A Case Study on:

Pulmonary Tuberculosis

A Case Study Presented to Clinical Instructor in

Level II SACR Nursing Department

In Partial Fulfillment of the Requirements in Related Learning Experience

Submitted to:Ms. J.E. Olilang, R.N.

Clinical Instructor

Submitted by:Joanne jeel dela Cruz

Group 4 (Rendu Ward)BSN 3C

I. Introduction

Definition

Tuberculosis(a bbrevia ted TBfor tubercle bacillus or Tuberculosis) is

a common and often deadly infectious disease caused by mycobacteria, in humans mainly

Mycobacterium tuberculosis. Tuberculosis usually attacks the lungs (as pulmonary TB)

but can also affect the central nervous system, the lymphatic system, the circulatory system,

the genitourinary system, the gastrointestinal system, bones, joints, and even the skin. Other

mycobacteria such as Mycobacterium bovis, Mycobacterium

africanum,Mycobacterium canetti, and Mycobacterium microti also cause tuberculosis, but these species are less common in humans.

Tuberculosis is spread through the air, when people who have the disease cough,

sneeze, or spit. Most infections in human beings will result in asymptomatic, latent infection,

and about one in ten latent infections will eventually progress to active disease, which, if left

untreated, kills more than half of its victims. The classic symptoms of tuberculosis are a

chronic cough with blood-tinged sputum, fever, night sweats, and weight loss. Infection of

other organs causes a wide range of symptoms.

Statistics:

(International)*Prevalence and Incidence

(Local)

Tuberculosis (TB) is a deadly disease. It is the world’s No. 1 cause of death around the world; about 3 million persons die of TB every year. It is one of the 10 top killer diseases in the Philippines; 75 Filipinos die of TB every day.

II. Objectives

GENERAL:

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

disease and develop skills on how to render the best possible care to a patient suffering

from Pulmonary Tuberculosis.

SPECIFIC:

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

acquired, factors, signs and symptoms.

To be able to know the pathophysiology of Pulmonary Tuberculosis.To be able to know the other problems that the client is suffering right

now not only PTB but also Pneumothorax and Hydrothorax To gain more information about patient’s condition.To apply skills learned in the classrooms to actual handling and caring

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

in patient’s prognosis. To be able to give the appropriate health teaching and better

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

SKILLS

Assess the patient’s condition in a cephalocaudal manner noting her general physique and patterns of functioning

Perform appropriate interventions to each of the NANDA-approved diagnoses we have formulated.

KNOWLEDGE :

Gain knowledge enough knowledge on what is hypertension and how to treat this condition.

Identify factors that can prevent the occurrence of the condition. Learn how to formulate and prioritize a Nursing Care Plan. Apply appropriate interventions.

ATTITUDE:

Understand patient’s feeling toward the condition and communicate to the folk’s to establish rapport.

Emphatize with the patient and show that you care in order for the patient not to feel alone.

III. Anatomy and Physiology

UPPER RESPIRATORY TRACT

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

The upper respiratory tract conducts air from outside the body to the lower respiratory tract and helps protect the body from irritating substances. The upper respiratory tract consists of the following structures: The nasal cavity, mouth, pharynx, piglottis, larynx, and upper trachea; the oesophagus leads to the digestive tract.

One of the features of both the upper and lower respiratory tracts is the mucociliary apparatus that protects the airways from irritating substances, and is composed of the ciliated cells and mucus-producing glands in the nasal epithelium. The glands produce a layer of mucus that traps unwanted particles as they are inhaled. These are swept toward the posterior pharynx, from where they are swallowed, spat out, sneezed, or blown out.

Air passes through each of the structures of the upper respiratory tract on its way to the lower respiratory tract. When a person at rest inhales, air enters via the nose and mouth. The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a tube like structure that connects the back of the nasal cavity and mouth to the larynx, a passageway for air, and the esophagus, a passageway for food. The pharynx serves as a common hallway for the respiratory and digestive tracts, allowing both air and food to pass through before entering the appropriate passageways.

The pharynx contains a specialised flap-like structure called the epiglottis that lowers over the larynx to prevent the inhalation of food and liquid into the lower respiratory tract.

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

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

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

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

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

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

IV. Vital Information

Name: C.A

Age: 84

Sex: Female

Address: Ilaya Pontevedra, Capiz

Civil Status: Widowed

Religion: Roman Catholic

Occupation: Retired Dentist

Date and Time Admitted: 8/29/10 6:45 am

Ward: St. Joseph Ward

Chief Complaint: Abdominal Pain and Dizziness

Diet: Diabetic Diet and Non-fat Diet

Admitting Dx: t/c UTI, DM2, HTN2, PTB

Final Dx: Gall bladder Hydrops secondary to acute cholecytitis and cholelithiasis, PNA community acquired, UTI, DM2, HCVD, Oral candidiasis

Surgical Operation: None

Attending Physician: Dr. F.B, Dr. M, Dr. N

V. Clinical Assessment

A. Nursing History

4 days prior to admission had experienced abdominal discomfort

associated with nausea and patient also experienced cold all over the

body. (-) fever, (-) chest pain.

B. Past Health Problems/Status

Past illness: (+) history of gall stones

Diabetic

Hypertensive

Allergies: Cassava Cake

Previous Hospitalization: March 2010 in Saint Anthony Hospital.

Medications Taken: Dyzolor150 mg, Esomeprazole 40 mg, PIP-TAZ 4.5 mg, fluimucil, Ranitidine, Isoniazid, Ethambutol, streptomyzine

C. Family History of Illness

(+) HPN and (+) DM

GENOGRAM

P M60Liver Cirrhosis

L.R80 DM

M.M85DM

C.A84PTB,

J.A81MI

CL59 healthy

M.A52DM

JAJ57DM

M.A61healthy

Legend:

O-Female

- Male

-Deceased

VI. Brief Social, Cultural, and Religious

Background

Educational Background : College graduate

Occupational Background: Retired Dentist/ housewife

Religious Practices : goes to church every Sunday.

Economic Status: belongs to a well off family. Supported by children.

VII. Clinical Inspection

A. Vital Signs

Upon admission: BP-160/80 AR-100 T-36.3 RR-19

During Care:BP-130/70 AR-89 PR-87 RR-20 T-36.5

B. Physical Assessment

General Appearance

C.A

Skin, eyes,hair and Nails

Hair-Short, white hair and evenly distributed.No lice present.Eyes- pink conjunctiva ,eye lashes are curved outward.

Nails-nails are long and no signs of cyanosis with nail angle of

160º and are intact with the skin.

Skin- Skin is white in complexion with good skin turgor.

Head, Face and Lymphatic

Head- round,proportion to the body, normocephalic, upright and still.Face-with symmetry to the body,smooth texture, no mass and involuntary twitching noted.

Lymphatic- Smooth and warm to touch and temperature is uniform over all the body with in normal range, white complexion and even coloration, Visible blood vessels on both arm, Absence of erythema, cyanosis and jaundice.

Eyes, Ears, Nose, Mouth and Throat

Ears- aligned to outer canthus of eyes, symmetrical without deformities.

Nose- Symmetrical, same color with face, smooth, size of the nose is proportional to the size of the face.

Lips- dryness or cracking noted. Oral mucosa is slightly dry.

Neck and Upper Extremities

Trachea - midline, accessory neck muscles are symmetrical. No

lumps on the neck noted. No pain and stiffness. It can move in

any direction.

Arms and Hands - are equal in length. No scars or lesions noted.

Fingers are complete. No lumps. rashes noted. Skin is intact with

full pulses and without edema.

Chest, Breast and Axilla

Tenderness in the chest not noted. No lumps noted.

The breast is symmetric. No mass/lumps noted. No discharges.

Pain and discomfort not noted.

No lumps in axilla. No lesions noted. Swelling, redness and

rashes and foul odor not noted.

Respiratory Sytem

Thorax is symmetric with good expansions. Lungs are resonant.

Breath sounds vesicular, no rales, murmur or bronchi noted.

Cardiovascular System

Has history of heart problems. (+) hypertension.(-) murmurs.

Gastrointestinal System

Soft, flabby abdomen.

Genito-urinary System

Urination is frequent . Pain or discomfort in urination not noted.

Voids via catheter.

Musculoskeletal System

Muscles and joints can move freely and with ease. Muscle and joint

pains not noted. Swelling, redness, tenderness, and stiffness not

noted. There is no limit of motion or activity.

C. General Appraisal

A. Speech/Language

She can speak hiligaynon and tagalon and english.

B. Hearing

Has poor hearing acuity.

C. Mental Status

She is conscious and coherent with a GCS of 15.

E. Emotional status

Emotionally stable and healthy. Conscious and coherent.

VIII. Laboratory and Diagnostic

Data

Hematology

Name and

Date of

Examination

Result Normal Values Significance of

Abnormal

Result

9-01-10 8am

hematocrit

o.33 0.40-0.50Decrease Insufficientoxygencirculating in thebloodstream.Indicates Anemiadue to blood lossafter surgery.

RCC 3.85x10^12/L m- 4.5-5.5

million/ul

F-4-5 million/ul

Hemoglobin 110 gms/L 140 – 170 g/LDecrease Insufficientoxygencirculating in thebloodstream.Indicates Anemiadue to blood lossafter surgery.

Eosinophil 0.05 (1-4%) Stress response,

cushing’s

Syndrome

Lymphocytes 0.32 25-30% Severe debilitating illness, such as heart failure, advanced TB.

Defective

lymphatic

circulation,

immunodeficien

cy,High levels of

adrenal

corticosteroids.

Hematology

8-29-10

hematocrit 0.36

hemoglobin 120

Red cell count 4.2

White cell count 12.7

segmenters o.75

Lymphocytes 0.23 25-30%

Monocytes 0.02 2-5%

Name and

Date of

Examination

Result Normal Values Significance of

Abnormal

Result

8-29-10

Urinalysis

Color

Pale yellow

Transparency hazy

pH 6.0

RBC 1-3 21-72

WBC 9-18 14-59

Epith. Cells Few

Bacteria Many bacterial infection

Name and

Date of

Examination

Result Normal Values Significance of

Abnormal

Result

9-2-10

Fecalysis

color

Yellowish

brown

Consistency Loose

Bacteria Many

Yeast cells Many

Name and

Date of

Examination

Result Normal Values Significance of

Abnormal

Result

9-1-10

Serum test

Sodium

135.4 137-145

Name and

Date of

Examination

Result Normal Values Significance of

Abnormal

Result

8-29-10

Serum test

Sodium

123.3 mmol/L 137-145

Creatinine 123 umol/L 53-115

Magnesium .68 70-1.00

Albumin 30.3 35-50

8-29-10

CHEST XRAY

Impression:

Right basal PNA,

PTB, Right upper lobe, no significant interval

chane atheromatous and tortuousaorta

Dextroscoliosis Thoracis spine.

8-30-10

ULTRASOUND

Impression:

Urinary retention 249.5 ml (52%)

Hydrops Gall Bladder with cholecystitis and

Cholelithiasis.

s/p hysterectomy

Diffuse renal parenchyma disease, both kidneys.

IX. Pathophysiology

Exposure or inhalation of infectedAerosol through droplet nuclei

(exposure to infected clients by coughing,sneezing, talking)

Tubercle bacilli invasion in the apices of theLungs or near the pleurae of the lower lobes

Bronchopneumonia develops in the lung tissue(Phagocytosed tubercle bacilli are ingested by macrophages)

bacterial cell wall binds with macrophages arrest of a phagosome which results to bacilli replication

Necrotic Degeneration occurs(production of cavities filled with cheese-like

mass of tubercle bacilli, dead WBCs, necrotic lung tissue)

drainage of necrotic materials into thetracheobronchial tree

eruption of coughing, formation of lesionsPrimary Infection

Predisposing Factors: Age

Precipitating Factors:

- Repeated close contact w/ infected persons

- Recurrence of

Lesions may calcify (Ghon s Complex)and form scars and may heal

over a period of time

Tubercle bacilli immunity develops(2 to 6 weeks after infection)

(maintains in the body as long as livingbacilli remains in the body)

PTB