I. IntroductionA. The Patient and the Problem
The researchers target to present a case study on Primary
Complex, taken during the second day of ourr 3rd week Related
Learning Experience duty on Barangay Boalan, Zamboanga City. There
were other interesting cases also, however, the researchers further
decided to conduct a comprehensive case study on Primary Complex.
Aside from being an interesting topic, the researchers would like
to conduct an in-depth study on primary complex to determine
further the patients health condition and the events that took
place before and during hospital admission, and to be able to
formulate Family Nursing Care Plans appropriate to the identified
problems of the patient in achieving his optimal level of
wellness.
B. Background of the Client
The researchers decided to choose Mr. X as the subject of our
study. He was already under treatment when we found him. Recently,
he was initially admitted to a government institution. May 28, 2014
and was diagnosed with Primary Complex. The patient is 11 years old
Zamboanganueo and is a Roman Catholic. Like normal children, Mr. X
goes to school but in recent times, his father asked for an excuse
to stop his education until he is recovers from said illness. The
patient also had previous hospitalization when he was 2 months old.
Before hospitalization, the patient has unhealthy life style
choices. He was fond of playing outside their house. According to
his father he has poor appetite. The parents still provides the
child the good nutrition unfortunately the child does not possess
the idea of a proper nutrition.
C. Overview of the Disease
D. Objective of Case StudyGeneral Objective:Acquisition and
application of knowledge, skills and attitude through the
utilization of the Family Nursing Process in the care of a patient
with Primary Complex disease with emphasis on promotive,
rehabilitive, and preventive aspects of health care. This case
study also intends to promote wellness, health and medical
understanding of the condition to the patient through the effective
implementation of nursing care services and client health
teachings.
To be able to achieve the goals of care for our patient at the
end of this case study, we have set specific objectives which are
as follows;
1. Establish and maintain rapport to achieve optimal well-being
of the patient2. Discuss the normal Anatomy and Physiology of the
Respiratory system3. Discuss the pathophysiology of the patients
condition, usual clinical manifestation and the factors possible
complications of the condition4. Identify and differentiate risks
for Primary Complex5. Formulate appropriate nursing diagnoses after
identifying the health problem6. Identify and understand different
types of medical management necessary for the treatment of Primary
Complex7. Formulate a workable Family Nursing Care plan based on
the health problem8. Discuss the theoretical framework that is
related to the clients condition9. Explain the Pathophysiology of
Primary Complex10. Be able to apply the learning and teachings on
how to provide counseling related to clients condition11. Evaluate
the effectiveness of care and interventions that was given to the
patient12. Implementation of Family Nursing Care Plan13. Lastly,
formulate conclusion based on the findings and enumerated
recommendations concerning Primary Complex
Nurse-Centered Objectives:At the end of the study, the
researchers:1. Shall have utilized the Nursing Process to
systematically organize the steps in caring the patient. 2. Shall
have familiarized used of effective inter-personal skills to
emphasize health promotion and illness prevention3. Shall have
conducted a comprehensive assessment to the patient as well as the
family and implement care based on the knowledge and skills of the
condition through the utilization of the Assessment Database
(ADB)4. Shall have critical thinking skills necessary for providing
safe and effective nursing care5. Shall have implanted the learning
experience from direct patient care to fellow nursing students
Patient/Family Centered Objectives:At the end of this study, the
patient/family shall be able to:1. Verbalize understanding of the
disease process and readiness for enhanced health well-being2.
Increase awareness on the risk factors of tuberculosis3. Identify
possible risk factors that may have contributed to the development
of tuberculosis 4. Identify measures that could minimize the risk
of occurrence of the disease5. Develop the familys support and
distinguish their respective roles in improving patients health
status
E. Anatomy and Physiology of the Respiratory SystemGross
AnatomyThe surface anatomy of the lungs in anterior and posterior
view. There are a number of key features that allow positioning of
the lungs within the chest. The suprasternal notch is located at
the apex of the sternal bone and between the left and right
clavicle. The sternal angle (angle of Louis) is located at the
second rib, and is a small ridge near the apex of the sternum. At
the base of the sternum is the xiphoid process. The nipple in the
male lies in the fourth intercostal space, but may be at a
different level in the female. On the posterior wall, the spinous
processes of the thoracic vertebrae can be palpated along the
midline. The scapula (shoulder blade) is flat and triangular and is
located on the upper part of the posterior surface of the
thorax.
Apart from the first rib, which lies deep to the clavicle, the
ribs can be palpated from below the clavicle. The apex of the lung
projects into the neck. Anterior and Posterior views of the thorax
of a male. The major location points on the surface of the thorax
are indicated, along with the sites of the major muscles covering
the surface of the chest wall.
Anatomy of the LungsFigure 1. shows the normal structure of
Respiratory System
The lungs consist of airways (trachea and bronchi) that divide
into smaller and smaller branches until they reach the air sacs,
called alveoli. The airways conduct air down to the alveoli where
gas exchange takes place. The lung itself is covered with a
membrane called the visceral (or pulmonary) pleura. The visceral
pleura is adjacent to the lining of the thoracic cavity which is
called the parietal pleura. Between the two membranes is a thin,
serous fluid which acts as a lubricant reducing friction as the two
membranes slide across one another when the lungs expand and
contract with respiration. The surface tension of the pleural fluid
also couples the visceral and parietal pleura to one another, thus
preventing the lungs from collapsing. Since the potential exists
for a space between the two membranes, this area is called the
pleural cavity or pleura.RESPIRATIONRespiration is a passive,
involuntary activity. Air moves in and out of the thorax due to
pressure changes. When the diaphragm, the major muscle of
respiration, is stimulated, it contracts and moves downward. At the
same time, the external intercostal moves the rib cage up and out.
The chest wall and parietal pleura move out, pulling the visceral
pleura and the lung with it. As the volume within the thoracic
cavity increases, the pressure within the lung decreases.
Intrapulmonary pressure is now lower than atmospheric pressure;
thus air flows into the lung inhalation. When the diaphragm returns
to its normal, relaxed state, the intercostal muscles also relax
and the chest wall moves in. The lungs, with natural elastic
recoil, pull inward as well and air flows out of the lungs
exhalation. The lungs should never completely collapse for there is
always a small amount of air, called residual volume, in them.Under
normal conditions, there is always negative pressure in the pleural
cavity. This negative pressure between the two pleurae maintains
partial lung expansion by keeping the lung pulled up against the
chest wall. The degree of negativity, however, changes during
respiration. During inhalation, the pressure is approximately 8 cm
H2O; during exhalation, approximately 4 cm H2O. If a patient takes
a deeper breath, the intrapleural pressure will be more negative.
Under normal conditions, the mechanical attachment of the pleurae,
plus the residual volume, keep the lungs from collapsing.
ABNORMAL ANATOMY OF RESPIRATROY SYSTEMFigure 2. shows the
Respiratory System of an Uninfected individualBefore a person get
infected with this certain disease naturally there is no deviation
from normal findings just a normal, clear and healthy respiratory
system.
Figure 3. shows Respiratory System of an infected individual
However, when somebody coughs and they get you a mycobacterium
tuberculosis into your lungs you got inhaled or breathed it in.
This bacteria loves to settle along the fissures of the lungs and
into the sub pleural space. The fissures separates the lobes of the
lung more like the boundaries of the upper lobes, middle lobe and
lower lobes. Pleural refers to the outside layer of the lungs so if
its sub pleural its right underneath that outside layer of the
lungs and so bacteria loves to go somewhere along the fissures or
somewhere in the sub pleural space.Figure 4. shows the microphages
engulfing the bacteriaBacteria multiply so fast that it could into
and affect millions of alveolar sacs. An infected individual will
have an immediate immune response whereas a microphage will engulf
and consumes foreign materials such as microorganism or bacteria
that is present in the alveolar sacs.
Figure 5. shows the microphages on alveolar sacs and lymph nodes
The microphage carries the bacteria that will take a journey
through the tissues of the lungs and it will drain down to a local
lymph node on the hilar regions which is called the hilar lymph
nodes. Now, the bacteria is in two spots which are the original
spot, alveolar sacs, and in the lymph nodes because they got
carried by the microphage.
Figure 6. Shows that the two spots literally turning into
battlefields or granulomasThis is the part where the primary
infection comes in because there will be reaction between the
bacteria and the microphages in which they will start fighting
against each other. And literally turning the two spots into a
battlefield with dead microbacteria, dead microphages and some of
the patients cell will be affected too.
Figure 7. Shows the close- up view of a Granuloma under a
microscope (left) and the caseous necrosis or the cheese-like
appearance found inside the granuloma (right)Now if you look at it
under the microscope, it actually looks like a granuloma as shown
in the fig.7. Granuloma is an inflammation found in many disease
particularly in this case. It is a collection of immune cells known
as the microphages. Granulomas form when the immune system attempts
to wall off substances that perceives as foreign but unable to
eliminate such substances include infectious organism like bacteria
and fungi. Figure 8. shows the (Right) Caseous necrosis is actually
found inside the granulomas. (Left) difference of Ghon's Focus and
Ghon's Complex also known as Primary ComplexGhons Focus is a
primary lesion usually sub pleural, often in the mid to lower
zones, caused by mycobacterium bacilli develop in the lung of a
non-immune host. Whilst, Primary complex is a primary tuberculosis
seen in children and it is the combination of parenchymal lung
lesion and nodal involvement particularly enlarged hilar lymph
nodes.
Figure 9. shows a X-ray sample of a child which shows a large
hilar lymph node on the right side of the lung shown by the blue
arrow and the yellow arrow points to a parenchymal lesion.
PATHOPHYSIOLOGYTB disease usually occurs in the lungs (pulmonary
TB), but it can also occur in other places in the body
(extrapulmonary TB). Miliary TB occurs when tubercle bacilli enter
the bloodstream and are carried to all parts of the body, where
they grow and cause disease in multiple sites.Tuberculosis occurs
when individuals inhale bacteria aerosolized by infected persons.
The organism is slow growing and tolerates the intracellular
environment, where it may remain metabolically inert for years
before reactivation and disease. The main determinant of the
pathogenicity of tuberculosis is its ability to escape host defense
mechanisms, including macrophages and delayed hypersensitivity
responses.Among the several virulence factors in the mycobacterial
cell wall are the cord factor, lipoarabinomannan (LAM), and a
highly immunogenic 65-kdM tuberculosisheat shock protein. Cord
factor is a surface glycolipid present only in virulent strains
that causesM tuberculosisto grow in serpentine cords in vitro. LAM
is a heteropolysaccharide that inhibits macrophage activation by
interferon-gamma and induces macrophages to secrete tumor necrosis
factor-alpha, which causes fever, weight loss, and tissue
damage.The infective droplet nucleus is very small, measuring 5
micrometers or less, and may contain approximately 1-10 bacilli.
Although a single organism may cause disease, 5-200 inhaled bacilli
are usually necessary for infection. The small size of the droplets
allows them to remain suspended in the air for a prolonged period
of time. Primary infection of the respiratory tract occurs as a
result of inhalation of these aerosols. The risk of infection is
increased in small enclosed areas and in areas with poor
ventilation. Upon inhalation, the bacilli are deposited (usually in
the mid-lung zone) into the distal respiratory bronchiole or
alveoli, which are subpleural in location. Subsequently, the
alveolar macrophages phagocytose the inhaled bacilli. However,
these nave macrophages are unable to kill the mycobacteria, and the
bacilli continue to multiply unimpeded.Thereafter, transportation
of the infected macrophages to the regional lymph nodes occurs.
Lymphohematogenous dissemination of the mycobacteria to other lymph
nodes, the kidney, epiphyses of long bones, vertebral bodies,
juxtaependymal meninges adjacent to the subarachnoid space, and,
occasionally, to the apical posterior areas of the lungs. In
addition, chemotactic factors released by the macrophages attract
circulating monocytes to the site of infection, leading to
differentiation of the monocytes into macrophages and ingestion of
free bacilli. Logarithmic multiplication of the mycobacteria occurs
within the macrophage at the primary site of infection.A
cell-mediated immune (CMI) response terminates the unimpeded growth
of theM tuberculosis2-3 weeks after initial infection. CD4 helper T
cells activate the macrophages to kill the intracellular bacteria
with resultant epithelioid granuloma formation. CD8 suppressor T
cells lyse the macrophages infected with the mycobacteria,
resulting in the formation of caseating granulomas. Mycobacteria
cannot continue to grow in the acidic extracellular environment, so
most infections are controlled. The only evidence of infection is a
positive tuberculin skin test (TST) result. However, the initial
pulmonary site of infection and its adjacent lymph nodes (ie,
primary complex or Ghon focus) sometimes reach sufficient size to
develop necrosis and subsequent radiographic calcification.Most
persons infected withM tuberculosisdo not develop active disease.
In healthy individuals, the lifetime risk of developing disease is
5-10%. In certain instances, such as extremes of age or defects in
CMI (eg,human immunodeficiency virus [HIV] infection,malnutrition,
administration of chemotherapy, prolonged steroid use),
tuberculosismay develop. For patients with HIV infection, the risk
of developing tuberculosis is 7-10% per year.Progression of the
primary complex may lead to enlargement of hilar and mediastinal
nodes with resultant bronchial collapse. Progressive primary
tuberculosis may develop when the primary focus cavitates and
organisms spread through contiguous bronchi. Lymphohematogenous
dissemination, especially in young patients, may lead to miliary
tuberculosis when caseous material reaches the bloodstream from a
primary focus or a caseating metastatic focus in the wall of a
pulmonary vein (Weigert focus). Tubercular meningitis may also
result from hematogenous dissemination. Bacilli may remain dormant
in the apical posterior areas of the lung for several months or
years, with later progression of disease resulting in the
development of reactivation-type tuberculosis (ie, endogenous
re-infection tuberculosis).
Pathophysiology Map of Primary ComplexPrecipitating Factors-
Socio Economic Factors- Improper Nutritional Intake - Environment
(poor hygiene)- Age. 11 years old- Exposed to 2nd hand smoking
Decrease O2supply in the body tissueDecrease O2supply in the
bloodDecrease gas exchangeAlveoli fluid increaseACTIVE INFECTION1.
Cough and ColdsProduction of the cavities filled with cheese like
mass of tubercle bacilli, dead WBC, and necrotic lung tissue.
Necrotic degeneration occursBacteria invasion at the lung tissue or
near pleurae of the lungsLow immunity/ resistance of patient
M. Tuberculosis (tubercle bacilli) enters the body Mode of
Transmission: Airborne
Arrest of the phagosome w/c result to bacteria
replicationBacteria is ingested by the macrophage
Drainage of the necrotic materials into the tracheobroncial
trees
Tubercle bacilli immunity develops (2-3 weeks of inection)2.
Difficulty in Breathing(DOB)
Tubercle bacilli remain in the body as long as living bacilli
remains in the body
3. Body malaise 4. Fatigue
Acquiring the immunity leads to further growth of infection
5. Loss of appetite6. Sudden weight loss
PRIMARY COMPLEX
Figure 10. shwos the complete Pathophysiology Map of a patient
with Primary ComplexII. NURSING PROCESSA. Biographic Data
NAME: Mr. XAGE: 11 year-oldSEX: MaleSTATUS: ChildADDRESS: Zone
III Boalan, Zamboanga City, Philippines, 7000RELIGION: Roman
CatholicETHNIC GROUP: ZamboanguenoOCCUPATION: N/ADIALECT/LANGUAGE:
ChavacanoCHIEF COMPLAINT/S: Shortness of Breath (SOB), Cough and
AnorexiaMEDICAL DIAGNOSIS: Primary ComplexATTENDING PHYSICIAN: Dr.
Sandy Macrohon
Patient History
HISTORY OF PRESENT ILLNESS:
According to the mother, the patient was exposed to the disease
primary complex because the father as well as the sister of the
patient had tuberculosis and the father is also a smoker. She
believes that it was through droplets that causes the transmission
of the disease to her son. Two weeks prior to admission, the
patient had an unexplained fever and cough for more than two weeks.
The patient is currently experiencing chronic cough (>2 weeks)
and shortness of breath. He has as well loss of appetite to eat
which leads to his weight loss.HISTORY OF PAST ILLNESS:
According to the mother, the patient was hospitalized when he
was 2-month-old and was diagnosed of bronchopneumonia. He was also
hospitalized last May 28, 2014 because of his present illness which
is Primary Complex.
HISTORY OF FAMILY:It was verbalized by the mother of the patient
that the patients father has a history of tuberculosis and the
other siblings as well.
B. Comprehensive Nursing History
According to the mother of the client, her child, Mr X was
sickly and frail so they often go to Health Center to seek for
medical attention. Moreover, the client was hospitalized before due
to primary complex. Chest X- Ray was performed last June 3, 2014
resulting to Extensive TB with upper cavities. The client hasnt
undergone any surgeries yet. However, he is currently on Multi-Drug
Therapy in which the client is taking several different antibiotics
at the same time to treat TB.
D. Physical Assessment PEDIATRIC ASSESSMENT TOOL:PHYSCIAL
ASSESSMENTI. SKIN( ) WNL( ) Jaundice ( ) Bruises( ) Cyanotic( )Poor
Turgor ( ) Burns( ) Lesions( ) Rash( ) Dry ( ) Birthmarks( )
Pallor( ) Absence Pigmentation( ) Simian Crease( ) Petichiae ( )
Others: _____________________________________Patients skin is equal
in color there were no rashes or burns observed. And the patients
is neither pale nor cyanotic.
II. Mental/ Psychosocial()) WNL( ) Short attention span( )
Hyperactive( ) Withdrawn( ) Hypoactive( ) Aggressive ( ) Others:
______________________________Family adjustment: ( ) Poor ( )
Fair() GoodParent bonding () Yes( ) NoPatient responds when talked
to and was not easily distracted. Patient is shy during the
interview.
III. Head and Neck() WNL6 months and over( ) Head Asymmetry ( )
Excessive neck skin( ) Head Log( ) Misaligned Trachea( ) Enlarged
head( ) Enlarged thyroid( ) Neck pain( ) Enlarged lymph nodes( )
Neck swelling( ) Neck Webbing( ) Others:
__________________________________The patient verbalized that he
doesnt feel pain on his neck and there was no facial grimace
observed. There was no swelling or enlargement on his head and neck
upon assessments
IV Eyes() WNL( ) Displaced Position( ) Redness( ) Jaundice( )
Ptosis( ) Discharge( ) Strabismus( ) Swelling ( ) Sunset eyes( )
Dull cornea( ) Pale Conjunctiva ( ) Others:
________________________Follow Object with eyes: () Yes( ) NoWears
glasses: ( ) Yes() No(Only during school activities-medical
check-up) most recent eye examinationPatients pupil is black in
color. Penlight was used to assess pupils reaction to light. When
light was shined on the pupil it constricts.
V Ears() WNL( ) Displace Position( ) Pain( ) Hearing loss( )
Others: __________________________( ) DrainagePatients ears are not
displaced and there was no drainage. Patient verbalized that he
doesnt feel any pain in his ears and there was no problem in his
hearing as he was able to interact with us.
VI Nose( ) WNL( ) Nasal flaring( ) Deviated septum( ) Nose
bleeds( ) Nasal congestion() Drainage( ) Others:
___________________________The patient manifest nasal drainage and
sticky mucus upon observation.
VII Gastro Intestinal Tract () WNL( ) Anomalies( ) GI reflux( )
Absent bowel sounds( ) Emesis( ) Hypoactive bowel sounds( )
Distension ( ) Hyperactive sounds( ) Abdominal tenderness()
Abdominal girth ________( ) Ostomy( ) Diarrhea( ) Constipation( )
Others ____________________Patient with diapers( ) Yes() NoPatient
is toilet trained() Yes( ) NoStool color Brown___Amount:
_________Frequency 1x/day
VIII Nutrition( ) WNLDiet/ Formula: Regular dietAmount:
______Frequency: 3X a dayRoute () Oral( ) Breast ( ) Bottle ( )
NGT/GTAppetite:() Good( )Fair( ) Poor
IX Musculoskeletal System( ) WNL( ) Muscle Conditions( )
Kyphosis() Poor muscle tone( ) Scoliosis( ) Contractures( )
Trendelenburg Gait( ) Limited ROM( ) Anomalies( ) Poor gross motor
skills( ) Fractures( ) Poor fine motor skills( ) Cast( ) Others
____________________
X GU/ Reproductive System () WNL( ) Anomalies( ) Hydrocele( )
Renal Disease( ) Vaginal Discharge( ) Polyuria ( ) Hernia( ) Labia
lesions( ) Inguinal hernia( ) Circumcision( ) Undescended testes (
) Hypospadias( ) Others __________________________The patient does
not manifest early problems with his reproductive organs. He does
not experience difficulty in his urination. He urinates 3-4 times a
day depending in his fluid intake. He is still uncircumcised as
verbalized by his father.
XI Endocrine System() WNL( ) Abnormal growth pattern( ) Abnormal
sexual development ( ) Abnormal hair texture( ) Others
________________________Diabetic Insulin dependent ( ) Yes () No
The patient is not a diabetic Insulin dependent. Patients height is
average for his age.
XII Cardiovascular System () WNL( ) Congenital Anomalies( )
Edema (Site: _____________________)( ) Cyanosis( ) Poor capillary
refill( ) Pallor( ) Umbilical Anomalies ( ) Murmur( ) Hypertensive(
) Others ______________________Patients capillary refill is 2-3
seconds and there was no edema observed. The patient has normal
heart beat sounds. Upon assessment, the patient is not cyanotic and
does not manifest early problems in his cardiovascular system.
XIII Neurologic System( ) WNL( ) Headache( ) Tetany( )
Drowsiness( ) Weakness( ) Spasms () Listlessness( ) Abdominal
fontantels( ) Irritability( ) Seizure( ) Fixed pupils/ unequal
pupils( ) Tremors( ) Neurologic disease( ) Others
___________________________________Patients LOC Awake and
alert____________________________________________Reflexes
appropriate for ages: () Yes( ) NoMental behavioural status: Enjoys
learning, likes challenges______________________Speech or language
difficulties: Speaks chavacano and tagalog_______________Cognitive
performance: The patient is not interacting much but he mostly
responds by nodding and smiling to us.Social Skills: The patient is
shy around strangers.___________________________Gross Motor Skills:
The patient mostly plays with their
cat.________________________
XIV Respiratory System ( ) WNL ( ) Rales( ) Flaring() Cough( )
Rhonchi( ) Retractions( ) Stridor( ) Dyspnea( ) Cyanosis( )
Crepitation( ) Clubbing() Wheezing( ) Others Difficulty of
breathing when coughing
XV Infusion () None( ) Intermittent( ) ContinuousPump type
_________________________________________Line type ( ) Peripheral (
) Central ( ) Brands __________ ( ) Gauge _______________Insertion
site _______________________________________Date Inserted
________________________________________________________Dressing
last change __________________________________________________Site
assessment:( ) Patent( ) Redness( ) Infiltrated( ) Swelling ( )
Drainage( ) Out of vein
XVI Pain Presence of Pain ( v) Yes( ) NoOnset
___________________Pain medication None_________Effective ( ) Yes(
) NoLocation/ Characteristics and frequency of pain:The patient
experiences discomfort during coughing and difficulty in
breathing._____Alleviating Factors: The patient usually takes a
complete rest when these signs are
manifested.___________________________________________________________Pain
Scale:
5/10_________________________________________________________Precipitating
factor Patient is usually interactive but easily gets tired. The
added factors causes the patient discomfort in his respiration and
increases the production of phlegm.
XVII Level of Independence SKILLSINDEPENDENT USES DEVICEHELP OF
ANOTHERTOTALLY DEPENDENT
Eating
Toileting
Transferring
Walking
Bathing
Dressing
XVIII Limitations( ) Contractures() Dyspnea with minimal
exertion (during coughing)( ) Hearing impairment ( ) Growth( )
Limited endurance( ) Language delay( ) Abnormal Speech ( )
Amputation
PEDIATRIC ASSESSMENT TOOL: SCHOOL AGE CHILD 6-12 YEARS OLDI.
HistoryA. Previous Hospitalizations: May
28,2014______________________________B. Common Childhood Illness:
Coughing, Fever, Sinusitis_____________________C. Allergies or
Allergic Responses: No allergies to food or dust_________________D.
Immunizations:
Complete_____________________________________________E. Health
Status of Family Members: Poor condition, his Father has a
Tuberculosis as well the patients
sibling.___________________________________________
II. Developmental MilestonesA. Physical
CharacteristicsCharacteristics6-12 years oldPatients
Characteristics
Average Weight6 years 24 kg (48 lbs)12 years 38kg
(84lbs)19KG
Average Height6 years 117cm (46in)12 years 150 cm
(59in)132CM
Prepubertal Growth Spurt10-12 years, girls taller than boysPubic
hair and other secondary changes: voice, moustaches for his age
were not yet developed.
Vital Signs
TemperaturePulse RateRespiratory RateB/P
37C (98F)90bpm21-22bpm110/70mmHg
34.6C101 BPM21BPM110/70 mmHg
B. Behavioral Characteristics
AgeGross/Fine Motor SkillsIntellectualPsychosocial
10 years old>>enjoys physical games with
peers>>Understand casual relationships>>behavior is
predictable, controlled>> expands peer relationships in
cliques
11 years old>>may be clumsy>>can solve simple math
problems>> shy around strangers
E. Diagnostic Test 1. Radiologic Test (Chest-Xray)Date: June 4,
2014Clinical ImpressionMedical Implication
Extensive Tuberculosis With Upper Cavities This category
comprises all findings typically associated with active pulmonary
TB. An applicant with any of the following findings must submit
sputum specimens for examination.1. Infiltrate or consolidation -
Opacification of airspaces within the lung parenchyma.
Consolidation or infiltrate can be dense or patchy and might have
irregular, ill-defined, or hazy borders.2. Any cavitary lesion -
Lucency (darkened area) within the lung parenchyma, with or without
irregular margins that might be surrounded by an area of airspace
consolidation or infiltrates, or by nodular or fibrotic (reticular)
densities, or both. The walls surrounding the lucent area can be
thick or thin. Calcification can exist around a cavity.3. Nodule
with poorly defined margins - Round density within the lung
parenchyma, also called a tuberculoma. Nodules included in this
category are those with margins that are indistinct or poorly
defined (tree-in-bud sign). The surrounding haziness can be either
subtle or readily apparent and suggests coexisting airspace
consolidation.4. Pleural effusion - Presence of a significant
amount of fluid within the pleural space. This finding must be
distinguished from blunting of the costophrenic angle, which may or
may not represent a small amount of fluid within the pleural space
(except in children when even minor blunting must be considered a
finding that can suggest active TB).5. Hilar or mediastinal
lymphadenopathy (bihilar lymphadenopathy) - Enlargement of lymph
nodes in one or both hila or within the mediastinum, with or
without associated atelectasis or consolidation.6. Linear,
interstitial disease (in children only) - Prominence of linear,
interstitial (septal) markings.7. Other - Any other finding
suggestive of active TB, such as miliary TB. Miliary findings are
nodules of millet size (1 to 2 millimeters) distributed throughout
the parenchyma
2. Sputum ExamDate: June 10, 2014- 1st Sputum Exam June 14,
2014- 2nd Sputum Exam June 16, 2014- 3rd Sputum Exam
Clinical ResultMedical Implication
Positive Sputum ExamHarmful bacteria or fungi are present. The
most common harmful bacteria in a sputum culture are those that can
causebronchitis,pneumonia, or tuberculosis. If harmful bacteria or
fungi grow, the culture is positive.
EVALUATIONThe group is studying the case of Mr. X who was
diagnosed of Primary Complex, last May 28, 2014and was hospitalized
at a government institution. We were able to identify three
problems; primary complex is related to the condition of patients
location, knowledge deficit on malnutrition and risk for improper
hygiene. During the course of the process of the case study, the
patient was the foremost concern of the group in prioritizing
hisproblems and needs. The group employed a lot of work in
providing quality nursing care to the client. The researchers were
provided with ample time to conclude this case study. Improving and
sharpening the skills and proper decorum was also an aspect of the
study that the group trained. With the help of this case study, the
group was able to go beyond the borderline about what they think,
know, and perform in giving quality nursing care. The group was
able to broaden their knowledge about specific topics such as
anatomy and physiology of the respiratory system and as well deeply
understand the pathophysiology of primary complex. On the other
hand, the group was able to enumerate and facilitate focal-point
interventions in accordance to patients level of comprehension and
ability to comply treatments. On the process of this case study,
the group was able to establish rapport. They had also done the
nursing assessment cephalocaudally and were able to identify all
the patients needs and problems according to their level of
priority which guided the group in formulating the Family Nursing
Care Plan. The group focused on a problem that revolves on the
health deficit- Primary Complex, health deficit- Malnutrition, and
health threat- Improper hygiene.The family nursing care plans were
being implemented in the health center during our visit and related
learning experience duty. All the nursing interventions were able
to help the client improve his condition well. The empathy, wisdom
and knowledge that the group gave to the client helped lessen her
problems and worries. With the help of nurse-patient relationship
and the rapport that has been established, the patient was able to
relate all his feelings and difficulties as he is struggling to
recuperate from this disease. At the end of the case study, the
group was able to meet their objectives and goals. The group worked
as a team and showed their cooperation to one another like a
family. This case study helped the group in broadening their
critical thinking abilities, improved and added new learning, ideas
and information which will be useful for them in the future. The
group gained the sense of responsibility and honesty. They also
learned a lot of things like working as a group, brainstorming and
sharing of information and knowledge with each other, accept all
suggestions from people who are more knowledgeable than us and
collaborate with others. Along the over-all process, the groups
came a crossed with some problems that may affect the case study,
these includes the availability of laboratory results, final
diagnosis, medications given during his stay in the hospital,
discharge plan and the time given to interact with the patient to
dig in more details to support our case study however, the over-all
process of our case study, in spite of the constraints met by the
group, the researchers conclude that this case study met their
goals and was a successful one.
RECOMMENDATIONS Patient and family members should be given
thorough instructions and teachings to help the patient cope up
with his condition. As student nurses, it is an obligation and a
privilege to work closely with the patient and his family to reach
the care desired and to the extent possible, or to facilitate a
transfer to the following: 1. Medications The patient is given
Isoniazid, Rifampin and Pyrazinamide. These medications are
classified as anti-tubercular. Patient should able to religiously
take this multiple-drug therapy within 6 months. Skipping these
medications will allow the microorganism to resistant to any drug
therapies in the future. 2. Exercises He is encouraged to exercise
in short session, such as walking for twenty (20) minutes or
completing two ten minute walks. He is advised to walk as often as
he is able to. He is assured to only do exercises by doctors
approval and to go outside if he has active tuberculosis. He is
told that moderate walking is a good way to start, most especially
if he has been inactive. As he builds his strength, he can slowly
increase his walking time, once his disease is no longer
contagious. He is provided with teaching that exercise can help his
body fight the infection, speed the recovery and improve the
mood.3. Treatment and Therapy He is assessed for hypersensitivity.
He is advised not to skip doses and to take medications for full
length of the prescribed therapy; is informed that urine, feces and
sweat are red orange and soft contact if Rifampin is taken. He is
told that the medications must always be taken as prescribed by the
physician; never save antibiotics that are given to you for another
illness. The treatment regimen that is ordered by his physician
must be followed strictly and should not be stopped to prevent from
the aggravation of the condition. He must not wait for the signs
and symptoms to be severe. Consult health care providers at the
health center if signs and symptoms are not diminished.4. Health
teaching He must keep all his medical appointments, take his
medicines as prescribed by his physician, report any side effects
after he has taken the medications, and most especially vision
problems. Advise patient to tell ahead to the physician if he plans
to postpone the schedule in order for an arrangement to be prepared
for the next treatment. Provide emotional support to him that he
doesnt have to feel embarrassed about his condition and let him not
worry that people may find out. He doesnt have to feel bad if
people wear masks when they go near him. He doesnt need to feel
isolated and alone because he cannot go to school. Encourage his
family not to worry about paying for the treatment. They dont have
to be rich to have treatment; there are always alternative ways to
regain normal health condition. They do not have to be guilty.
Patient must not go yet to his school where he can easily spread
the disease, and must be kept in a separate bed room. Inform family
to open windows in the room for this can get rid of tuberculosis
from the air in the room and he must cover his mouth whenever he
sneezes or coughs. Until he has been on antibiotics for about two
weeks, he can easily give off the infection to others. After
coughing dispose of the soiled tissue in a covered container. He
must talk to his physician to further educate him about the
precautions and prevention of tuberculosis.
12
