MANILA DOCTORS COLLEGEPresident Diosdado Macapagal Boulevard, Metropolitan Park, Pasay City

HEALTH CARE: RELATED LEARNING EXPERIENCENURSING PROCESS

I. ASSESSMENT

A. General Data

Patient’s Initials: L.R.T.Address: Tondo, Manila Age: 20years oldSex: MaleDate of birth: 10/2/1989Civil Status: SingleOccupation: Pedicab driver at Divisoria (Before he got sick)Informant: Client (L.R.T.)Order of Admission: Out Patient Department /Home visitDate of history taking: January 28, 2010

B. Chief Complaint

The client goes to the health center for the compliance to the drug therapy prescribed by the physician. Client is under the Directly Observed Treatment Short Course (DOTS) program for duration of ten days. He was diagnosed with Pulmonary Tuberculosis Category I on January 12, 2010.

C. History of Present Illness

Last November 2009 the patient started to experience productive cough, difficulty of breathing, intermittent fever, chest pain, and night sweats. On December 16, 2009, the patient vomited sputum with blood (hemoptysis). That prompts him to seek medical attention at GAT Emilio Aguinaldo Medical Center. He also had a second opinion last December 22, 2009 at the San Lazaro Hospital where he had Chest X-Ray and the finding was suggestive of PTB. He went back to GAT Emilio Aguinaldo Medical Center for further testing for his disease. On January 11, 2010 and January 12, 2010, he took Sputum test at GAT (Results will be further discuss later on Laboratory Findings). He was referred to the Barrio Magsaysay Health center for his medication.

D. Past History

Childhood Illness: NoneAdult Illness: Pulmonary TuberculosisImmunization: UnrecalledAdult Immunization: NonePrevious Hospitalization: NoneOperations: NoneInjuries: None

Medications taken prior to going to the hospital: BiogesicAllergies: No known allergies

E. System Review

1. Health Perception – Health Management

Before L.R.T was diagnosed of Pulmonary Tuberculosis (PTB), he sees health as being able to do everyday things well and according to the manner he wants it and not getting sick easily. In terms of supplements, he doesn’t take vitamins or any medication to help treat his acute conditions like fever, coughs and colds. He just lets it subside. However, if his condition worsens, he goes to the health center or to any nearby drugstore to buy medicine (e.g Biogesic) . He used to smoke 1 pack of Marlboro cigarette in one day and would drink alcohol with his friends at Divisoria where they share single glass and pass it to the next person, only if there are people who invite him.

When L.R.T. started to experience (November 2009) coughing, intermittent fever, difficulty of breathing, right upper chest pain (8 out of 10, 10 being the highest, 1 being the lowest), excessive sweating while sleeping, fatigue, and loss of appetite he begins to be conscious of his health and sought advice. He ranked his health 5 out of 10 (10 being the highest, 1 being the lowest).

At the present, L.R.T is more conscious with his health since he was diagnosed with PTB. Now, he sees health as a need; a need for him to work effectively and continuously. He is compliant with his medications because he wants to work once again to help his mother with the family finances. He has stopped smoking and drinking. Even though he has taken medications for PTB, he still has productive cough as he verbalizes: “Yung ubo ko ma-plema… yellow o kaya green yung kadalasang kulay. Minsan nga lang, mahirap ilabas yung plema,” Since he started undergoing DOTS therapy, he verbalized that there was decrease in coughing, difficulty of breathing, chest pain (4 out of 10 with 10 being the highest, 1 being the lowest), absence of excessive sweating when sleeping, fever, and increased appetite. He ranked his health as 7 out of 10 (10 being the highest, 1 being the lowest).

2. Nutritional Metabolic Pattern

Before he was diagnosed with PTB, he had a good appetite. He only eats when he feels hungry. His usual food intake includes rice and street foods (kwek-kwek, kalamares, fish ball) since he works near Divisoria which is the food available and affordable for him. He drinks 6 to 7 glasses of water every day. He drinks alcohol (Ginebra) every night where they share a single glass then pass it to the next person. He did not experience any difficulty in swallowing. He also does not have any allergies in food and in medications.

When he was diagnosed with PTB, his appetite decreased. He wasn’t able to eat much because he felt weak. He also experienced a drastic decrease of weight; 72 kg to 60 kg (12 kg weight loss) for two months duration. He verbalizes: “Wala akong ganang kumain, kaya nga nabawasan talaga timbang ko mula 72 kilograms naging 60 kilograms nalang ako sa loob ng 2 buwan.”

Last January 28, 2010, according to the patient, there was an improvement in his appetite in comparison to the time when he is experiencing cough, intermittent fever, difficulty of breathing, chest pain, excessive sweating when sleeping, and fatigue. He now eats three times a day, which includes rice (1 to 2 cups a meal) and viand usually fried fish (tuyo, galunggong), pork, chicken, and vegetables (e.g ginisang kangkong). He still drinks 6 to 7 glasses of water a day. He no longer drinks alcoholic beverages as verbalized by the client. He is now taking anti-tuberculosis drugs (Rifampacin, Ethambutol, Isoniazide, Pyrazinamide) as adherence to DOTS therapy.

3. Elimination Pattern

Before being diagnosed with PTB, L.R.T didn’t have any problems regarding his elimination pattern and didn’t use any laxatives to aid him in eliminating feces. He defecates once a day, usually early in the morning or before going to bed, his stool was formed and can be easily eliminated. He would urinate three times a day depending on his fluid consumption. He describes his urine as slightly yellowish and clear in color. He does not have odor problems.

During the month of November 2009, the patient verbalized that he has sputum secretions ranging from yellow to green in color. Last December 16, he coughed out blood. He also told us that he experienced night sweating.

Last January 28, 2010, his elimination pattern remains the same. He verbalized that he no longer experiences night sweating. Patient’s urine change from yellow to orange as a side effect of the medication he is taking (Rifampacin).

4. Activity – Exercise Pattern

Before he was diagnosed with PTB, he is usually found working as a pedicab driver at Divisoria where they drink alcohol and share a single glass then pass it to the next person. He cleans the house everyday and plays basketball with friends. At this time he doesn’t get tired easily.

After the diagnosis of PTB, he doesn’t go out much anymore. He stoppped working as a pedicab driver and stayed at home to rest and get better. He has stopped smoking and drinking as well. According to L.R.T “Isa talaga sa malaking pagbabago sakin ay yung madali nakong mapagod at hingalin, di na ko makapag-side car at makagawa ng ilang bagay.”

According to L.R.T last January 28, 2010, he can walk short distances only because he gets tired easily and feels shortness of breath. His main form of exercise now is walking. As verbalize by the patient: “Simula nung lagi na akong inuubo, madali na akong hingalin at parang nauubusan ng hininga.”

5. Sleep and Rest Pattern

Before he was diagnosed, he sleeps at 9:00 am and wakes up at 9:00 pm since he works as a pedicab driver at night. He would sleep 12 hours every day because he is always tired from work. He feels well rested when he wakes up and doesn’t need any sleeping pills to get him to sleep.

According to the patient, during the month of November 2009, he had difficulty in sleeping because of persistent cough. He would read comics or stay outside the house until he feels sleepy. He sleeps for seven hours with interruption and would feel pain in his chest area when he sleeps on his left side. He usually wakes up sweaty as verbalized.

When L.R.T was interviewed last January 28, 2010, he told us that at present he is able to sleep better. His cough has lessened and his numbers of hours of sleep have somehow increased (12 hours). He now wakes up at 9:00 am and sleeps at 10:00 pm with naps (30 minutes) in the afternoon. The reason of this change in sleep pattern is because the client already stopped working. Until now he still feels chest pain while sleeping in left side lying position. He feels rested and energetic whenever he wakes up.

6. Cognitive Perceptual Pattern

Before the diagnosis of PTB, L.R.T. does not need to use any aids for vision and hearing. At first, he was not aware of his condition and its complications that prompt him to seek medical attention.

At present, upon understanding the severity, the patient immediately adhered to the medications needed to cure his condition. The patient can relate to ideas and topics. He grasps ideas and questions easily, and he does not have difficulties in learning with regards to health teaching. He thinks futuristically as evidenced by setting a goal- to be healthy again. He still does not need to use aids for vision and hearing.

7. Self Perception or Self Concept Pattern

Before he was diagnosed with PTB, he was confident about himself because he can do everything that he wanted. He can work, socialize, and play basketball with his friends.

Last January 2010 when he found out that he has PTB, his perception about himself changed. He immediately stopped his job and limited himself from his previous activities. He felt conscious about talking with other people that’s why he wears a mask when he speaks. He separated his utensils from his family’s things and normally stays at the second floor to avoid contact with his siblings.

According to the patient last January 28, 2010 he feels secure because he is able to control his illness by compliance to medication and he knows that his condition can get better. Since then he is now able to walk around, do some house hold chores and talk other people.

8. Role-Relationship Pattern

Before the diagnosis, he acted as a father figure to his younger siblings since their parents are separated. He helps with their finances by working as a pedicab driver at Divisoria. He serves as a role model to his younger siblings as he tell them how to act in different situations of life. Whenever they have problem they would just let it pass and talk about it as soon as they have relaxed. There are no problems in relationship among family members for they have close ties. He has close friends that he can rely on. The patient knows his right as a person and he follows rules and regulation desired for the group and the society he belongs to.

At present time he no longer serves as the bread winner of his family because of his illness. Even in his illness, his family is supportive to him. He separates his things, especially utensils in able to prevent transmission of disease. His friends remained supportive despite his condition.

9. Sexual Reproductive Pattern

Mr. L.R.T. is still dependent to his mother when it comes in facing big decisions; but mostly he decides and does things independently. He is happy with his friends and significant other. L.R.T has undergone circumcision when he was 12 years old. And before he was diagnosed he has had sexual intercourse seldom without the use of contraceptives. For him being a man is able to stand up for his family and being able to give the needs of his mother and younger siblings financially.

Nothing has changed in the present except that he is not sexually active because it may cause transmission of the disease.

10. Coping/Stress Pattern

Before he had PTB, he goes out of their house and talks to his friends to relieve his stress. At times he would sleep or read comics to help him forget about his problem.

Upon diagnosis, he sleeps to help him relax and stays at home to avoid other distraction. For him not being able to do things he usually do, like hanging out with friends and working as a pedicab driver causes him stress.

At present time he doesn’t feel any stress. He feels better because he can now walk around their community and socialize.

11. Values and Beliefs

L.R.T is a Roman Catholic but seldom goes to church except when somebody invited him to go with them. He prays at home and doesn’t lose his faith. According to him, he also has sets of beliefs that were influenced by the people around him.

At present time, his faith in God has become stronger. Even though he does not go to church every Sunday he exercises his faith by praying that he would surpass this challenge in life. He was able to attend the recent Feast of the black Nazarene, hoping that it would help him recover from his illness.

F. Family Assessment

Initials Relationship Age Sex Occupation Educational Attainment

Y.R.T. Mother 42 Female Banana-cue and Camote-cue Vendor

High School Graduate

L.R.T. Sister 19 Female None High School Graduate

L.R.T. Sister 18 Female None High School Graduate

L.R.T. Brother 9 Male None Elementary

(Grade 3)

G. Heredo-Family Assessment

Maternal –Cancer (Colon), Tuberculosis

Paternal- none

H. Developmental History

Theorist Age Task Patient’s Description

Erik Erikson-Theory of psychosocial development.

20 Identity vs. Role Confusion

Mr. L.R.T. is confident and sure about his identity. He knows his role as a child, a friend and member of the society.

Sigmund Freud-Theory of psychosexual development

20 Genital Mr. L.R.T. is still dependent to his mother when it comes in facing big decisions; but mostly he decides and do things independently. He is happy with his friends and significant others.

Jean Piaget-Cognitive development theory

20 Formal Operation Phase

Although Mr. L.R.T.’s educational attainment is Grade 3, he thinks and decides rationally. The patient can relate to ideas and topics. He grasps ideas and questions easily, and he does not have difficulties in learning. He thinks futuristic as evidenced by setting a goal- to be healthy again.

Lawrence Kohlberg-Moral development theory

20 Law and Order Orientation

The patient knows his right as a person. He follows rules and regulation desired for the group and the society he belongs to.

Fowler-Spiritual development theory

20 Individuating-Reflective

Mr. L.R.T. is a catholic and even though he does not go to church every Sunday he exercises his faith especially this time. According to him, he also has sets of beliefs that were influenced by the people around him.

I. Physical Examination:

Day 1: January 28, 2010Vital Signs: Temp: 37.6 CPR: 94 bpmRR: 26 cpmBP: 130/80 mmHgHeight: 5’9’’ or 175.4 cmWeight: 60 Kgs (BMI: 19.5)Ideal Body Weight: 72.72kg

Day 2: January 29, 2010Vital Signs: Temp: 37 CPR: 79 bpmRR: 24 cpmBP: 110/70 mmHgHeight: 5’9’’ or 175.4 cmWeight: 60 Kgs (BMI: 19.5)Ideal Body Weight: 72.72kg

Day 3: January 30, 2010Vital Signs: Temp: 37.1 CPR: 85 bpmRR: 24 cpmBP: 120/90Height: 5’9’’ or 175.4 cmWeight: 60 Kgs (BMI: 19.5)Ideal Body Weight: 72.72kg

BMI: 19.5

Underweight = <18.5 Normal weight = 18.5-24.9 Overweight = 25-29.9 Obesity = BMI of 30 or greater

Regional Examination:

General Survey

The patient appears alert and coherent. He is able to stand still with posture in a slouched stance. The patient has slight difficulty of breathing because according to him, he walked a long way.

The patient is cooperative in our nursing assessment and he was able to answer most of our questions. He is very attentive and listens carefully to the questions and discussion the group is performing. Patient is easy to talk with. He understands fully what was happening during the interview and assessment.

A. SkinI:

Is brown to dark brown in color Absence of lesions.

P: Is warm to touch Absence of tenderness and masses Has normal skin turgor.

B. NailsI:

Are convex. Have long and transparent nails. Nail bed is pinkish in color.

P: Nail has a smooth texture. Has good capillary refill of 2-3 sec.

C. Head & FaceI:

Is elongated. Is aligned at the center of the body. Facial features are symmetrical

P: Skull is smooth. Absence of tenderness and masses. Hair is short, smooth and shiny. Facial movements are symmetrical.

D. EyesI:

Eyebrows are symmetrically aligned and hair is evenly distributed. Pinkish conjunctiva The eyelids do not cover the sclera and blink reflex is present. Corneas are transparent and colorless Pupils are equal in size, rounded and reactive to light and accommodation

E. EarsI:

Has the same color with facial skin. Are symmetrical. Are aligned with the outer cantus of the eyes. Showed good hearing results to various volume level of the interviewer.

P: Absence of tenderness and masses

F. NoseI:

Nares are symmetrical Absence of discharge Nasal flaring is present during speaking

P: Absence of tenderness, especially in the sinuses.

Absence of masses or nodules

G. Mouth & PharynxI:

Internal structures of his mouth are pinkish in color. Lips are dark pink in color, dry and it is symmetrical Tonsils are pinkish to reddish in color with no swelling. Teeth are yellowish in color Two front teeth are present of tooth decay. Tongue can move freely tonsils show no signs of inflammation Absence of swelling.

P: Absence of tenderness. Gag reflex not tested.

H. NeckI:

Is at the center of the body Neck muscles can move if full ROM, without any discomfort Absence of neck vein distention Enlarged Superficial Anterior cervical lymph nodes were observed.

P: Tenderness was noted at the location of the right superficial Anterior cervical

lymph node

I. Thorax & Lungs

I: With spontaneous breathing pattern Depressed clavicular area Retractions at 2nd-10th intercostals spaces are visible during respiration. Spine is straight without any deviations. Ribs slope across and down. Active movement occurs within the intercostals spaces. Client is in a slouch position, observable during standing and sitting position

Pa: Vibration was felt during tactile fremitus test stronger at the top (Supra Clavicular

Region), diminishing as it goes down (Infra Scapular Region). Diaphragmatic excursion is asymmetrical; right side slightly expands more than

the left. Per:

Percussion notes resonate across the posterior thorax except at the scapular region The lowest point of resonate is just above the diaphragm region.

A: Diminished vesicular and vesicular breath sounds are present at the posterior

thorax Bronchovesicular breath sounds are heard louder at the upper right part of the

thorax Anterior thorax so as bronchial, especially in placing the stethoscope midsternal

line and tubular breath sound at the anterior thorax. Crackles heard at both posterior lungs

J. Cardiovascular/HeartI:

The aortic, pulmonic and the tricuspid areas are absent from pulsations Absence of lifts and heaves was observed in the tricuspid area. The apical area has visible pulsation apical area has no visible lifts or heaves. The epigastric area has visible pulsation. Carotid has symmetric pulse as the radial pulse and the apical pulse.

Pa: A heart rate of 94 beats per minute (based on January 29, 2010); beat is strong

and fast, with regular rhythmA:

No extra heart sounds was heard.

K. Breast and AxillaeI:

A tattoo of “Juliet” was seen on the middle of the chest; 2x5inches in size No lesion was present. Presence of hair was noted on the axillae.

P: Axillary is dry. Palpable axillary lymph nodes were noted.

L. AbdomenI:

Stomach is flat, no scars is noted. Umbilicus is at midline.

A: The bowel sounds are intermittent (every 5-35 times per minute)

Pa: Percussed dullness over the liver 6-12cm and tympanic all over quadrants

M. ExtremitiesI:

Tattoo of a dragon is present at the right deltoid (approximately 2x4 inches) Able to stand still and walk in slow manner Posture is in a slouch stance but with alignment of the hips and shoulders. There are no gross deformities that are found in the body. Hair evenly distributed Skin color is dark brown.

P: Absence of tenderness

M. Genitals Client refused to perform Client does not perform self testicular examination

N. Rectum & Anus Client refused to perform Client verbalized the absence of palpable lesions or masses, tenderness, pain in

defecation.

O. Neurologic Exam

A. Mental and Emotional Status

Conscious, coherent and oriented to time, place and date Responds quickly to the question asked Client keeps nail long, keeps hair short Is able to understand written and spoken words very well.

B. Intellectual Function The client’s immediate recall, recent and remote memory is normal. The client is able to answer simple questions properly. He is able to explain phrases in a complete detail and associates related concepts

normally. Able to weigh the importance of seeking help.

II. PERSONAL HISTORY

Habits: L.R.T walks around the community, playing basketball with his friends, helping his mother in their household chores.

Vices: Started Smoking 15 years old and he consumes one pack per day. Drinking Alcohol (Before diagnosis of Tuberculosis)

Lifestyle: He has changed his lifestyle from sedentary to a healthy one. He now eats a balanced meal, which includes, rice, vegetables, and meat. And also, he drinks 6-7 glasses of water and has already stopped drinking alcohol and refrained from smoking.

Social Affiliation: None

Client’s usual day like: He wakes up at 9 in the morning, eats breakfast, cleans the house and bathes. On Mondays, Wednesdays and Fridays, at around 10am, he goes to the health center to get his medicine. He socializes with their neighbors. Then he goes home and sleeps at around 10pm.

Rank in the Family: Second Child

Travel: None

III. ENVIRONMENTAL HISTORY

L.R.T lives in a two-story house with one door and five windows. Their house has a height of 4.20 meters, a width of 3.74 meters and a length of 5.94 meters. There are two windows on the first floor and three on the second floor. The house has 2 bedrooms, one in the 1st floor and the other one in the 2nd floor. The client sleeps in the 1st floor, separated from his mother and siblings. The client stated that they have no problems with ventilation at night because the air is cold during the evenings. They have their own private bathroom. They gather all their garbage in the morning at around 5:30am and put

it in the street where it is being collected every six in the morning by the municipal garbage collector. They do not experience any flooding in the area. They do not have problems with mosquitoes because they spray Baygon around once every three days. They have no problems with seeking health care because they are located near a health center, although L.R.T. verbalized that they still prefer going to a hospital because of the higher quality of health care. They usually drink mineral water, and they get their tap water from Nawasa. They get their electricity from Meralco. The client verbalized that since they are near a market place, they do not have problems with buying food. They do not own the house they live in. As the client stated, “Caretaker lang kami nitong bahay. Hindi na kami nagbabayad ng renta pero kami bahala sa pagmamaintain ng bahay.”

The client worked in Divisoria before. He verbalized that the surroundings were dusty, crowded, dirty, and “lahat ng puede mong langhapin malalanghap mo na.” Currently, L.R.T. does not work due to his current health condition.

IV. OB/GYNE HISTORY (Not Applicable)

V. PEDIATRIC HISTORY

MATERNAL AND BIRTH HISTORYBirth date: 10/2/1989Birth weight: UnrecalledType of Delivery: Normal Spontaneous DeliveryCondition after Birth: NormalHospital: Unrecalled

VII. LABORATORY RESULTS

Chest X-Ray Procedure

Before the Procedure

The physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

Generally, no prior preparation, such as fasting or sedation, is required. Dress in clothes that permit access to the area to be tested or that are easily removed. Notify the radiology technologist if you have any body piercing on your chest. Based upon your medical condition, your physician may request other specific

preparation.

During the Procedure

Generally, a chest x-ray follows this process:

1. You will be asked to remove any clothing, jewelry, or other objects that may interfere with the procedure.

2. You will be given a gown to wear.3. The particular view that the physician orders will determine how you are positioned for

the x-ray such as lying, sitting, or standing. You will be positioned carefully so that the desired view of the chest is obtained. The physician will also specify the number of films to be made.

4. For a standing or sitting film, you will stand or sit in front of the x-ray plate. You will be asked to roll your shoulders forward, take in a deep breath, and hold it until the x-ray exposure is made. For patients who are unable to hold their breath, the radiology technologist will take the picture at the appropriate time by watching the breathing pattern.

5. It will be important for you to remain still during the exposure, as any movement will blur the film.

6. For a side-angle view of the chest, you will be asked to turn to your side and raise your arms above your head. You will be instructed to take in a deep breath and hold it as the x-ray exposure is made.

7. The radiology technologist will step behind a protective window while the images are being made.

While the x-ray procedure itself causes no pain, the manipulation of the body part being examined may cause some discomfort or pain, particularly in the case of a recent injury or invasive procedure such as surgery. The radiology technologist will use all possible comfort measures and complete the procedure as quickly as possible to minimize any discomfort or pain.

Chest X-Ray

Institution: San Lazaro Hospital

Date of examination: 12-22-09

X-Ray No. 10181 Date: 12-22-09

FAMILY NAME: FIRST NAME: M.I. AGE: SEX: CS: PAVILION:

T L R. 20 M S OPD

ADDRESS:

ATTENDING PHYSICIAN:

EXAMINATION:

Chest X-ray

ROENTOGENOLOGICAL AND ULTRASOUND FINDING:

There is undue haziness of the right upper lobe with cystic and cavitary images.

Heart and great vessels are normal in size and configuration.

The rest of the visualized chest structures are unremarkable.

IMPRESSION:

= EXTENSIVE CAVITARY PTB RIGHT

Hospital Interpretation:

Findings suggestive of PTB. Both upper lungs with cavitations in the right upper lung

Significance:

This examination was performed to specify which lobe and which part of the lung parenchyma is affected or has cavitations already. This is also done to know the extent of damage that was caused by the bacteria.

Interpretation:

The results of this examination have shown that the patient has positive cavitations at the right upper lung.

Direct Sputum Smear Microscopy

Institution: GAT Emilio Aguinaldo Memorial Medical Center

Date of examination: 1/11/2010 and 1/12/2010

Specimen Date Diagnosis

1 1/11/2010 S 0 negative

2 1/12/2010 P 1+ positive

3 1/12/2010 P 1+ positive

LEGEND:

S – Saliva

P – Purulent (sputum)

Hospital Interpretation

In the client’s case, LRT was tested three times, with the first result as negative while the next two results came out positive. The first result came out negative because the specimen collected was saliva from the client. Saliva may not contain Mycobacterium tuberculosis organisms. The second and third came out positive because the sample collected was purulent. Mycobacterium tuberculosis may live in the sputum of the client.

For the first test, the result was 0. This means that there was no Mycobacterium tuberculosis organisms found. For the second and third tests, the results were 1+. This indicates the presence of Mycobacterium tuberculosis on the sputum of the client. The highest result is 3+, which means that the client is still in the early stages of the disease.

Significance:

DSSM is the primary diagnostic test used by the Philippine Government, specifically the DOH as a confirmatory examination for Tuberculosis. This examination detects the specific bacteria which caused the disease.

Interpretation

A definitive diagnosis of tuberculosis can only be made by culturing Mycobacterium tuberculosis organisms from a specimen taken from the patient (most often sputum, but may also include pus, CSF, biopsied tissue, etc.). A diagnosis made other than by culture may only be classified as "probable" or "presumed". For a diagnosis negating the possibility of tuberculosis infection, most protocols require that two separate cultures both test negative.

In the client’s case, LRT was tested three times, with the first result as negative while the next two results came out positive. The first result came out negative because the specimen collected was saliva from the client. Saliva may not contain Mycobacterium tuberculosis organisms. The second and third came out positive because the sample collected was purulent. Mycobacterium tuberculosis may live in the sputum of the client.

For the first test, the result was 0. This means that there was no Mycobacterium tuberculosis organisms found. For the second and third tests, the results were 1+. This indicates the presence of Mycobacterium tuberculosis on the sputum of the client. The highest result is 3+, which means that the client is still in the early stages of the disease.

VIII. DRUG STUDY

DRUG INDICATION ACTION SIDE EFFECT/ADVERSE

REACTION

NURSING CONSIDERARTION

PATIENTS TEACHINGS

DATE ORDERED: January 18, 2010GENERIC NAME:EthambutolCLASSIFICATION:Antituberculous drug DOSAGE:Tablet: 500mg once a day for 6 months

Treatment of pulmonary tuberculosis in conjunction with at least one other antituberculous drug to prevent the development of resistant organisms.

Inhibits tuberculosis bacterial growth by altering cellular ribonucleic acid (RNA) synthesis and phosphate metabolism.

CNS: Optic neuritis (loss of visual acuity, changes in color perception red – green vision changes), fever, malaise, headache, dizziness, mental confusion, disorientation, hallucinations, peripheral neuritis.GI: Anorexia, nausea, vomiting, GI upset, abdominal pain, transient liver impairment.Hypersensitivity: Allergic reactions-dermatitis, pruritus, anaphylactoid reaction.Other: Toxic epidermal necrolysis, thrombocytopenia, joint pain, acute gout.

Assessment:History: Allergy to ethambutol, optic neuritis, impaired renal function.Physical: Skin color, lesion; orientation, reflexes, ophthalmologic examination; liver evaluation, bowel sounds; CBC, liver and renal function test.Intervention:-Encourage the patient not to discontinue therapy without first consulting the health care provider.-Administer daily dose with food to minimize nausea and vomiting.-Single daily dose must be used in combination with other antituberculous agents. -Perform baseline assessment of patient’s degree of alertness and orientation to name, place and time before initiating therapy.-Make regularly scheduled subsequent mental status evaluations and compare findings. Report development of alterations.

-Take drug in a single daily dose; it may be taken with meals if GI upset occurs.-Take this drug regularly; avoid missing doses. Do not discontinue this drug without first consulting your health care provider.-Following side effects may occur: nausea, vomiting, epigastric distress; skin rashes or lesion; disorientation, confusion, drowsiness, dizziness (use caution if driving or operating dangerous machinery; use precaution to avoid injury)-Arrange to have periodic medical check – up. This will include an eye examination and blood test.-Report changes in vision and rash.

-Provide patients safety during episodes of altered behavior or period of dizziness.-Before initiating therapy, check for any visual alterations using color vision chart. -Report the development of visual disturbances for the health care provider’s evaluation.

GENERIC NAME:IsoniazidCLASSIFICATION:Antituberculous drug DOSAGE:Tablet: 500mg once a day for 6 months

It interferes with lipid and nucleic acid biosynthesis in actively growing tubercle bacilli. It also disrupts the M. tuberculosis cell wall and inhibits replication.

CNS: Peripheral neuropathy, convulsions, toxic encephalopathy, optic neuritis and atrophy, memory impairment, toxic psychosis.GI: Nausea, vomiting, epigastric distress, bilirubinemia, bilirubinuria, elevated AST, ALT levels, jaundice, and hepatitis.Hematologic: Agranulocytosis, hemolytic or aplastic anemia, thrombocytopenia, eosinophilia, pyridoxine deficiency, pellagra, hyperglycemia, metabolic acidosis,

Assessment:History: Allergy to isoniazid, isoniazid associated adverse reactions; acute hepatic disease; renal dysfunction; lactation.Physical: Skin color, lesion; orientation, reflexes, peripheral sensitivity, bilateral grip strength; ophthalmologic examination; adventitious sound; liver evaluation; CBC, liver and renal function test, blood glucose.Intervention:-Encourage the patient not to discontinue therapy without first consulting the health care provider.-Give on an empty stomach, 1hr before or 2 hrs after meals; may be given with foods if GI upset occurs.-Single daily dose must be used in combination with other antituberculous agents.

-Take drug in a single daily dose. Take on empty stomach, 1 hr before or 2 hr after meals. If GI upset occurs take with foods. -Take this drug regularly; avoid missing doses. Do not discontinue this drug without first consulting your health care provider.-Do not drink alcohol, or drink as little as possible. There is an increased risk of hepatitis if these two drugs are combined.- Avoid tyramine-containing and histamine-containing food in diet.-Following side effects may occur: nausea, vomiting, epigastric distress; skin rashes or lesion; numbness, tingling, loss of sensation. -Arrange to have periodic medical check – up. This will include an eye examination and blood test.-Report weakness, fatigue, loss of appetite, nausea, vomiting, yellowing of skin or eyes, darkening of the

hypocalcemia, hypophosphatemia due to altered vitamin D metabolism. Hypersensitivity: Fever, skin eruptions, lymphadenopathy, vasculitis.

-Decrease tyramine-containing and histamine-containing food in diet.-Consult with physician and arrange for daily pyridoxine in diabetic, alcoholic or malnourished patients; also for patients who develop peripheral neuritis.-Discontinue drug and consult with physician if signs of hypersensitivity occurs.-When paresthesias are present, the patient must be cautioned to inspect the extremities for any skin breakdown because of diminished sensation.-Caution the patient not to immerse feet or hands in water without first testing the temperature.-Monitor patients with paresthesias for adequate nutrition.-Provide patient safety and assistance in ambulation.-Incidence of hepatotoxicity increases with age and with consumption of alcohol. This reaction usually occurs within the first 3 months of therapy and is thought to be an allergic reaction. Symptoms are anorexia, nausea,

urine, numbness or tingling in hands or feet.

vomiting, jaundice, hepatomegaly, slpenomegaly and abnormal liver function test.

GENERIC NAME:RifampicinCLASSIFICATION:Antituberculous drug DOSAGE:Tablet: 500mg once a day for 6 months

Prevents RNA synthesis in mycobacterium by inhibiting DNA-dependent RNA polymerase. This blocks the key metabolic pathways needed for mycobacterium cells to grow and replicate.

CNS: headache, drowsiness, fatigue, dizziness, inability to concentrate, mental confusion, generalized numbness, ataxia, muscle weakness, visual disturbances, exudative conjuctivitis. Dermatologic: Rash, pruritus, urticaria, pemphigoid reaction, flushing, reddish-orange discoloration of body fuids-tear, sweat, urine, saliva, sputum.GI: Heartburn, Anorexia, nausea, vomiting, gas, cramps, diarrhea, pseudomembranous colitis, pancreatitis, elevations of liver enzymes, hepatitis.GU: Hemoglobinuria, hematuria, renal insufficiency, acute renal failure,

Assessment:History: Allergy to rifampicin, acute hepatic disease, pregnancy, lactation. Physical: Skin color, lesion; gait, muscle strength; orientation, reflexes, ophthalmologic examination; liver evaluation; CBC, liver and renal function test and urinalysis.Intervention:-Encourage the patient not to discontinue therapy without first consulting the health care provider.-Administer daily dose with food to minimize nausea and vomiting.-Single daily dose must be used in combination with other antituberculous agents. -Prepare patient for the reddish-orange coloring of body fluids. Soft contact lenses may be permanently stained; advice the patient not to wear them during therapy.-Arrange for follow-up of liver and renal function tests, CBC, ophthalmologic examinations.

-Take drug in a single daily dose; it may be taken with meals if GI upset occurs.-Take this drug regularly; avoid missing doses. Do not discontinue this drug without first consulting your health care provider.-Following side effects may occur: reddish-orange coloring of body fluids, nausea, vomiting, epigastric distress, skin rashes, numbness, tingling, and drowsiness, fatigue (use caution if driving or operating dangerous machinery; use precaution to avoid injury.)-Arrange to have periodic medical check – up. This will include an eye examination and blood test.-Report fever, chills, muscle and bone pain, excessive tiredness or weakness, loss of appetite, nausea, vomiting, yellowing of skin or eyes, unusual bleeding or bruising, skin rash nor itching.

menstrual disturbances.Hematologic: Eosinophilia, thrombocytopenia, transient leucopenia, hemolytic anemia, decreased hgb, hemolysis.Other: Pain in extremities, osteomalacia, myopathy, fever, flulike syndrome.

GENERIC NAME:PyrazinamideCLASSIFICATION:Antituberculous drug DOSAGE:Tablet: 500mg once a day for 6 months

Dermatologic: Rashes, photosensitivity.GI: hepatotoxicity, nausea, vomiting, diarrhea.Hematologic: Sideroblastic anemia, adverse effects on clotting mechanism or vascular integrity.Other: Active gout.

Assessment:History: Allergy to pyrazinamide, acute hepatic disease, gout diabetes mellitus, acute intermittent porphyria, pregnancy, lactation.Physical: Skin color, lesion; joint status; liver evaluation; liver function test, serum and urine uric acid level, blood and urine glucose, CBC. Intervention:-Administer only in conjunction with other antituberculous agent.-Administer once a day.-Arrange follow-up of liver function test (AST,ALT) prior to and every -4wks during therapy.-Discontinue drug if liver damage

-Take this once a day with any other antituberculous agents.-Take this regularly; avoid missing doses. Do not discontinue this drug without first consulting health care provider.-Following side effects: loss of appetite, nausea, vomiting, rash, sensitivity to sunlight.-Have periodic medical check-up including blood test to evaluate drug effects.-Report fever, malaise, loss of appetite, nausea, vomiting, darkened urine, yellowing of skin or eyes, severe pain in great toe, instep, ankle, heel, knee and wrist.-Increase fluid intake to help remove

or hyperuricemia in conjunction with acute gouty arthritis occurs.

uric acid.

IX. List of priority problem

1. Ineffective airway clearance related to copious tracheobronchial secretions secondary to bacterial infection as evidenced by difficulty of breathing.2. Ineffective breathing pattern related to decreased lung volume capacity and frequent productive cough as evidenced by difficulty of breathing.3. Imbalanced Nutrition: Less than Body Requirements related to loss of appetite as evidenced by weight loss.4. Activity intolerance related to inadequate oxygen supply, as evidenced by easy fatigability.5. Ineffective coping related to lower activity level and the inability to work as evidenced by verbalization of problem.

X. Nursing Care Plan

CUES/DATA NURSING DIAGNOSIS

RATIONALE GOALS and OBJECTIVES

INTERVENTIONS RATIONALE EVALUATION

Subjective: “ Yung ubo ko ma-plema… yellow o kaya green yung kadalasang kulay. Minsan nga lang, mahirap ilabas yung plema”, as verbalized by the patient

Objective: - Presence of crackles upon auscultation.-Continuous dry coughing.- Vital Signs taken as follows:Temperature=37.6Pulse Rate=94 beats per minuteRespiratory Rate= 26 breathes per minuteBP= 130/80

Ineffective airway clearance related to copious tracheobronchial secretions secondary to bacterial infection as evidenced by Dyspnea

- Airway must be given the first attention as based on the rule of ABC which is Airway, Breathing and Circulation. In addition, difficulty of breathing can cause anxiety to the client that is why immediate attention must be done. Retained secretions can cause blockage of airway which will further cause difficulty of breathing.(Fundamentals of Nursing 7th edition by Kozier et al. p. 1299)

-Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However,

Within 1 hour of intervention:

1. The patient will be able to maintain patent airway through mobilization of secretions as evidenced by productive cough.

2. The patient will be able to effectively cough up secretions after treatments and deep breaths.

Independent1. Teach and encourage the use of diaphragmatic breathing and coughing techniques.(Please see attach)

2. Perform postural drainage with percussion and vibration. -Position patient in a side lying with both knees flexed with pillow at waist level

3. Encourage oral intake of fluids within the limits of cardiac reserve (3L of fluids)

These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue

Uses gravity to help raise secretions so they can be more easily expectorated.

Increased fluid intake reduces the viscosity of mucus produced by the goblet cells in the airways. It is easier for the patient to mobilize thinner secretions with coughing.

Within one hours, the goals and objectives have been fully met as indicated by:

1. Patent airway through mobilization of secretions as evidenced by productive cough.

2. Ability to effectively cough up secretions after treatments and deep breaths.

the cough may be ineffective in both normal and disease states secondary to factors such as pain, trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Likewise, conditions that cause increased production of secretions can overtax these mechanisms.

4. Explain effects of smoking, including second-hand smoke.

Smoking contributes to bronchospasm and increased mucus production in the airways.

CUES/DATA NURSING DIAGNOSIS

RATIONALE GOALS and OBJECTIVES

INTERVENTIONS RATIONALE EVALUATION

Subjective: “Simula nung lagi na akong inuubo, madali na akong hingalin at parang nauubusan ng hininga.”, as verbalized by the patient

Objective:- Use of accessory muscles while breathing- Retractions in ribs present while breathing-Continuous coughing- Vital Signs taken as follows:Temperature=37.6Pulse Rate=94 beats per minuteRespiratory Rate= 26 breathes per minuteBP= 130/80

Ineffective breathing pattern related to decreased lung volume capacity and frequent productive cough as evidenced by dyspnea

-Inspiration and/or expiration that does not provide adequate ventilation

-Respiratory pattern monitoring addresses the patient’s ventilatory pattern, rate, and depth. Most pulmonary deterioration is preceded by a change in breathing pattern. Respiratory failure can be seen with a change in respiratory rate, change in normal abdominal and thoracic patterns for inspiration and expiration, change in depth of ventilation, and respiratory alternans.

After 30 minutes of intervention:

1. The patient’s breathing pattern is maintained as evidenced by eupnea, and regular respiratory rate/pattern.

Independent1. Encourage sustained deep breaths by:

o Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation)

o Asking patient to yawn.

These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue

This simple technique promotes deep inspiration.

After 30 minutes of intervention, the goals and objectives have been fully met, proven that:

1. Vital Signs as follows:

Temperature=37.3Pulse Rate=90 beats per minuteRespiratory Rate= 20 breathes per minuteBP= 130/80

CUES/DATA NURSING DIAGNOSIS

RATIONALE GOALS and OBJECTIVES

INTERVENTIONS RATIONALE EVALUATION

Subjective:“Wala akong ganang kumain, kaya nga nabawasan talaga timbang ko mula 72 kilograms naging 60 kilograms nalang ako sa loob ng 2 buwan” as verbalized by the client.

Objective:-Thin-Signs of weakness

Imbalanced Nutrition: Less than Body Requirements related to loss of appetite as evidenced by weight loss

- This condition needs to be addressed immediately for the client to be able to gain enough strength in performing her usual activities.

-The body obtains energy in the form of calories from carbohydrates, protein and fat. The body uses energy for voluntary activities such as walking and involuntary activities such as breathing.(Fundamentals of Nursing 7th edition by Kozier et al.)

Immediately after intervention, the patient will verbalize and demonstrate selection of foods or meals that will achieve a cessation of weight loss.

1. Discuss eating habits, including food preferences.

2. Discourage beverages that are caffeinated or carbonated before meals.

3. Review and reinforce the following to patient or caregivers:o The basic four food groups, as well as the need for specific minerals or vitamins.-Vitamin C (Helps the immune system to produce antibodies)-calcium (help relief for tuberculin lesions-vitamin B6(combats toxic effect of INH)

o Importance of maintaining adequate caloric intake; an average adult needs

To appeal to client’s likes or dislikes.

These may decrease appetite and lead to early satiety.

Patients may not understand what is involved in a balanced diet.

The goals and objectives have been fully met as the patient verbalizes and demonstrates selection of foods or meals that will achieve a cessation of weight loss.

1800 to 2200 kcal/ day. o Foods high in calories and protein that will promote weight gain and nitrogen balance (e.g., small frequent meals of foods high in calories and protein)*Perform health teaching according to client’s level of understanding.

CUES/DATA NURSING DIAGNOSIS

RATIONALE GOALS and OBJECTIVES

INTERVENTIONS RATIONALE EVALUATION

Subjective: “Isa talaga sa malaking pagbabago sakin ay yung madali nakong mapagod at hingalin, di na ko makapag-side car at makagawa ng ilang bagay.” as verbalized by the client. Objective:- Increased heart rate and respiratory rate response to minimal activity.- Exertional discomfort or dyspnea

Activity intolerance related to inadequate oxygen supply, as evidenced by easy fatigability

- This nursing diagnosis is not life threatening and doesn’t need immediate attention, however, it can affect the body’s normal functioning.(Fundamentals of Nursing 7th edition by Kozier et al. p. 1068)

-Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. Activity intolerance may also be related to emotional states such as depression or lack of confidence to exert one's self.

After 8 hours of intervention,

1. The patient will maintain activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue.

2. Patient will verbalize and use energy-conservation techniques.

Independent1. Determine patient's perception of causes of fatigue or activity intolerance. These may be temporary or permanent, physical or psychological.

2. Establish guidelines and goals of activity with the patient and caregiver. (Avoid any kind of heavy work)

3. Encourage adequate rest periods, especially before meals, exercise sessions, and ambulation.

4. Refrain from performing nonessential activities.

Assessment guides treatment.

Motivation is enhanced if the patient participates in goal setting.

Rest between activities provides time for energy conservation and recovery. Heart rate recovery following activity is greatest at the beginning of a rest period.

Patients with limited activity tolerance need to prioritize tasks.

The goals and objectives have been partially met as evidenced by:

1. The patient still experienced shortness of breath during activities.

2. Patient verbalized and used energy-conservation techniques.

5. Support patient in establishing a regular regimen of exercise according to the patient’s level of functioning. Example is exercise through walking.

Muscles that are deconditioned consume more oxygen and place an additional burden on the lungs. Through regular, graded exercise, these muscle groups become more conditioned, and the patient can do more without getting as short of breath.

CUES/DATA NURSING DIAGNOSIS

RATIONALE GOALS and OBJECTIVES

INTERVENTIONS RATIONALE EVALUATION

Subjective:“Isa talaga sa malaking pagbabago sakin eh yung madali nakong mapagod at hingalin, di na ko makapag-side car at makagawa ng ilang bagay.” As verbalized by the patient.“Kinakaya ko namang iwasan yung mga dati kong bisyo”

Objective:-Verbalization of inability to cope-Physical symptoms such as lack of appetite is a possible evidence

Ineffective coping related to lower activity level and the inability to work

-For most persons, everyday life includes its share of stressors and demands, ranging from family, work, and responsibilities to major life events such as illness How one responds to such stressors depends on the person’s coping resources. Such resources can include optimistic beliefs, social support networks, personal health and energy, problem-solving skills, and material resources. Vulnerable populations such as those in adverse socioeconomic situations and those with complex medical problems may not have the resources or skills to cope with their acute

After 8 hours of interventions:

1. The patient will identify own maladaptive coping behaviors.

2. Patient will identify available resources and support systems.

3. Patient will describe and initiate alternative coping strategies.

Independent

1. Evaluate resources and support systems available to patient. Resources may include significant others, health care providers such as home health nurses, community resources, and spiritual counseling.

2. Assess level of understanding and readiness to learn needed lifestyle changes.

3. Establish a working relationship with patient through continuity of care.

Appropriate problem solving requires accurate information and understanding of options. Often patients who are ineffectively coping are unable to hear or assimilate needed information.

The patient could not start changing his lifestyle if he cannot understand the teachings and if he is not motivated and convinced to do so.

An ongoing relationship establishes trust, reduces the feeling of isolation, and may facilitate coping.

The goals and objectives have been fully met as indicated by:

1. The patient identified his own maladaptive coping behaviors.

2. Patient identified available resources and support systems.

3. Patient described and initiated alternative coping strategies.

or chronic stressors.

4. Provide opportunities to express concerns, fears, feelings, and expectations.

5. Encourage patient to identify own strengths and abilities.

6. Encourage patient to set realistic goals.

7. Instruct in need for adequate rest and balanced diet.

Verbalization of actual or perceived threats can help reduce anxiety.

During crises, patients may not be able to recognize their strengths. Fostering awareness can expedite use of these strengths.

This helps patient gain control over the situation. Guiding the patient to view the situation in smaller parts may make the problem more manageable.

These facilitate coping strengths. Inadequate diet and fatigue can themselves be

8. Teach use of relaxation, exercise, and diversional activities as methods to cope with stress.

stressors.

Relaxation reduces stress, anxiety, and dyspnea and helps patient cope with disability.

XI. ON GOING APPRAISAL

The patient started to take the medication ordered by his doctor last January 18, 2010. He takes 4 types of pulmonary tuberculosis medications every two days in the Bario Magsaysay Health Center at around 10:00am. The medicines that he takes are isoniazid, Rifampicin, pyrazinamide, Ethambutol. During Fridays, he gets his medicine for Sunday because the Health Center is closed during weekends. The patient is currently adhering to the medications given to him and applying techniques such as using his own utensils to prevent/break the chain of infection. Below is a list of activities that was done by the group during the OPD Duty:

January 28, 2010: The group performed initial interview and assessment to the patient. Physical examination was done. Discussed to the patient interventions that will alleviate some of his problems regarding his condition. Interventions are as follows:

1. Determine the patient’s perception of causes of fatigue or activity intolerance.

2. Establish guidelines and goals of activity with patient and caregiver.

3. Encourage patients adequate rest periods.4. Refrain from performing nonessential procedures. 5. Support patient in establishing a regular regimen of

exercises.6. Evaluate resources and support systems available to patient. 7. Assess level of understanding and readiness to learn needed

lifestyle changes.8. Establish a working relationship with patient.9. Provide opportunities to express concerns.10. Encourage patient to identify own strengths and abilities.11. Encourage patient to set realistic goals.12. Instructed patient need to rest and have balanced diet.13. Teach use of relaxation, exercises, and diversional

activities.

January 29, 2010: The group performed nursing interventions to address the problems experience by the patient. The following are the intervention rendered on this day:

1. Teach and encourage the patient the use of diaphragmatic breathing and coughing techniques.

2. Perform postural drainage with percussion and vibration.3. Encourage oral intake of fluids within the limits of cardiac

reserve. 4. Explain effects of smoking, including second hand smoke.5. Encourage sustained deep breaths.

January 30, 2010: The group performed additional interviews and assessment to the patient and rendered interventions that were not discuss previously. The interventions are:

1. Discuss eating habits.2. Discourage beverages that are caffeinated or carbonated. 3. Review patient about the food types he needs to eat more or

less.

XII. DISCHARGE PLAN

Medication – Remind client’s to maintain compliance of any medication (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol and vitamin B6) that the doctor prescribes. To take the drugs at the exact time as indicated by the doctor’s order. Teach patient on the side effect they might encounter in taking the drug. Teach patient on the consequences of not taking the drugs on time. Explanation: The drugs for Pulmonary Tuberculosis like Rifampicin should be taken on schedule because if the drug was discontinued for 2 weeks the medication should be repeated again from the start. And the resistance of the bacteria to the drug will strengthen.

Exercise – Teach patient on the importance of regular physical exercise such as 30 minutes brisk walking. Teach patient Deep Breathing Exercise and coughing exercise. Resume previous activities. Avoid extraneous activities. Explanation: this techniques helps to improve ventilation and mobilize secretions.

Treatment - Continue the medication as prescribed by the physician. Drink a lot of water. If regular sputum test is ordered, have the test taken.Explanation: The drugs for Pulmonary Tuberculosis like Rifampicin should be taken on schedule because if the drug was discontinued for 2 weeks the medication should be repeated again from the start. And the resistance of the bacteria to the drug will strengthen. Water is an effective to decrease the viscosity or dissolve the phlegm.

Health Education - Advice patient to do regular hand washing. Reiterate importance of avoiding smoking, second hand smoke, polluted areas and drinking. Advice patient to cover his mouth while sneezing and coughing. Advice patient to do not spit anywhere. Tell the patient about the importance of using his own utensilExplanation: To break the chain of infection. Smoking, second hand smoke, polluted areas, and drinking can increase severity of the disease.

OPD – Follow up – Follow the Directly Observed Treatment program of the government. Visit the health center for check-ups, at least one check up per week. Advice the patient to tell the physician if the symptoms are severe, such as if has difficulty in breathing, fatigue, chest pain, and productive cough for 5 days. Explanation – Follow ups are important to monitor the effectiveness of the prescribe medications. DOTS is a program by the government to check whether TB patients are complying to the treatment regimen.

Diet – Advice patient to not to skip meals, diet should be high caloric content, drink a lot of water (at least 8 glasses of water a day). Eat fruits and vegetables. Eat calcium rich foods (Milk). Eat vitamin c rich foods (mangoes, broccoli, cauliflower, tomato). Avoid high fat diets (Candies).Explanation: calcium rich food provides relief for Tuberculin lesions. Vitamin C will strengthen the immune system of the patient

Signs and Symptoms – Dyspnea, Non-productive or productive cough, Hemoptysis (Blood tinge sputum), Chest pain that maybe pleuritic or dull, Chest Tightness, Fatigue, Anorexia, and Weight Loss.Explanation: Signs and symptoms are integral part in diagnosis of a Pulmonary Tuberculosis patient.

ATTACHMENTS:

Breathing exerciseGeneral Instructions-Breath slowly and rhythmically to exhale completely and empty the lungs completely.-Inhale through the nose to filter, humidify, and warm the air before it enters the lungs.-If you feel out of breath, breath more slowly6 by prolonging the exhalation time.-Keep the air moist with a humidifier.

Diaphragmatic Breathing-Place one hand on tyh3 abdomen and the other hand on the middle of the chest to increase the awareness of the position of the diaphragm and its function in breathing.-Breath in slowly and deeply through the nose, letting the abdomen protrude as far as possible.-Breath out through pursed lip while tightening the abdominal muscles.-Press firmly inward and upward on the abdomen while breathing out.-Repeat for one minute follow with a rest period of two minutes.-Gradually increase duration up to five minutes, several times a day.

Pursed Lip Breathing-Inhale through the nose while slowly counting to three the amount of time need to “smell a rouse”-Exhale slowly and evenly against pursed lips while tightening the abdominal muscle.-Count to seven slowly while prolonging expiration through pursed lips the length of time to say blow out the candle.-While sitting in a chair fold arms over the abdomen-Inhale through the nose while counting to three slowly-Bend forward and exhale slowly through pursed lips while counting to seven slowly.-While walking; Inhale while walking two stepsExhale through pursed lip while walking four or five steps

Effective coughing technique-The patient assumes a sitting position and bends slightly forward. This upright position permits a stronger cough-The patient’s knees and hips are flexed to promote relaxation and reduce strain in abdominal muscle while coughing.-The [patient inhales slowly through the nose and exhale through the pursed lip several times-The patient should cough twice during each exhalation while contracting the abdomen sharply with each cough-the patient splits incision area, if any, with firm hand pressure or supports it with a pillow or rolled blanket while coughing.