baseline.2. Identify circumstances that interruptsleep and frequency.R: to be able to provide baseline forcomparison.3. Arrange care to provide foruninterrupted periods for rest.R: determines ability to participate inplanning/ executing care.4. Provide quiet environment and comfortmeasures.
R: helps limit oxygen needs/consumption.5. Recommend midmorning nap if one is
After 8 hours ofNursing Care andinterventions, GOALWAS MET, patient wasable to achieved anoptimal amounts ofsleep as evidenced byrested appearance,verbalization of feelingrested andimprovement in sleeppattern.
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required.R: Napping, especially in the afternoon,can disrupt normal sleep patterns.
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