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Right Massive Pleural Effusion with Tension
Secondary to Moderately Advanced Pulmonary Tuberculosis (PTB)
and Atherosclerotic Aorta
A Nursing Case Study
Presented to
The Faculty of the College of Nursing
Of the University of St. La Salle
Bacolod City
In Partial Fulfillment
Of the Requirements for the Degree
Bachelor of Science in Nursing
By
BSN 4A
Group II
Richard Ejorcadas
Rene John Francisco
Joffrey Jay Garrido
Liza Marie Gatuslao
Nicolas Gabriele Gatuslao
Francesa Antonnet Hinolan
Ma. Jemaimah Isubal
Kevin Kee
Sheena Joy Lobaton
Ma. Angelica Macrohon
Jayvee Mangana
Sarah Jean Medina
Aljay Charyl Mingay
Kcyl May Montaño
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BSN4A (GROUP 2) 2
Mary Joyce Montibor
October 4, 2012
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I. Introduction
Every day we are exposed to innumerable agents that could threaten the equilibrium of
our health. Among them are the different types of bacteria and viruses present in our
environment which bring about different types of diseases. With these diseases are
accompanying complications that result after an infection has undergone. In the case of our
chosen patient, he has developed a massive pleural effusion as a result of pulmonary tuberculosis
(PTB) infection and aortic atherosclerosis. PTB, being caused by pathogenic bacterial specie
called Mycobacterium Tuberculosis, is a chronic, recurrent, infection of the lungs. According to
the World Health Organization (WHO), TB is considered as the second to HIV/AIDS as the
greatest killer worldwide due to a single infectious agent, and based on the latest Philippine
Health Statistics from the DOH, which was for the year 2004, TB was listed as the cause of some
25,000 deaths, making it the sixth leading cause of death in the country and at the same time the
sixth (6th) leading cause of illness in the country. Tuberculosis is an ancient disease that is
already curable today but still prevails due to many factors contributing to its palpable existence
not only in our country but as well as to other underdeveloped and developing countries.
Poverty is one of the biggest factors why Tuberculosis is still very much prevalent.
Having insufficient resources to fund the individual needs of nutrition leads them to a weaker
state of immunity which further makes them highly vulnerable to the said disease. In addition,
poor housing and congested living conditions increase the risk of acquiring the disease. Having
greater percentage of contact with an infected individual poses a higher chance of one getting a
TB infection and even without knowing it due its characteristic of being an airborne disease.
With this, knowledge deficit and stigma could also alter and influence health practices and
preventive measures towards the said disease. “Prevention is always better than cure” the quote
echoes in redundancy, nevertheless it is resoundingly true. Tuberculosis is deadly and produces
an array of complications to patients, and in this particular case study, pleural effusion is the
culprit.
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Pleural effusion, or “water on the lungs,” is a condition wherein there is excess fluid that
accumulates between the two pleural layers; the fluid-filled space that surrounds the lungs. The
pleura are thin membranes that line the lungs and the inside of the chest cavity and act to
lubricate and facilitate breathing. Depending on the cause, the excess fluid may be either protein-
poor (transudative) or protein-rich (exudative). These two categories help physicians determine
the cause of the pleural effusion, and among them is PTB, which causes the exudative type.
Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs
during ventilation, and thus leads to oxygen deficits to the body.
Pleural effusion occurs in TB infected individuals thru the presence of irritation on the
lining of the pleural cavity, thus altering the permeability of the membrane and decreasing the
oncotic pressure needed to drain the excess fluid in the pleural space. The presence of the
atherosclerotic aorta in the patient also contributes by pushing blood in the pulmonary veins back
to the lungs and therefore causing pulmonary edema which greatly increases the degree of the
pleural effusion in the patient.
Out of the patients in our Medical Isolation Ward Exposure, RC’s case caught the
group’s attention due to its complex situation of different existing conditions that contribute to
the patient’s massive pleural effusion.
This case study aims to broaden the group’s understanding of the current health condition
that would serve as a great tool or basis for promoting good and individualized care to clients,
especially in extreme cases. Through this case study, we will be able to learn more about the
disease process, thus widening our knowledge on how to care for future clients with the same
disease.
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II. Objectives of the Study
General Objective
After 1 hour of case presentation the student nurses will be able to:
• Present information regarding right massive pleural effusion with tension secondary to
Moderately Advanced PTB and atherosclerotic aorta in relation to patient’s clinical
manifestations, treatment, and general health status.
Specific Objectives
After 1 hour of case presentation the student nurses will be able to:
Knowledge:
1. Define PTB, massive pleural effusion and atherosclerotic aorta and enumerate its
causes and explain its effects to the body.
2. Explain the Anatomy and Physiology of the Respiratory System and the areas
affected by the patient’s condition.
3. Trace the pathophysiology of right massive pleural effusion with tension aggravated
by Moderately Advanced Pulmonary Tuberculosis (PTB) and Atherosclerotic Aorta.
4. Enumerate the prioritized nursing problems related to the case.
5. State the importance of the Nursing Case Study in terms of dealing with patients
having right massive pleural effusion with tension secondary to MA PTB and
atherosclerotic aorta.
Skills:
1. Identify the classification, mechanism of action, indication, contraindications and
adverse effects of the drugs used by the patient in the drug study.
2. Formulate a Nursing Care Plan on the identified and prioritized problems for
substance abuse.
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3. Discuss the significance of the deviation of the laboratory results and findings of the
patient.
4. Design a comprehensive health teaching plan based on the specific needs of the
patient.
Attitude:
1. Demonstrate a positive attitude in caring for clients who have massive pleural
effusion secondary to MA PTB and atherosclerotic aorta.
2. Participate attentively in presenting the case of the patient.
3. Verbalize changes in outlook towards patients having massive pleural effusion
secondary to MA PTB and atherosclerotic aorta.
4. Display a positive behavior towards the possibility of having future patients with such
disease.
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III. Anatomy & Physiology of the Respiratory System
Overview
Cells in the body require
oxygen to survive. Vital functions of
the body are carried out as the body is
continuously supplied with oxygen.
Without the respiratory system
exchange of gases in the alveoli will
not be made possible and systemic
distribution of oxygen will not be
made possible. The transportation of
oxygen in the different parts of the
body is accomplished by the blood of
the cardiovascular system. However, it
is the respiratory system that carries in oxygen to the body and transports oxygen from the tissue
cells to the blood. Thus, cardiovascular system and respiratory system works hand in hand with
each other. A problem in the cardiovascular system would affect the other and vice versa.
Functional Anatomy of the Respiratory System
Nose
The nose is the only external part of the respiratory system and is the part where the air
passes through. During inhalation and exhalation, air enters the nose by passing through the
external nares or nostrils. Nasal cavity is found inside the nose and is divided by a nasal septum.
The receptors for the sense of smell, olfactory receptors are found in the mucosa of the slit-like
superior part of the nasal cavity which is located beneath the ethmoid bone. Respiratory mucosa
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lines the rest of the nasal cavity and rests on a rich network of thin-walled veins that warms the
air passing by.
Important information about nose is the presence of the sticky mucus that is produced by
the mucosa’s gland. This important characteristic moistens the air and traps the incoming
bacteria and other foreign debris passing through the nasal cavity. Cells of the nasal mucosa are
ciliated and it creates a gentle current that moves the contaminated mucus posteriorly towards the
throat, where it is swallowed and digested by stomach juices.
Conchae
These are three mucosa-covered projections or lobes that greatly increase the surface area
of the mucosa exposed to the air. Aside from that, conchae increase the air turbulence in the
nasal cavity.
Palate
A partition that separates the nasal cavity from the oral cavity. Anteriorly, the palate that
is supported by a bone called the hard palate and the one which is unsupported is the soft palate.
Paranasal Sinuses
These are structures surrounding the casal cavity and are located in the frontal, sphenoid,
ethmoid and maxillary bones.
Pharynx
The pharynx is a 13 cm long muscular tube that is commonly called the throat. This
muscular passageway serves as a common food and air pathway. This structure is continuous
with the nasal cavity anteriorly via the internal nares.
Parts of pharynx:
1. Nasopharynx – the superior portion of the pharynx. The pharyngotympanic tubes that
drain the middle ear open in this area. This is the main reason why children who have otitis
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media may follow a sore throat or other tyoes of pharyngeal infections since the two
mucosae of these regions are continuous.
2. Oropharynx – middle part
3. Laryngopharynx – part of pharynx that enters the larynx.
Tonsils – clusters of lymphatic tissues found in the pharynx.
1. Palatine tonsils – tonsils found at the end of the soft palate.
2. Pharyngeal tonsils – lymphatic tissues located high in the nasopharynx. This is also
called adenoid.
3. Lingual tonsils – located at the base of the tongue.
Larynx
The larynx is the one that routes the air and food into their proper channels. Also termed as
the voice box, it plays an important role in speech. This structure is located inferior to the
pharynx and is formed by:
1. Eight rigid hyaline cartilages
2. Spoon-shaped flap of elastic cartilage, which is called the epiglottis.
Thyroid cartilage – this is the largest hyaline cartilage that protrudes anteriorly in males and is
referred to as the Adam’s apple.
Epiglottis
This is a flap of tissue that serves as a guardian of the airways as it protects the superior
portion of the larynx. The epiglottis does not restrict passage of air into the lower respiratory
passages when a person is not swallowing. However, when a person swallows food, the
epiglottis tips and forms a lid or blocks the opening of the larynx so that food will not be directed
to the lower respiratory passages. The food will be then routed to the esophagus and in cases
where it enters the larynx, a cough reflex is triggered to expel the substance and prevent it from
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continuing into the lungs. This protective reflex does not work when a person is unconscious that
is why it is not allowed to offer or administer fluids to an unconscious client.
Vocal folds – a pair of folds which are also called the true vocal cords that vibrate when air is
expelled.
Glottis – the slit-like passageway between the vocal folds.
Trachea
Also called the windpipe, the trachea is about 10 to 12 cm long or about 4 inches and
travels down from the larynx to the fifth thoracic vertebra. This structure is reinforced with C-
shaped rings of hyaline cartilage and these rings are very important for the eating and breathing.
The trachea is lined with ciliated mucosa that primarily serves for this purpose: To propel mucus
loaded with dust particles and other debris away from the lungs towards the throat where it can
either be swallowed or spat out.
Main Bronchi
The main bronchi, both the right and the left, are both formed by tracheal divisions. There
is a slight difference between the right and left main bronchi. The right one is wider, shorter and
straighter than the left. This is the most common site for an inhaled foreign object to become
lodged. When air reaches the bronchi, it is already warmed, cleansed of most impurities and well
humidified.
Lungs
The lungs are fairly large organs that occupy the most of the thoracic cavity. The most
central part of the thoracic cavity, the mediastinum, is not occupied by the lungs as this area
houses the heart.
Divisions of the Lungs
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The lungs are divided into lobes by the presence of fissures. The left lung has two lobes
while the right lung has three.
Pleural Layers
1. Visceral pleura – also termed as the pulmonary pleura and covers each surface of the lings.
2. Parietal pleura – covers the walls of the thoracic cavity.
- Pleural fluid – a slippery serous secretion that allows the lungs to slide along over the thorax
wall during breathing movements and causes the two pleural layers to cling together.
Bronchioles – smallest air-conducting passageways.
Bronchial tree or respiratory tree – a network formed due to the branching and rebranching of
the respiratory passageways within the lungs.
Alveoli – air sac: This is the only area where exchange of gases takes place.
Respiratory Zone – this part includes the respiratory bronchioles, alveolar ducts, alveolar sacs,
alveoli.
Physiology of Respiration
The respiratory primarily supplies oxygen to the body and disposes of carbon dioxide
through exhalation. Four events chronologically occur, for respiration to take place.
1. Pulmonary ventilation – this process is commonly termed as breathing. With pulmonary
ventilation, air must move out into and out of the lungs so that the alveoli of the lungs are
continuously drained and filled with air.
2. External respiration – this is the exchange of gases or the loading of oxygen and the
unloading of carbon dioxide between the pulmonary blood and alveoli.
3. Respiratory gas transport – this is the process where the oxygen and carbon dioxide is
transported to the and from the lungs and tissue cells of the body through the bloodstream.
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4. Internal respiration – in internal respiration the exchange of gases is taking place
between the blood and tissue cells.
Mechanics of Breathing
Breathing, also called pulmonary ventilation is a mechanical process that completely
depends on the volume changes occurring in the thoracic cavity. Thus, a when volume changes
pressure also changes, and this would lead to the flow of gases equalizing with the pressure.
Inspiration – also called inhalation. This is the act of allowing air to enter the body. Air is
flowing into the lungs with this process. Inspiratory muscles are involved with inspiration which
includes:
1. The diaphragm
2. External intercostals
These muscles contract when air is flowing in and thoracic cavity increases. When the
diaphragm contracts it slides inferiorly and is depressed. As a result the thoracic cavity increases.
The contraction of the external intercostal muscles lifts the rib cage and thrusts the sternum
forward. This increases the anteroposterior and lateral dimensions of the thorax.
Expiration – also called expiration. It the process of breathing out air as it leaves the lungs. This
process causes the gases to flow out to equalize the pressure inside and outside the lungs. Under
normal circumstances, the process of expiration is effortless.
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IV. Definition of Terms
1. Admission - the act of being received into a place, a patient accepted for in patient
service in the hospital.
2. Anicteric - pertaining to the absence of jaundice.
3. Aortic atherosclerosis - is the buildup of a waxy plaque on the inside of blood
vessels
4. Chamber - a hollow but not necessarily empty space/cavity in an organ.
5. Chest tube thoracotomy - is the insertion of a tube (chest tube) into the pleural
cavity to drain air, blood, bile, pus, or other fluids.
6. Chronic - persisting for a long period, often for the remainder of a person’s lifetime.
7. Equilibrium - A state of physical balance.
8. Nasal cavity - a large air filled space above and behind the nose in the middle of the
face.
9. Oncotic pressure - also known as colloid osmotic pressure, is a form of
osmotic
pressure exerted by proteins in blood plasma that usually tends to pull water into the
circulatory system.
10. Pathogenic - capable of causing disease.
11. Pleura - are thin membranes that line the lungs and the inside of the chest cavity and
act to lubricate and facilitate breathing.
12. Pleural effusion - it occurs when too much fluid collects in the pleural space (the
space between the two layers of the pleura). It is commonly known as "water on the
lungs."
13.Pulmonary edema - is a condition in which fluid accumulates in the lungs, usually
because the heart's left ventricle does not pump adequately.
14. Ventilation - also known as breathing; the exchange of air between the lungs and the
environment, including inhalation and exhalation.
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V. Baseline Data
Name: R.C.
Home Address: Purok Manuslok, Brgy. Kapitan Ramon, Silay City
Current Address: Missionaries of Charity, Brgy. Banago, Bago City
Age: 59 years old
Birth Date: October 10, 1952
Birth Place: Silay City, Negros Occidental
Gender: Male
Marital Status: Married
Religion: Roman Catholic
Educational Level: Elementary School Undergraduate (Grade 5)
Nationality: Filipino
Occupation: Farmer & Albularyo
Person next to kin: R.C.
Number of Dependents: 8
Relationship: Son
Date of Admission: August 13, 2012
Attending Physician: Dr. Jimmy Villo and Dr. Sanchez
Chief Complaint: Difficulty of Breathing
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Medical Diagnosis: Pulmonary Tuberculosis (PTB), TB effusion
Name of Agency: Corazon Locsin Montelibano Memorial Regional Hospital
(CLMMRH) - Medical Isolation Ward
Financial Support: Medical Assistance (Mayor Bing Assistance) and Missionaries of
Charity
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VI. Nursing History
Health Maintenance – Perception Pattern
“Sin-o man bala nga tawo ang wala ga la-um nga mag-ayo”, is one of the statement
of R.C. Mr. R.C. views health as an important factor of his life and described his current
condition as a great challenge. He is not ashamed of having a PTB because as what his doctor
said, PTB has a cure and no one nowadays should keep it for themselves because everyone
has the chance to be cured. Mr. R.C. is a well known “albularyo” in their village. He uses
herbal plants and made a concoction out of it as a medicine. He uses ginger as a mean to cure
their sick from bad spirits and curse of supernatural beings.
R.C. smoke 1-2 sticks of cigarette for almost twenty-five to fifty years already which
started when he was young, about twenty-five years as he can remember. Also, he drinks
alcohol specifically three bottle of long neck together with his friends. When he first
experienced the signs and symptoms of PTB such as fever, productive cough with blood at
times, difficulty of breathing, and chills, etc. that made him sick for almost 8 months last
year, he started to realize to minimize the bad vices he used to have.
Since he was diagnosed with PTB on May 2012 , he already stops his vices. His last
intake of alcohol was on November 2011 and refuses to take any if his friends would ask him
to join them. He took PTB drugs under DOTS (direct observed short course) of DOH
(Department of Health) program such as rifampicin, isoniazid, pyrazinamide and ethambutal
hydrochloride. He took it using his own money for almost 20 days because of financial
constraint.
R.C. claimed that he is not allergic to any form or kind of food, drug, tape or dye. He
takes does not take vitamin daily instead he eats more vegetables and fruits from his plants
grown in their village. He uses herbal plants as a remedy for his illness such as bayabas,
alibhon, and etc. Also, he takes medicines such as paracetamol and other over-the-counter
drugs for usual sickness like cough, colds and fever.
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Financial constraint and poor family support is one of the problem of Mr. R.C. faced
due to the low socioeconomic factors that they have. Luckily, the Missionaries of Charity
support him. They are the one who provide his needs and medications. He takes his
medications religiously when available. His family does not visit him daily because they are
busy and no money to go to the hospital from their village but he is always assisted by his
youngest son J. during his confinement. Through the chest X-ray, client was able to find out
that there was a pleural effusion in his right lungs. The patient participates in deep breathing
and coughing exercise to enhance the unaffected lungs and increase lung expansion.
Regarding his current condition, Mr. R.C. fully understands that along with his pleural
effusion, he should be cured from his PTB that may progress and metastasize anytime.
Patient recognizes that his cousin and nephew who dwell in the same village has a history of
PTB infection, but other than that patient knows no medical problems in his family.
Nutritional – Metabolic Pattern
Mr. R.C. is not nourished upon assessment as manifested by cachexia, sunken
eyeball and face. He has a normal to poor appetite depending on his condition. According to
him, he eats two to three meals a day composed of one-half plate of rice, and viand which he
himself cooks for the whole family. Viands contain vegetables, fish, and chicken; he seldom
eats pork and meat. He has his own little farm where he get her daily food such as the
vegetables and rice. He even claims that he able to drink 8-9 glasses of water a day.
During his first day of admission in the medical isolation ward, he was on DAT (diet
as tolerated) as ordered. He was able to eat the food catered by the hospital and given by the
nuns. It is contains a cup of rice, a cup of vegetables, a slice of chicken or fish and a piece of
banana or a slice of mango and drank water at about 50 ml. R.C. experienced poor appetite
when he experienced severe pain due to his incision. Patient is not bothered by the sanitation
of the food tray and the food process in the hospital because he believed if they will not eat
what is serve he will surely feel weaker because the foods from the nuns usually came late
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and is not enough for him and J. sometimes. His other family members do not bring food for
him on daily basis because they seldom visit him.
Elimination Pattern
Mr. R.C. has never experienced having any disease of the digestive system and
urinary. But, R.C. has white scar in his lower leg and foot from his previous skin infection
due to his daily work in a wet, muddy rice field at their backyard. He usually defecates daily
to a well-formed, soft, brownish stool within normal limits. There is no difficulty in
defecating as claimed by the patient. R.C. also claimed that he defecate once a week during
hospital admission due to his uncomfortable condition. His bladder is within normal limits
and no reported pain nor difficulty in urinating. Client is able to void freely to a clear to
straw-colored urine approximately at 550 ml at our 6-2 shift. He noticed that before he
usually urinate five times a day but lessens to three times a day when he is admitted but he
drinks a lot of water especially when taking his medicine but it may be due to his ongoing
chest tube drainage.
Activity and Exercise Pattern
Mr. R.C. develops a routine every day. R.C. is a “kargador” or sugarcane farmer since
he was 8 years old as a primary source of income of his family before. Now, his piece of land
for sugarcane is rented by a co-farmer was given him a parcel of harvest or money. Then, his
rice field is take care by him and his children. At dawn, he likes to stretch and stroll outside
as he prepares his tools for the day’s work. He also do some chores before he leave. He
makes his own lunch and snacks, and cooks for the family. When he was not in the field, he
plants vegetables as a source of food and income for him. Sometimes in the afternoon, he
likes to walk around the neighborhood and converse with his friends to unwind. In normal
condition, he is able to do all these activities without any assisted devices or assistance. But
when his body capacity declines, feelings of weakness, severe cough, easy fatigability and
difficulty of breathing he restricts activities such as heavy lifting and sowing the fields. He
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stays at his house to make him more comfortable. During his admission, he could not
independently do his self-care needs such as dressing, grooming, toileting, bed mobility,
transferring, ambulating due to his pain in the chest tube drainage incision. He was assisted
by his youngest son to recover much faster.
Sleep and Rest Pattern
Mr. R.C. wakes up at 4:00 in the morning which he used to do since he goes to his
rice and sugarcane field before. Then, he usually goes to bed at about nine to ten o’clock in
the evening for approximately six to seven hours a day. He likes to take morning nap and
feels more rested. In the afternoon, he is out with his neighbor friends or does his vegetable
planting. Client experience no difficulty of going back to sleep whenever he is disturbed or in
urged to urinate. Other than that, there are no sleeping problems reported. He always feels
relaxed during sleep. R.C. complains of a decrease of his sleeping hours due to his pain with
five to thirty minutes duration of sleep. Therefore, he hardly rested for the whole night. So,
he always takes a short nap in between.
Cognitive Perception Pattern
Mr. R.C. is mentally alert, conscious, and oriented to time, place and person. He does
not difficulty in speech. R.C. is a Grade 5 undergraduate and opted to go to the sugarcane
fields to help his parents due to financial instability. But he has the ability to read,
communicate, and comprehend Hiligaynon and a little English and Cebuano. On the other
hand, he can clearly express and comprehend his thoughts and ideas about his condition and
family health background. He perceives his pain as a stubbing pain, with a scale of seven.
Sometimes, it hinders him to move and do his self-care which irritates him most. Also, the
foul smelling from the drainage that sometimes leaks from the incision site makes him more
uncomfortable and angry. He also mentioned if he can just go home with his CTT (chest tube
thoracostomy) drainage and be monitored accordingly. He mentioned that the procedure is
not new to him since his nephew once had a CTT procedure when he was twelve years old
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and have a good prognosis as a result of PTB infection as claimed by the patient. Therefore,
R.C. is positive that he will soon be okay and all the excess fluid will be drained out. Above
all he does not have any problems and difficulties in his hearing, vision, tactile, olfactory,
and taste functions at all. Moreover, the client displays having a good memory and
responsive to conversation and health intervention.
Self-Perception Self Concept Pattern
Patient R.C. is conscious of his appearance since he has not taken a bath since
admission and only sponge bath. He is eager to go home to take a bath and be free from foul
smelling drainage. He sometime he wondered why his CTT site is not cleaned. He said that he
loose wait and his appearance makes a big difference unlike before due to his illness and poor
appetite sometimes. R.C. does not directly tell his children when he feels something wrong
because he does not want to be a burden to his family because he knows they are financial
incapable as well. He has a very strong attitude and seldom can hear any resentment towards
his family. He is very optimistic regarding his recovery and he knows that it can be medically
cured. At the same time, he greatly believes in his faith in God that it is not yet the end
because if will by God then thy will be done.
Role Relationship Pattern
Mr. R.C. is the father of eight children, with five sons and 3 daughters, and lives in a
peaceful community. His wife died many years ago and became a sole provider for his
children. He supported them in their education but not all of them finish their education
because he could not afford to send them to school anymore because he is getting old and the
farm cannot sustain their needs. As a result, some of his children go to manila, Bacolod and
other big cities to find a job. Some of them had already had a family of their own. One of his
sons with a family of two kids lives with him in his own house together with his youngest
son who still depends on him. He still looks after for his children whereabouts and advises
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them when problems arise. But he became sad lately because his children could not visit him
in the hospital. He also thankful because J. is with him always.
He is a farmer in his village and respected by many people. He is a person that
everyone looks up to. Aside of being a farmer, he is the first one whom the families seek for
treatment for their sick children because he is a well-known traditional healers. He has many
friends because most of the villagers are his relatives too. During his free time, he would go
with them for a drink and have a chat. Until, he became ill he refused to join them in their
drinking session. He further expressed that he prefer to stay at home, in order to avoid these
vices.
Sexuality and Reproductive Pattern
Regarding sexuality, R.C. finds contentment with what and who he is. He claimed
that he does not have any disease nor experienced any dysfunction of the reproductive
system. Client was assessed of his past sexual relations and he claimed he had a wife and
have a well-grown eight children. During coitus, he never used any contraceptives and
further claimed that he had plain sexual satisfaction from it. According to him, he is
contented with his family and children.
Coping Stress Pattern
Mr. R.C. would go with his friends and drink when we had problems. He do not
usually voice out when he feels something wrong. Whenever he encounters problems in their
home, he would usually share it to his eldest son and sometimes to his peers though he
usually tends to keep it himself. He also likes to hang out with his neighbor and friends just
to make him unwind and temporarily forget his problems. Also, he does not pay too much
attention to such problems because he believes that it is just a part of our life that we continue
to face trials every day. Most importantly, he never forgets to confess and ask for help to the
heavenly father.
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Values and Belief Pattern
According to patient R.C it is important to understand the love and care of those
around you and the intentions they have for you. R.C claimed that he is satisfied with his life
despite of his condition and accepted it openly. He is aware that problems normally occur,
and it should not stop him from living his life. With good catholic Christian values never
questioned God about his condition, instead he hopes in God’s will he will be given a chance
to get back to his home and family and to do the work he used to have. Most importantly, he
has a positive outlook towards life. Furthermore, it is time for him to realize that what he has
done was not good to his health and for him to eradicate his vices and initiate a healthy
lifestyle. Lastly, patient R.C does not pray the rosary and seldom went to church because of
the remote distance of church from their home but he prays at night asking for strength and
courage to face life’s challenges every day.
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VII. Health History
History of Present Illness
Eight months prior to admission, Patient R.C experienced weakness and fatigue,
coughing up of blood for 2 days, night sweats and chills. He doesn’t seek consultation rather
make a concoction of herbal plants to ease the symptoms.
In the month of May, four months prior to admission, due to aggravated symptoms he
consulted in Teresita Lacson Jalandoni Provincial Hospital (TLJPH) and was diagnosed of
having Pulmonary Tuberculosis (PTB), DOTS medicine were prescribed such as Rifampicin,
Isoniazid, Pyrazinamide, and Ethambutol for a duration of only about 20 days due to financial
difficulties.
At the end of May, he was advised by his eldest son and relatives specifically his cousin
who was also diagnosed with PTB to stay at the Missionaries of Charity, Brg. Banago where his
children are currently living. Having assured by a nun in charge to eagerly help him for his
recovery.
He stayed in the institution for two months (June-July) and was treated.. He was provided
with all his needs ; physical (food, shelter and medications), spiritual and emotional support.
However his condition worsen. He experienced swelling of the feet and severe difficulty of
breathing therefore the nun in charge and his nephew (previously diagnosed with PTB)
accompany him to CLMMRH to have a checkup about his condition.
On Aug. 13, 2012, Patient R.C was brought to CLMMRH for his checkup due to his
worsening condition of difficulty of breathing. The doctor in charge decided to admit him in the
hospital on the same day and diagnostic findings revealed fluid accumulated in the thoracic area.
RC was diagnosed to have Pulmonary Tuberculosis (PTB), TB effusion and was undergoing
treatment in Medical Isolation Ward up to the present. The medications prescribed to him were
provided by the nuns in the Missionary of Charity.
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Past Health History
A. Childhood Illness
R.C. experienced illnesses such as flu, cough, fever and colds.
B. Past Hospitalization
R.C. had previous hospitalizations due to severe fatigue for almost 4 months when he was
12 years old as claimed by him.
C. Serious Illness/ Chronic Illness
R.C. had experienced severe fatigue for almost 4 months.
D. Previous Surgery
R.C. has not undergone any previous surgery.
Family/ Social History
Patient lived with his children at Brgy. Kapitan Ramon, Silay City. According to him,
there are no any illnesses or diseases present within their immediate family members but his
cousin’s wife and his nephew have tuberculosis and are being treated currently.
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VIII.Physical Assessment
Date: August 29, 2012
Time of Assessment: 8:00 AM
GENERAL APPEARANCE
• Uncomfortable status on bed as claimed
• Tidy hair and with unkempt clothes
• With decrease body mass
• No piercings noted
LEVEL OF CONCIOUSNESS (LOC)
• Lethargic
• Awake, lying on bed, conscious and coherent
• Responsive to both verbal and non-verbal stimuli
• Oriented to time, place and person
HEENT
• Head is symmetrical, scalp is intact with no lesions and no swelling noted
• Pupils equally round reactive to light and accommodation. Patient’s eyebrows are
symmetrically aligned; with anicteric sclera and pinkish conjunctiva. Eyes are
proportional to the face with sunken eyeballs noted.
• Ears are symmetrical, firm and non-tender. There are no unusual discharges noted and
without hearing difficulty. Color of the skin is the same with the facial skin
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• Nose is symmetrical with no deviations, uniform in color and non-tender. Patent nares
with no discharge noted and client claimed no olfactory problems.
•Lips are dry and pale. There is symmetry of contour. Tongue is central in position, pink
in color, moist, and moves freely. Tonsils are pink in color. Mouth hygiene is not
maintained. Patient has incomplete set of teeth.
CARDIOVASCULAR
• With heplock at right cephalic vein
• With BP of 80/70 mmHg taken at left arm in semi-fowler’s position
• With normal heart rhythm and regularity auscultated
• With strong palpable pulse of 83 bpm taken at the left wrist; with irregular rhythm
•With good capillary refill of <2seconds
• With clubbing of fingers noted.
RESPIRATORY
• Breathes spontaneously to room air with rapid, shallow breathing at 36 cpm
• With difficulty of breathing as claimed
• With productive cough to a greenish sputum
• With symmetrical rise and fall of chest
• With limited chest wall expansion noted
• Increased fremitus
• Dullness upon percussion on lung fields
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• Wheezing upon auscultation in left lower quadrant of the lung and crackles upon
auscultation in the left upper quadrant of the lung; wheezing to diminished breath sound
on the right lung
• With right CTT H2O level of 200mL (+) oscillation, with an output of 350 cc of a foul
smelling, greenish-colored drainage
GASTRO-INTESTINAL TRACT
• On DAT (Diet as tolerated) with poor appetite
• With 6 normative bowel sounds on both right and left lower iliac region auscultated
• Not able to defecate upon assessment
• With no distention in the abdominal area
GENITO-URINARY TRACT
• Not able to void upon assessment
• With no distention of the bladder upon palpation in the pubic region
• No difficulty of urination as claimed
MUSCULOSKELETAL
• Able to ambulate with assistance due to weakness of lower extremities
• With body weakness and fatigue as claimed
REPRODUCTIVE
• With no penile, scrotal lesions and abnormal discharges as claimed
INTEGUMENTARY
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• With brown-black complexion
• With hyperpigmentation noted esp. in the extremities
• Warm to touch, afebrile at 37 °C
• With dry skin and poor skin turgor
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IX. Laboratory and Radiology Test
Complete Blood Count - The complete blood count is the calculation of the cellular
(formed elements) of blood. These calculations are generally determined by special machines
that analyze the different components of blood in less than a minute. A major portion of the
complete blood count is the measure of the concentration of white blood cells, red blood cells,
and platelets in the blood.
Date of testing: 08-15-12
Exam Name Result Unit Normal Value Implication
Hematocrit 0.29 L/L 40-54 Represents
anemia, results
from chronic
inflammatory
conditions
Hemoglobin 88 g/L 130-180 Low level of
hemoglobin
indicates anemia
Red Blood Cells Count 3.35 10 12/L˄ 4.5-5.5 Indicates anemia
White Blood Cell Count 6.7 10 9/L˄ 4.5-11.0 Normal
Segmenters 67 % 50-70 Normal
Lymphocytes 16 % 25-35 It indicates
infection
Monocytes 8 % 0-15 Normal
Eosinophils 9 % 1-5 Indicates lung
disease and
reaction to
certain
medications
Platelets 425 10 9/L˄ 150-400 Caused by
inflammatory
diseases that lead
to the increase in
the number of
platelets
Complete Blood Count
Date of testing: 08-19-12
Exam Name Result Unit Normal Value Implication
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Hematocrit 0.30 L/L 40-54 Represents anemia,
results from chronic
inflammatory
conditions
Hemoglobin 104 g/L 130-180 Low level of
hemoglobin indicates
anemia due to
compromised O2
and CO2 exchange
Red Blood Cells Count 4.4 10 12/L˄ 4.5-5.5 Indicates anemia
White Blood Cell Count 10.9 10 9/L˄ 4.5-11.0 Normal
Segmenters 84 % 50-70 Indicates infection
Lymphocytes 19 % 25-35 It indicates infection
Monocytes 8 % 0-15 Normal
Eosinophils 2 % 1-5 Normal
Platelets 470 10 9/L˄ 150-400 Caused by
inflammatory diseases
that lead to the
increase in the number
of platelets
Complete Blood Count
Date of testing: 08-28-12
Exam Name Result Unit Normal Value Implication
Hematocrit 0.29 L/L 40-54 Represents anemia,
results from chronic
inflammatory conditions
Hemoglobin 85 g/L 130-180 Low level of hemoglobin
indicates anemia due to
ineffective ventilation.
Red Blood Cells
Count
3.29 10 12/L˄ 4.5-5.5 Indicates anemia
White Blood Cell
Count
15.4 10 9/L˄ 4.5-11.0 Presence of infectious
process specifically in
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the lungs
Segmenters 71 % 50-70 Indicates infection.
Lymphocytes 14 % 25-35 Due to infection
Monocytes 12 % 0-15 NormalEosinophils 3 % 1-5 Normal
Platelets 432 10 9/L˄ 150-400 Caused by inflammatory
diseases that lead to the
increase in the number of
platelets
Potassium- potassium test checks how much potassium is in the blood. Potassium is both
an electrolyte and a mineral. It helps keep the water (the amount of fluid inside and outside the
body's cells) and electrolyte balance of the body. Potassium is also important in how nerves and
muscles work.
Date of testing: 08-21-12
Exam Name Result Unit Normal Value Implication
Potassium 3.50 mEq/L 3.5-4.5 Normal
Creatinine Levels- Creatinine is a chemical waste molecule that is generated from
muscle metabolism. Creatinine is produced from creatine, a molecule of major importance for
energy production in muscles. Creatinine is transported through the bloodstream to the kidneys.
The kidneys filter out most of the creatinine and dispose of it in the urine.
Date of testing: 08-15-12
Exam Name Result Unit Normal Value Implication
Creatinine 0.24 mEq/L 0.70-1.30 Low level of creatinine
indicates an efficient and
effective functioning pair of
kidneys.
Pleural Fluid Analysis- Pleural fluid analysis is used to help diagnose the cause of
inflammation of the pleura (pleuritis) and/or accumulation of fluid in the pleural space (pleural
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effusion). There are two main reasons for fluid accumulation, and an initial set of tests (fluid
protein, albumin, or LDH level, cell count, and appearance) is used to differentiate between the
two types of fluid that may be produced.
Date of testing: 08-14-12
Results: No fungal element seen on smear Implication: Normal
Urinalysis- The urinalysis is used as a screening and/or diagnostic tool because it can
help detect substances or cellular material in the urine associated with different metabolic and
kidney disorders. It is ordered widely and routinely to detect any abnormalities that require
follow up. Often, substances such as protein or glucose will begin to appear in the urine before
patients are aware that they may have a problem. It is used to detect urinary tract infections
(UTI) and other disorders of the urinary tract. In patients with acute or chronic conditions, such
as kidney disease, the urinalysis may be ordered at intervals as a rapid method to help monitor
organ function, status, and response to treatment.
Date of testing: 08-08-12
Exam Name Result Unit Normal Value Implication
Uric Acid 9.77 mg/dL 3.5-7.2 Increase uric acid levels may
be due to alcohol
consumption, organ such as
liver disease, and starvation
Potassium 2.90 mEq/L 3.6-5.4 Decrease level due to chronic
illness, medication use such as
antibiotics and poor intake of
potassium rich foods.
IONIZED
(Free) Ca
1.23 mEq/L 1.12-1.32 Normal
SCPT/ALT 11.00 U/L 3-41 Normal
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Chest X-ray- The chest x-ray is the most commonly performed diagnostic x-ray
examination. A chest x-ray makes images of the heart, lungs, airways, blood vessels and the
bones of the spine and chest. An x-ray (radiograph) is a noninvasive medical test that helps
physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part
of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-
rays are the oldest and most frequently used form of medical imaging.
Results: PTB, moderately advanced, left
with cavity formation. Massive pleural
effusion, right with tension.
Arteriosclerotic Aorta
Implication: Inflammation of the lungs due to
infectious process of the agent Mycobacterium
tuberculi causes accumulation of excessive
fluid in the pleural cavities which aggravated
by the atherosclerotic aorta causing a backflow
of blood in the lungs causing pulmonary
congestion.
Other ideal Diagnostic Tests/ Procedures
1. FBC- Full blood Count- An FBC, as the name suggests, is used to obtain a count of the
blood cells in the sample of blood taken. The counts from this small sample are used to
estimate the levels of different blood cells within your body’s blood system.
2. Pleural Biopsy- A pleural biopsy is a procedure to remove a sample of the tissue lining
the lungs and the inside of the chest wall to check for disease or infection.
3. Bronchoscopy- Bronchoscopy is a test to view the airways and diagnose lung disease.
It may also be used during the treatment of some lung conditions.