2. I INTRODUCTION
A. Background of the Study
Pulmonary tuberculosis, a chronic sub-acute or acute respiratory disease commonly affecting
the lungs characterized by the formation of tubercles in the tissues which tend to undergo cessation,
necrosis and calcification. It is also known as poor man’s disease or consumption disease. The causative
agent in this disease is Mycobacterium Tuberculosis, a rod shaped bacteria. The disease is transmitted by
deliberate inoculation of microorganisms by droplet. This disease is transmitted to other people through the
inhalation of organisms directly into the lungs from contaminated air. According to the department of Health
(DOH) PTB is the 6th cause of mortality and morbidity in the Philippines as of 2007. (Navales, Handbook of Common
Communicable and Infectious disease revised edition, pages 280-281.)
This disease is can be acquired easily by person being in contact with an infected one, when you are
living in a crowded area like the squatter’s area and when you have poor nutrition. It is commonly present
in third world or developing countries like the Philippines.
In 2004, mortality and morbidity statistics included 14.6 million chronic active cases, 8.9 million new
cases, and 1.6 million deaths, mostly in developing countries. In addition, a rising number of people in the
developed world are contracting tuberculosis because their immune systems are compromised by
immunosuppressive drugs, substance abuse, or AIDS. The distribution of tuberculosis is not uniform across
the globe with about 80% of the population in many Asian and African countries testing positive in tuberculin
tests, while only 5-10% of the US population testing positive. (http://en.wikipedia.org/wiki/Pulmonary_tuberculosis)
B. Rationale for Choosing the Case
The researchers decided to choose this case because they wanted to acquire more knowledge
about Pulmonary Tuberculosis. They wanted to use the knowledge that they have acquired in promoting
awareness to the people especially to the poor that they should seek for medical care in order to prevent
the development and progression of PTB. The researchers also wanted to focus on preventive measures.
PTB can cause Tuberculosis meningitis, a very rare and fatal disease and the researchers would not want
that to happen, so they will focus more on information campaign as part of primary prevention of health.
Presently our country has so many cases of PTB.
C. Significance of the Study
This study will help the nursing profession by providing information about the proper management
and care for PTB patient. It will also educate the people, especially those with PTB and vulnerable
individuals to seek medical care in order to prevent TBM. It will increase awareness about the importance
of having a healthy lifestyle and clean environment.
3. This study will elaborate the inter relatedness of environment, life style habits and acquiring
Pulmonary Tuberculosis.
D. Scope and Limitation of the Study
This study is focused on the nursing aspect of care to those patients who have Pulmonary
Tuberculosis. This study will only be used in the nursing profession. The researchers only focused their
attention on the medications, diagnostics, care plan, pathophysiology and discharge planning. This study is
not limited to the PTB patients only, but it is for all people who are interested in PTB. We are more focused
on primary prevention through health education because primary prevention is the true prevention.
II CLINICAL SUMMARY
A. General Data
• Name: Eufemia Bugoy y Cia
• Age: 46 y/o
• Birthplace: Pulangi, Albay
• Sex: Female
• Religion: Roman Catholic
• Civil Status: Married
• Address: Baras, Rizal
• Date Admitted: September 19, 2008
• Time Admitted: 2:10 am
• Attending Physician: Dr. San Jose
B. Chief Complaint:
The patient was admitted at Rizal Provincial Hospital last September 19, 2008 at 2:10 in the morning
due to the complaint of difficulty of breathing (DOB). She was attended at the Emergency department and
had taken a clinical history and physical assessment. She was transferred at the Medical Ward particularly
in the isolation room of the hospital for further evaluation of the complaint. She was attended by Dr. San
Jose, a resident physician of the said hospital.
4. C. History of Present Illness:
Patient’s condition started about 6 months prior to consultation, as onset of cough, non-productive
and an intermittent fever usually in the afternoon, moderate grade temperature which are not documented.
According to her it was relieved by an intake of paracetamol.
One week prior to admission the patient experienced worsening of the condition, she had productive
cough non-bloody with whitish secretions. There is also difficulty of breathing and vomiting. The patient
can’t eat properly because she has no appetite for food. She also experience stabbing pain on her chest
according to the assessment it is 6/10 and it radiates to his back. The patient only took paracetamol for her
fever. On the day of September 19, 2008 she was rushed to the hospital because of difficulty of breathing.
Previously when she started experiencing these conditions, she does not seek for any medical care from
the physician because according to her it is still tolerable.
D. Past Medical History
The patient had upper respiratory tract infection when she was a child, she cannot remember.
Previously she was not hospitalized. She does not have complete immunizations because according to her
it is not available in their place during those days, She has no history of hypertension and Diabetes mellitus.
Whenever she had any flu or cough, she uses herbal plants. She does not have any regular medical and
dental check-ups. She does not have allergies to what ever kind of foods and medications as far as she
knows. Whenever she had fever she takes Paracetamol and Bioflu. She does experience any severe
accidents.
6. Allan,25
Analyn, Anabel, Analiza, Ana Arnold, 10
23 22 19 Marie, 15
Legends
Male
Female
PTB Pulmonary
F. Physical
Tuberculosis Assessment
• Upon Admission
CVA Cerebro Vascular Date: September 19, 2008
Attack • GCS-15 oriented to 3 spheres-(E4M6V5) Height: 62 inches
• V/S: BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-37.5 C Weight: 31.5 kilograms
• LOC: Oriented BMI: 12.5 (Severe Malnutrition)
AREA TECHNIQUE NORMS FINDINGS ANALYSIS and INTERPRETATION
A. SKULL
1. Size, shape and Inspection Rounded Rounded(normocep Normal
symmetry of the skull Palpation (normocephalic halic); smooth skull
and symmetrical, contour
with frontal,
parietal, and
occipital
prominences);
Smooth skull
contour
2. Presence of Palpation Smooth, uniform Has no tenderness; Normal
nodules, masses, and Inspection consistence; no masses nor
7. depressions absence of nodules nodules
or masses
3. Facial Features Inspection Symmetric or Symmetrical and Normal
Palpation slightly asymmetric palpebral fissure
facial features; equal in size,
palpebral fissure nasolabial folds are
equal in size; symmetrical
symmetric
nasolabial
4. Presence of Inspection No edema and Has Hollowness Abnormal, Volume deficiency of fat
edema and hollowness within the orbit (the space inside of the
bony eye socket). This condition of the
hollowness in the eye.
patient is related to his nutritional
status, she is malnourished. Her BMI is
12.5.
(http://www.drmeronk.com/hollowed/under-eye-
hollows.html)
C. HAIR
1. Evenness of Inspection Evenly distributed Evenly distributed Normal
growth, thickness, or Palpation and covers the with no patches of
thinness of hair whole scalp; hair loss; thick hair
Maybe thick or thin
2. Texture and Inspection Silky; resilient hair Silky, smooth and Normal.
oiliness over the Palpation resilient hair
scalp
3. Presence of Inspection No infection and Presence of lice Abnormal, There is pediculosis, a type
infection and Palption infestation of parasitic infection. Lice may be
infestation contracted from infcetd clothes and
direct contact with an infected person.
The idea is that an oily substance, such
8. as oil, smothers the lice and they may
die. (Kozier, Fundamentals of Nursing 7th ed.
Page 733)
D. FACE
Facial features, Inspection Symmetric or Symmetrical facial Normal
symmetry of facial slightly asymmetric features while
movements facial features; talking or elevating
palpebral fissures the eyebrow. Equal
equal in size; palpebral fissure,
symmetric symmetrical
nasolabial folds nasolabial folds.
IV. EYES
A. EYEBROWS
Hair distribution, Inspection Symmetrical and in Symmetrical and Normal
alignment, skin quality line with each aligned with each
and movement other; maybe black, other; black; evenly
brown or blond distributed.
depending on race; Movements are
evenly distributed symmetrical.
B. EYELASHES
Evenness of Inspection Evenly distributed; Turned outward Normal
distribution and Palpation turned outward eyelashes; hair
direction of curl equally distributed
C. EYELIDS
Surface Inspection Upper eyelids Able to close the Normal
9. characteristics and cover the small eyes and has the
position (in relation to portion of the iris, ability to blink.
the cornea, ability to cornea, and sclera
blink, and frequency when eyes are
of blinking) open; eyelids meet
completely when
the eyes are
closed;
symmetrical
D. CONJUNCTIVA
1. Color, texture, and Inspection Pinkish or red in Pale color; smooth in Abnormal, pale conjunctiva may be
the presence of Palapation color; with texture related to the low RBC level of the
lesions in the bulbar presence of small patient. (Fundamentals of Nursing 5th
conjunctiva capillaries; moist; edition by Taylor, page 642)
no foreign bodies;
no ulcers
2. Color, texture, and Inspection Pinkish or red in Pale Abnormal, pale conjunctiva may be
the presence of Palpation color; with related to the low RBC level of the
lesions in the presence of small patient. (Fundamentals of Nursing 5th
palpebral conjunctiva capillaries; moist; edition by Taylor, page 642)
no foreign bodies;
no ulcers
E. SCLERA
10. Color and clarity Inspection White in color; White sclera with Normal
clear; no yellowish some visible
discoloration; some capillaries, anicteric
capillaries maybe sclera.
visible
F. CORNEA
Clarity and texture Inspection No irregularities on Clear and smooth in Normal
the surface; looks texture
smooth; clear or
transparent
G. IRIS
Shape and color Inspection Anterior chamber is Dark brown in color; Normal
transparent; no transparent anterior
noted visible chamber
materials; color
depends on the
person’s race
H. PUPILS
1. Color, shape, and Inspection Color depends on Pupil size is 3mm. Normal
symmetry of size the person’s race;
size ranges from
3-7 mm, and are
equal in size;
equally round
2. Light reaction and Inspection Constrict Dilates when looking Normal
accommodation briskly/sluggishly at far objects and
11. when light is constricts when
directed to the eye, looking at near
both directly and objects. Constricts
consensual when there is light.
I. VISUAL ACUITY
1. Near vision Inspection Able to read Nearsightedness Abnormal, it is a refractive defect of the
newsprint (Myopia) eye in which collimated light produces
image focus in front of the retina when
accommodation is relaxed. It is caused
by an eyeball that is longer than
normal, which may be a familial trait.
Transient mayopia occurs due to
influenza, steroids, sever dehydration
and large intake of antacids. (Black,
Medical Surgical Nursing7th edition, page 1963).
J. LACRIMAL GLAND
Palpability and Palpation No edema or No tenderness and Normal
tenderness of the tenderness over edema noted.
lacrimal gland lacrimal gland
K. EXTRAOCULAR
MUSCLES
Eye alignment and Inspection Both eyes Moves in Unison Normal
coordination coordinated, move
in unison, with
parallel alignment
L. VISUAL FIELDS
Peripheral visual Inspection When looking Can see objects in Normal
fields straight ahead,
12. client can see the periphery.
objects in the
periphery
V. EARS
A. AURICLES
1. Color, symmetry of Inspection Color same as Same color as the Normal
size, and position facial skin; facial skin; tip of
symmetrical; auricle aligned at the
auricle aligned with outer canthus of the
outer canthus of eye.
eye, about 10
degrees from
vertical
2. Texture, elasticity Palpation Mobile, firm, and Smooth in texture, Normal
and areas of not tender; pinna flexible and elastic
tenderness recoils after it is pinna; no
folded tenderness
C. HEARING ACUITY
TESTS
1. Client’s response Inspection Normal voice tones Can hear normal Normal
to normal voice tones audible volume tones or
words.
VI. NOSE
1.Any deviations in Inspection Symmetric and Symmetric and Abnormal, Nasal flaring suggests
13. shape, size, or color straight; no straight; Uniform airway obstruction. Nasal discharge
and flaring or discharge or color with nasal shows the presence of mucus
discharge from the flaring; Uniform flaring. secretions in the air tract.
nares color
2. Nasal septum Inspection Nasal septum Nasal septum intact Normal
(between the nasal Palpation intact and in midline and in midline
chambers)
3. Patency of both Inspection Air moves freely as Only left nares is Abnormal, not patent right nares show
nasal cavities the client breathes patent. Right nares the presence of mucus secretions and
through the nares is with secretion. would suggest there is an infection in
the respiratory system.
4. Tenderness, Palpation Not tender; no Nor tenderness nor Normal
masses, and lesions lesions.
displacements of
bone and cartilage
VII. SINUSES
Identification of the Inspection Not tender Not painful when Normal
sinuses and for palpated
tenderness
VIII. MOUTH
A. LIPS
Symmetry of contour, Inspection Uniform pink color; Pink in color, dry and Abnormal, May suggest cellular
color and texture Palpation soft, moist, smooth cracked lips dehydration. (Black, Medical Surgical
texture; symmetry Nursing7th edition, page 208).
of contour; ability to
14. purse lips
B. BUCCAL MUCOSA
Color, moisture, Inspection Uniform pink color; Pink color and dry. Abnormal, May suggests dehydration.
texture, and the moist, smooth, (Black, Medical Surgical Nursing7th
presence of lesions soft, glistening, and edition, page 208).
elastic texture
C. TEETH
Color, number and Inspection 32 adult teeth; Has 31 adult teeth. Abnormal, most unpleasant odors are
condition and smooth, white, The patient has known to arise from proteins trapped in
presence of dentures shiny tooth enamel; yellowish teeth. the mouth which are processed by oral
smooth, intact Have bad breath. bacteria. The most common location
dentures Have tooth decay in for mouth-related halitosis is the
the lower right tongue.
second molars. (http://en.wikipedia.org/wiki/Halitosis).
It is also related to dental carries and
frequency of tooth brushing.
D. GUMS
Color and condition Inspection Pink gums; no Pink gums; has no Normal
retraction visible retractions
E. TONGUE/FLOOR OF
THE MOUTH
1. Color and texture of Inspection pink color; moist; Pink and moist. Normal
the mouth floor and slightly rough; thin Tongue moves freely
and no pain felt.
15. frenulum. whitish coating;
moves freely; no
tenderness
2. Position, color and Inspection Central position; Located and Normal
texture, movement pink color; smooth positioned in the
and base of the tongue base with center.
tongue prominent veins
3. Any nodules, Palpation Smooth with no No tenderness nor Normal
lumps, or excoriated Inspection palpable nodules, masses
areas lumps, or
excoriated areas
F. PALATES and UVULA
1. Color, shape, Inspection Light pink, smooth, The hard palate has Normal
texture and the Palpation soft palate; lighter a lighter color than
presence of bony pink hard palate , the soft palate; has
prominences more irregular quite rough texture
texture
2. Position of the Inspection Positioned in Positioned at the Normal
uvula and mobility midline of soft center of the
(while examining the palate oropharynx
palates)
G. OROPHARYNX and
TONSILS
1. Color and texture Inspection Pink and smooth Dry, pinkish in color. Abnormal, May suggests dehydration.
posterior wall (Black, Medical Surgical Nursing7th
edition, page 208).
16. 2. Size, color, and Inspection Pink and smooth; Has no discharge; Normal
discharge of the no discharge; of pinkish
tonsils normal size
3. Gag reflex Inspection Present Present Normal
X. THORAX
A. ANTERIOR THORAX
1. Breathing patterns Inspection Quiet, rhythmic, Difficulty of breathing Abnormal, labored breathing is a
and effortless common manifestation affecting clients
respirations with cardiac and pulmonary disorders.
It is related to obstructed airway. It also
related to the decreased size of the
lungs due to PTB. (Black, Medical
Surgical Nursing7th edition, page
1566).
2. Temperature, Palpation Skin intact; uniform Has an intact skin; Normal
tenderness, masses temperature; chest has equal warmth on
wall intact; no both sides. No
tenderness; no masses.
masses
3. Anterior thorax Auscultation Bronchovesicular Has crackles sounds Abnormal, crackles or rales are audible
auscultation and vesicular on the upper thorax when there is a sudden opening of
breath sounds & lower thorax small airways that contain fluid. It is
usually heard during inspiration. (Black,
Medical Surgical Nursing7th edition,
page 1756).
17. B. POSTERIOR THORAX
1. Shape, symmetry, Inspection Anteroposterior to Has a Normal
and comparison of Palpation transverse anteroposterior to
anteroposterior diameter in ratio transverse diameter
thorax to transverse 1:2; Chest ratio of 1:2, elliptical
diameter symmetric in shape and
symmetrical chest
2. Spinal alignment Inspection Spine vertically Has a vertical Normal
aligned alignment
3. Temperature, Palpation Skin intact; uniform No masses nor Normal
tenderness, and temperature; chest tenderness; has
masses wall intact; no equal warmth on
tenderness; no each side
masses
7. Posterior thorax Auscultation Vesicular and Has crackles heard Abnormal, the condition is related to
auscultation bronchovesicular on the anterior and the decreased size of the right lung
breath sounds middle part of right and poor inspiratory effort due to pain.
and left lungs. (http://www.nurse411.com/Heart_Lung_Sounds.a
Diminished lung sound on sp)
the posterior right lung.
XI. CARDIOVASCULAR
A. AORTIC and Auscultation No pulsations No pulsations felt Normal
PULMONIC AREAS
B. TRICUSPID AREA Auscultation No pulsations; no No pulsations of lifts Normal
lift or heave
18. C. APICAL AREA Auscultation Pulsations visible in Has full pulsation Normal
50% of adults and
palpable in most
PMI in fifth LICS at
or medial to MCL
D. EPIGASTRIC AREA Auscultation Aortic pulsations Has pulsation Normal
E. CARDIOVASCULAR Auscultation S1: Usually heard at Has full and rapid Normal
AREAS AUSCULTATION all sites pulsation. 84
bpm/minute.
Usually louder at
the apical area Sounds on the aortic Normal
and pulmonic areas;
S2: Usually heard has a lub sound on
at all sites the apex and dub
sounds on the
Usually louder at
tricuspid area. Normal
the base of heart
Blood pressure is
Systole: silent
90/70 mm Hg.
interval; slightly
shorter duration
than diastole at
normal heart rate
(60 to 90
beats/min)
Diastole: silent
interval; slightly
longer duration
than systole at
normal heart rates
19. S3: in children and
young adults
S4: in many older
adults
XII. CAROTID ARTERIES
1. Carotid artery Palpation Symmetric pulse Has weak pulsation. Abnormal, decreased amount of blood
palpation volumes; full Symmetrical pulse. volume passing the artery. (Black,
pulsations, Medical Surgical Nursing7th edition,
thrusting quality; page 1574).
quality remains
same when the
client breathes,
turns head, and
changes from
sitting to supine
position; elastic
arterial wall
XIV. AXILLAE
1. Axillary, Inspection No tenderness, Have no masses Abnormal, The appocrine glands
subclavicular, and masses, or nodules and nodules. located in the axillae produces sweat.
supraclavicular lymph Presence of a foul The secretion of these glands is
nodes smelling odor. odorless, but when decomposed or
acted upon by bacteria in the skin, it
takes on a musky, unpleasant odor.
(Kozier et.al, Fundamentals of Nursing
7th ed. Page 699)
XV. ABDOMEN
20. 1. Skin integrity Inspection Unblemished skin; Uniform color and Normal
uniform color has no blemishes
2. Abdominal contour Inspection Flat, Has a concave Normal
rounded(convex), abdomen.
or
scaphoid(concave)
3. Enlargement of Inspection No evidence of No enlargement of Normal
liver or spleen enlargement of the spleen and liver
liver or spleen seen
4.Symmetry of Inspection Symmetric contour Has a symmetrical Normal
contour abdominal contour
5. Abdominal Inspection Symmetric Abdominal Normal
movements movements caused movements noted
associated with by respiration; when inhaling.
respirations, visible peristalsis in
peristalsis or aortic very lean people;
pulsations aortic pulsations in
thin persons at
epigastric area
6. Vascular pattern Inspection No visible vascular Has no blood Normal
pattern vessels visible
XVI.
MUSCULOSKELETAL
SYSTEM
A. MUSCLES
21. 1. Muscle size and Inspection Proportionate to Proportionate to the Normal
comparison on the the body; even in body; even in both
other side both sides sides
2. Fasciculation and Inspection No fasciculation Has no fasciculation Normal
tremors in the and tremors and tremors
muscles
3. Muscle tonicity Palpation Even and firm Weak muscle tone Abnormal, possibly related to the
muscle tone amount of food that patient is eating.
Possible exhaustion experienced by
the patient when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)
4. Muscle strength Palpation Has equal muscular Weak muscle Abnormal, possibly related to the
strength on both strength amount of food that patient is eating.
Possible exhaustion experienced by
sides the patient when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)
C. JOINTS
1. Joint swelling Inspection No swelling, no No swelling, no Normal
warmth, no warmth, no redness,
redness, no pain, no pain, no crepitus
no crepitus
EXTREMETIES Inspection, No swelling, no No edema, no pain Normal
Palpation warmth, no when moved.
redness, no pain.
22. Neurologic Assessment:
Category Normal Findings Actual Findings Analysis and interpretation
Mental Status
Level of Consciousness Alert Alert Normal
Orientation Oriented Oriented to person, Normal
time and place.
Language test Coherent Coherent Normal
Recall Able to remember Able to state what Normal
happened to her in the
past.
Cranial Nerves
CN 1 Able to smell and Able to identify the Normal
Olfactory recognize stimuli scent of the alcohol
CN 11 20x20 vision, able Pupil size is 3 mm, able Abnormal, it is a refractive defect of the eye in
Optic to read, 3-5 mm to read, myopia or which collimated light produces image focus in
[pupil size] nearsightedness. front of the retina when accommodation is
relaxed. It is caused by an eyeball that is
longer than normal, which may be a familial
trait. Transient mayopia occurs due to
influenza, steroids, sever dehydration and
large intake of antacids. (Black, Medical Surgical
CN III, IV, VI (+) Extraoccular Pupils react to light. Nursing7th edition, page 1963).
Movement (EOM); There is constriction Normal
Occulomotor
Trochlear Lateral Upward and consensual
Abducens and downward; accommodation. Able
23. pupils reactive to to move the eyes in any
light. direction in unison.
CN V Normal
Trigeminal Able to feel and Able to feel my finger on
clearly identify her face while covering
stimulus, with her eyes.
bilateral facial
sensation. With
CN VII active corneal Normal
Facial reflex. (+) Facial symmetry
(+) Corneal reflex ,
CN VIII Facial asymmetry
Vestibulocochlear Normal
Can hear clearly and
can walk.
Able to hear
CN IX, X clearly, can
Glossopharyngeal maintain balance Normal
Vagus Present gag reflex, able
to swallow and able to
idebtify the taste of the
CN XI (+) gag reflex, food.
Accessory (Spinal) uvula at the Normal
center, soft palate
rises Can shrug shoulders
against resistance and
can turn the head fro
Able to shrug right to right.
shoulders against
CN XII resistance and Normal
Hypoglossal able to turn the
head side and
against resistance. Able to protrude the
tongue and move it side
24. Able to move to side.
tongue from side
to side
Muscle Strength MNT Grading
System:
Left Arm +4 active motion Abnormal, possibly related to the amount of
(+5) Active motion against some food that patient is eating. Possible exhaustion
against full resistance. experienced by the patient when she coughs.
resistance (http://en.wikipedia.org/wiki/Muscle_weakness)
Abnormal
Right Arm
+4 active motion
(+5) Active motion against some
against full resistance. Abnormal
Left Leg
resistance
+4 active motion Abnormal
Right Leg
(+5) Active motion against some
against full resistance.
resistance +4 active motion
(+5) Active motion against some
against full resistance.
resistance
G. Patterns of Functioning
25. The researchers utilized the Gordon’s typology in assessing the pattern of functioning of our patient
in her life. How does she manages and takes care of herself based on Eleven Patterns.
Functional Health Pattern
Prior to Hospitalization Norms and Standards
Health perception- Health Management Measure for personal cleanliness and grooming, called
personal hygiene, promote physical and psychological well-
• The patient doesn’t have complete immunization being. Various studies have confirmed that improved personal
because according to her it is not available during hygiene practices reduce illness rates. (Larson, 2002; Larson
those days and having immunization during those years and Aiello, 2001).
are expensive and they cannot afford it. Personal hygiene practices vary widely among people.
• She was never been hospitalized. The time of the day one bathes and how often one shampoo
• No known allergies to any foods and drugs. She can eat or changes the bed linens, and sleeping garments are
fish, oyster and others. relatively unimportant. What is important is that personal care
• Does not experience any accidents. be carried out conveniently and frequently enough to promote
• When she had a disease, she used herbal medicines personal hygiene.
like guava leaves, oregano, lagundi, etc. Illness, hospitalization and institutionalization generally
• For her, being healthy is important. A person is healthy require modifications in hygiene practices. In these situations,
when she is strong, she can do what she wants and the nurse helps the patient to continue some hygiene
does not experience any diseases. practices, and can teach the patient and family members,
• She does not have any regular medical and dental when necessary, regarding hygiene. Nurses assist the patient
check-ups. with basic hygiene must respect individual patient
• When she is experiencing something wrong in her preferences, providing only the care that patients cannot or
body, she does not tell it promptly because according should not provide for themselves.
to her it is tolerable. (Fundamentals of Nursing 5th edition by Taylor, page 1005).
• She does not have a regular exercise, instead she Malnutrition is the lack of sufficient nutrients to maintain
cleans the house and washes the clothes of her family. healthy bodily functions and is typically associated with
• The patient is malnourished. extreme poverty in economically developing countries. Most
commonly, malnourished people either do not have enough
• She takes a bath once a day and brushes her teeth
calories in their diet, or are eating a diet that lacks protein,
once a day.
vitamins, or trace minerals. Medical problems arising from
• She does use lotion, shampoo and soap. malnutrition are commonly referred to as deficiency diseases.
• She washes her hands regularly but not always using Deficiency in micronutrients such as Vitamin A reduces the
soap. capacity of the body to resist diseases. Deficiency in iron,
• When she feels discomfort in her body she also goes to iodine and vitamin A is widely prevalent and represent a major
the manghihilot because it is available on their area and public health challenge. An array of afflictions ranging from
it is more approachable. stunted growth, reduced intelligence and various cognitive
26. • She often forgot to cover her mouth and nose when abilities, reduced sociability, reduced leadership and
someone sneezes and coughs in front of her. assertiveness, reduced activity and energy, reduced muscle
• A person has a disease when she eats little amount of growth and strength, and poorer health overall are directly
food, when she is weak. implicated to nutrient deficiencies.
(http://en.wikipedia.org/wiki/Malnourishment)
• Health for her is important for proper functioning.
The main purpose of washing hands is to cleanse the
• Whenever she is sick, she get’s money from her
hands of pathogens (including bacteria or viruses) and
children especially to the eldest, which is working
chemicals which can cause personal harm or disease,
abroad.
particularly diarrhea and pneumonia. To maintain good
• She wears slippers while inside their house. She feels hygiene, hands should always be washed after using the
that her hygienic practices are adequate, and she feels toilet, changing a diaper, tending to someone who is sick, or
clean and neat. handling raw meat, fish, or poultry, or any other situation
• The patient is non-smoker and she does not drink any leading to potential contamination. Hands should also be
alcoholic beverages. washed before eating, handling or cooking food.
• She denies the use any illicit drugs. Conventionally, the use of soap and warm running water and
the washing of all surfaces thoroughly, including under
fingernails is seen as necessary. Alcohol rub sanitizers kill
bacteria, multi-drug resistant bacteria (MRSA and VRE),
tuberculosis, and viruses (including HIV, herpes, RSV,
rhinovirus, vaccinia, influenza, and hepatitis) and fungus. (http://
en.wikipedia.org/wiki/Hand_washing)
Herbalists treat many conditions such as asthma, eczema,
premenstrual syndrome, rheumatoid arthritis, migraine,
menopausal symptoms, chronic fatigue, and irritable bowel
syndrome, among others. Herbal preparations are best taken
under the guidance of a trained professional. Be sure to
consult with your doctor or an herbalist before self-treating.
Some common herbs and their uses are discussed below.
Please see our monographs on individual herbs for detailed
descriptions of uses as well as risks, side effects, and
potential interactions. (http://www.umm.edu/altmed/articles/herbal-
medicine-000351.htm)
Nutritional Metabolic Pattern Nutrition is a basic human need that changes throughout
• She loves to eat pork, fish and vegetables. the life cycle and along the wellness-illness continuum.
• She is not choosy when it comes to any cook and kind (Fundamentals of Nursing 5th edition by Taylor, page 1135)
of food. An adequate food intake consists of balance essentials
• She eats 3x a day nutrients: water, carbohydrates, fats, proteins, vitamins and
minerals. Habits about eating are affected by many factors
• She does not eat any junk foods.
27. • She drinks 5 glasses of water a day. like financial and health conditions. (Kozier et.al,
• For her, the amount of food she consumes is adequate. Fundamentals of Nursing 7th ed. Page 1171,1175)
• She takes food supplement but it is not frequent. The middle aged adult should continue to eat a healthy
• During snack time, she usually eats banana because it diet, following the recommended portions of the 5 food
is affordable and readily available in their place. groups, with special attention to protein, calcium and limiting
• When her cough started, she is not eating the consumption to cholesterol. Two to three liters of fluid should
appropriate amount of food. be included in the diet. Pre menopausal women need to
• According to her husband, she usually eats 4 spoons of ingest sufficient calcium and vitamin d to prevent
rice with viand only. It is due to her cough. osteoporosis. (Kozier et.al, Fundamentals of Nursing 7th ed.
• During her hospitalization, she is on diet as tolerated Page 1180,1181)
with aspiration precaution. An adult individual needs to balance energy intake with his
• She eats food given by the hospital. or her level of physical activity to avoid storing excess body
• She is taking vitamin B6 and other medications. fat. Dietary practices and food choices are related to wellness
and affect health, fitness, weight management, and the
prevention of chronic diseases such as osteoporosis, cardiovascular
diseases, cancer, and diabetes.
For adults (ages eighteen to forty-five or fifty), weight
management is a key factor in achieving health and wellness.
In order to remain healthy, adults must be aware of changes
in their energy needs, based on their level of physical activity,
and balance their energy intake accordingly.
(http://www.faqs.org/nutrition/A-Ap/Adult-Nutrition.html)
Inadequate nutrition is associated with marked weight
loss, generalized muscle weakness, altered functional ability,
increased susceptibility to infection, impaired pulmonary
function and prolonged length of hospitalization. (Kozier et.al,
Fundamentals of Nursing 7th ed. Page 1190).
Elimination Elimination can be affected by a person’s developmental
stage, daily patterns, the amount and quality of fluid or food
• She defecates twice a week and sometimes she feels
intake, the level of activity, lifestyle, emotional states,
pain and difficulty.
pathologic processes, medication, and procedures such as
• According to her the characteristic of her stool is hard,
diagnostic test and surgery. Most people have individual
dry and colored dark brown.
pattern of elimination including frequency, timing
• She feels pain at her abdomen on the hypogastric and
considerations, position and place. For most people
umbilical area.
defecation is a private affair experienced easily only in the
• She urinates 7x a day and does not feel any pain and comfort of one’s own bathroom. Defecation may be difficult
difficulty.
28. • Previously her defecation pattern is daily, but when her in shared hospital room with only a curtain for privacy.
condition exacerbated, it is also affected. (Fundamentals of Nursing 5th edition by Taylor, page 1341)
The frequency of defecation is highly individualized,
varying from several times per day to two to three times per
week. Sufficient bulk in the diet is necessary to provide fecal
volume. Bland diets and low-fiber diets are lacking in the bulk
and therefore create insufficient residue of waste products to
stimulate the reflex for defecation. Low-residue foods such as
rice, eggs and lean meats move more slowly through the
intestinal tract. (Kozier et.al, Fundamentals of Nursing 7th ed.
Page 1228).
Activity stimulates peristalsis, thus facilitating the
movement of chime along the colon. (Fundamentals of
Nursing 5th edition by Taylor, page 1229).
A person’s urinary habits depend on social culture,
personal habits and physical abilities. Urine collects in the
bladder contains between 250 to 450 ml of urine. (Kozier
et.al, Fundamentals of Nursing 7th ed. Page 1256).
The excretory function of the kidney diminishes with age
but usually not significant below normal levels unless disease
intervenes. With age, the number of functioning nephrons
decreases to some degree, impairing the kidneys filtering
abilities. The amount of flood intake affects the urinary
frequency of an individual. Foods high in sodium or fluids high
in sodium ca cause fluid retention because water are retained
to maintain the normal concentration of the electrolyte.
(Kozier et.al, Fundamentals of Nursing 7th ed. Page
1258-1259).
Activity and Exercise The human body was designed for motion, and regular
• She does not have any work, she is a plain house wife, exercise is necessary for its healthy functioning. Individuals
who is in-charge of her children. who choose inactive lifestyles or who are forced into inactivity
by illness or injury placed themselves at high risk for serious
• Her usual activity is cleaning the house, cooking and
health problems.
washing the clothes of her children.
(Fundamentals of Nursing 5th edition by Taylor, page 1116)
• She loves to listen to radio programs usually in the Vigorous physical activity is not always needed to achieve
afternoon. positive result.
• She likes to converse with her friends and (Fundamentals of Nursing 5th edition by Taylor, page 1117)
neighborhood.
29. • When she cleans, it is usually for 1 hour because she Lack of exercise, inactivity, or immobility related to illness,
gets easily tired. or injury place a person at high risk for serious health
• Her youngest child helps her in the household chores. problems. Immobility can affect the major body systems. Like
• When after all the chores are done she will rest and the benefits, a person receives from exercise, complications
watch television. resulting from immobility differ occurrence and severity based
• She does not involve her self in any vigorous activities. on the patients age and overall health status. (Kozier et.al,
• However, she is aware that her activity is not enough, Fundamentals of Nursing 7th ed. Page 1118).
and she recognizes the importance of having regular The wonderful tool of exercise can help teens become fit
exercise. and healthy. Performing some form of physical activity daily
will significantly boost your “basal metabolic rate”—the
number of calories your body burns in order to keep you alive.
By having a high metabolism, you burn calories 24 hours a
day—even while you sleep! You can literally turn your body into
a fat-burning machine!
This has many benefits: With a strong metabolism comes a
strong immune system. When you burn fat, the toxins are
released into the bloodstream, and are quickly carried out of
the body through sweat. This inoculates you against the
probability of developing cancerous and diseased cells.
Therefore, hard exercise—that makes you sweat—is very good
for you.
Exercise also helps to regulate the amount of insulin
released into the bloodstream. Insulin is commonly referred to
as “the fat-making hormone.” Its job is to metabolize blood
sugar into energy. But too much insulin in the bloodstream
keeps your body from burning stored fat. Years of an
overworked pancreas—the organ that produces insulin—can
lead to “onset (type 2) diabetes.” However, if you use—burn
—more calories than you consume, you significantly reduce
the chances of developing this disease.
Exercise can also help control other problems, such as:
Sleep apnea, moodiness, stress, decreased energy,
cardiovascular disease, high cholesterol and others. There
are too many benefits to list here. But be assured that this
tool can help you become a fit, stronger, disease-free, and
overall healthier person. The main goal of aerobic exercise is
to keep the heart elevated for an extended period of time for
the purpose of strengthening the heart and lungs. The most
30. common aerobic exercise is walking. Running is the quickest
way to lose weight, because it burns many calories. It also
tones your calves and thighs. However, to avoid extreme
muscle aches or injuries, do not begin a running routine until
you have performed two to three months of aerobic walking.
(http://www.thercg.org/youth/articles/0201-tioe.html)
Cognitive-perceptual Cognition is greatly affected by education. Those who
• The patient is an elementary graduate. study and develop their skills have better cognitive
• She stops studying because of financial problem performances because they have been provided with different
information and chances to develop their self. Perception is
• She can read and write properly.
affected by the sensory diseases. Presence of any sensory
• She is aware to different people or happening around
abnormalities affects or halters perception that would affect
her.
proper communication. (Black, Medical Surgical Nursing7th
• She can talk properly.
edition, page 1880).
• During the interview her voice is weak.
Cognition involves a person’s intelligence, perceptual
• According to her she is sensitive to the feelings of the ability and ability to process information. It represents a
people around her. progression of mental abilities from illogical to logical thinking,
• There are no any blockages of communication noted. from simple to complex problem solving and from concrete to
• She is not always reading any books like pocket books. abstract ideas. (Kozier et.al, Fundamentals of Nursing 7th ed.
• She can express her feelings appropriately. Page 359).
• She does not have any difficulty when it comes to
communication.
Sleep and Rest For no known reason, 8 hours of sleep a night has been
the accepted standard for adults despite obvious variations
• The patient regularly sleeps at 8:00pm and wakes up at
seen in the general population. It is important however that a
1:00 pm.
person follows a pattern of rest that maintains well-being.
• She is experiencing intermittent sleep disturbance
Many factors affect a person’s ability to rest. Illnesses and
because according to her she feels difficulty of
various life situations that causes physiological stress tends to
breathing and cough.
disturb sleep. Sleep quality is also influenced by certain drugs
• She usually sits because according to her she can Some decreases REM sleep (barbiturates ,amphetamines and
breath more easily. antidepressants) and some are seen to
• She takes a nap in the morning from 8 am to 11 am. cause sleep problems (steroids, caffeine and asthma
• She feels that her sleep and rest is inadequate. medications)
• She sleeps together with her husband. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1169-117).
• They have a separate room from their children. The National Sleep Foundation in the United States
• Sleeping is important to her. maintains that eight to nine hours of sleep for adult humans is
31. optimal and that sufficient sleep benefits alertness, memory
and problem solving, and overall health, as well as reducing
the risk of accidents.[8] A widely publicized 2003 study[9]
performed at the University of Pennsylvania School of
Medicine demonstrated that cognitive performance declines
with fewer than eight hours of sleep.
It has also been shown that sleep deprivation affects the
immune system and metabolism. In a study by Zager et al in
2007,[21] rats were deprived of sleep for 24 hours. When
compared with a control group, the sleep-deprived rats' blood
tests indicated a 20% decrease in white blood cell count, a
significant change in the immune system.
Scientists have shown numerous ways in which sleep is
related to memory. In a study conducted by Turner,
Drummond, Salamat, and Brown[28] working memory was
shown to be affected by sleep deprivation. Working memory
is important because it keeps information active for further
processing and supports higher-level cognitive functions such
as decision making, reasoning, and episodic memory. Turner
et al. allowed 18 women and 22 men to sleep only 26 minutes
per night over a 4-day period. Subjects were given initial
cognitive tests while well rested and then tested again twice a
day during the 4 days of sleep deprivation. On the final test
the average working memory span of the sleep deprived
group had dropped by 38% in comparison to the control
group. (http://en.wikipedia.org/wiki/Sleep)
Self-perception Self concept is one’s mental image of oneself. A positive
• According to her there is something wrong in her health self concept is essential to a person’s mental and physical
and body. health. Individuals with a positive self concept are better able
• As a mother, she sometimes feels sad because she to develop and maintain interpersonal relationship and resist
cannot do the previous things like going with her psychological and physical illness.
husband in the farm. Self concept involves all of these self perceptions, that is,
• According to her husband she is a good mother and a appearance, values and beliefs that influences behaviors and
good wife. that are referred to when using the words I or me. Body
image is ho the person perceives the size, appearance and
• Her strength is her family, when there are any
functioning of the body. If a person’s body image closely
circumstances that involving any family member she is
resembles one’s ideal body, the individual is more likely to
concerned and make some moves.
32. • She is simple. think positively about the physical and non-physical concept of
self.
Self concept is also affected by role-strains. People
undergoing role-strains are frustrated because they feel or
made to feel inadequate or unsuited to a role.
Illness and trauma can also affect the self-concept. People
responds to different stressors such as illness and alterations
in function related to aging in a variety of ways: acceptance,
denial, withdrawal and depression are common. (Kozier et.al,
Fundamentals of Nursing 7th ed. Pages 957-962).
Role-relationship Relationship to another person is a developed manner in
• She was the fourth child in her family. which there is the sharing of self, showing care and putting
• She is married to Arsenio and they have 6 children. trust. A healthy relationship affects an individual’s emotional
• She is performing the trypical responsibilities of a plain development, it will facilitate the channeling of the ideas,
house wife. feeling of joy an others.
An interpersonal relationship is a relatively long-term
• Her children have a good relationship to her.
• She is being cared by her children who are very association between two or more people. This association
supportive to her. may be based on emotions like love and liking, regular
• Her husband is a good husband he is a provider who business interactions, or some other type of social
does everything for the family to have food. commitment. Interpersonal relationships take place in a great
• She has a harmonious relationship with her brothers variety of contexts, such as family, friends, marriage,
and sisters. Whenever there are any problems, they are acquaintances, work, clubs, neighborhoods, and churches.
helping each other. They may be regulated by law, custom, or mutual agreement,
• She can form a healthy relationship with others. and are the basis of social groups and society as a whole. A
• She is the person who chooses her friends. relationship is normally viewed as a connection between two
• She is a very quite person. individuals, such as a romantic or intimate relationship, or a
• She does not have any enemies. parent-child relationship.
All relationships involve some level of interdependence.
People in a relationship tend to influence each other, share
their thoughts and feelings, and engage in activities together.
Because of this interdependence, anything that changes or
impacts one member of the relationship will have some level
of impact on the other member. Psychologists have
suggested that all humans have a basic, motivational drive to
form and maintain caring interpersonal relationships.
According to attachment theory, relationships can be
viewed in terms of attachment styles that develop during early
childhood. These patterns are believed to influence
33. interactions throughout adulthood by shaping the roles people
adopt in relationships.
(http://en.wikipedia.org/wiki/Intimate_relationship)
Sexuality-reproductive Sexuality is defined not only by a person’s genetalia but
also by attitudes and feelings. It can also be defined as
• She is engage in sexual activity to her husband only.
learned behaviors in how a person reacts to his or her own
• Presently she is still active in her sex life.
sexuality and by how one behaves in relationships with others.
• She still have regular menstruation.
(Fundamentals of Nursing 5th edition by Taylor, page 931)
• She is aware that she will have cessation of her
Sexuality is a crucial part of a person’s identity. Sex is
menstruation.
central to who we are, to our emotional well-being and to the
• She dresses appropriately, based on her gender.
quality of our lives. The world health organization defined
• She is also able to express her feminine attitudes.
sexual health as the integration of the somatic, emotional,
intellectual and social aspect of sexual beings in ways that are
positively enriching and that enhances personality,
communication and love. (Kozier et.al, Fundamentals of
Nursing 7th ed. Pages 973).
During the middle adulthood both men and women
experience decreased hormone production causing the
climacteric, usually called menopausal in women. These
events often affect the individuals self-concept, body image
and sexual identity.
Women through the menopausal period experiences hot
flushes, vasomotor instability, sleep disturbances, vaginal
dryness, genital tract atrophy, mood changes and skin, hair
changes. The incidence of osteoporosis and cardiovascular
lipid changes also increases. The climacteric in the males is
no as dramatic in the females; changes are more gradual.
Sexual response love and play involve people’s emotional,
psychologic, physical and spiritual make up, which plays a
significant role in the satisfaction. Sexual desires fluctuates
within each person and varies from person to person. If
people suppresses or block out conscous sexual desires,
they may not experience any physiological respose. (Kozier
et.al, Fundamentals of Nursing 7th ed. Pages 975,980).
Coping-stress Coping mechanisms which are behaviors used to decrease
• Whenever she has problem, she asks guidance from stress and anxiety. Many coping behaviors are learned, based
our Lord on one’s family past experiences, and socio-cultural
influences and expectations.
• She watches television as her stress management.
34. • She always listen to radio programs when she feels (Fundamentals of Nursing 5th edition by Taylor, page 855)
lonely.
• When she gets mad, she just keep quiet.
• When she experiences coughing and difficulty of
breathing she just relaxes and breathes deeply.
• Her husband or children taps her back when she
coughs.
Value-belief Spiritual well-being is the condition that exists when the
• She is a Roman Catholic universal spiritual needs for meaning and purpose, love and
belonging, and forgiveness are met. O’ Briens conceptual
• She attends mass occasionally.
model of spiritual well-being in illness identified three empirical
• She always ask the guidance of our Lord
referents of spiritual well-being: personal faith, religious
• Whenever there are Christian events, like Holy week,
practice and spiritual contentment. Spiritual beliefs are of
she participates in the activities like fasting.
special importance to nurses because of the many ways they
• She believes in ghosts, and elementals. can influence a patient’s level of health and self-care
• She seldom reads the bible. behaviors. (Kozier et.al, Fundamentals of Nursing 7th ed.
• Does not always pray the rosary. Pages 975,979).
• She respects and obeys her husband. Spiritual well-being is manifested by a generally feeling of
• For her education is very important to her children, so being alive, purposeful and fulfilled. People nurture or enhance
she and her husband is doing all the efforts to send their spirituality in many ways. Some focus on development of
their children to school. the inner self or world; others focus on the expression of their
spiritual energy with others or outer world. Relating to one’s
inner self or soul may be achieved through conducting an
inner dialogue with a higher power or with one’s self through
prayer or medications. The expression of a person’s spiritual
energy to others is manifested in loving relationship with and
service to others, joy and laughter and participation in
religious services and associated fellow gatherings and
activities and by expression of compassion, empathy,
forgiveness and hope. (Kozier et.al, Fundamentals of Nursing
7th ed. Pages 996).
H. Activities of Daily Living
ASPECT PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION INTERPRETATION and ANALYSIS
35. 1. Nutrition Patient loves to eat meat, fish The patient is on diet as tolerated The patient can eat any food she
and vegetables. She eats with aspiration precaution. She wants as long as it is dry,
anything that is being served to eats dry, thickened food on a thickened, and frothy. It should be
her. She does not eat junk foods. small frequent feeding. She is in a small frequent feeding, as to
She is not taking food advised to chew food properly. avoid aspiration.
supplements like vitamins
frequently.
She eats 4 spoons of rice with
viand because according to her it
is due to her cough. She eats
thrice a day.
2. Elimination Patient voids 7 times a day, and The patient does not defecate or The patient does not defecate for
defecate twice a week. She urinated during the conduct of more than a week due to
doesn’t experience any pain the interview. decreased gastric motility related
and difficulty in terms of to decrease physical activity. For
urination. Previously her most people defecation is a private
defecation pattern is daily, but affair experienced easily only in the
when her condition exacerbated, comfort of one’s own bathroom.
it is also affected. Defecation may be difficult in
shared hospital room with only a
curtain for privacy.
(Fundamentals of Nursing 5th
edition by Taylor, page 975 & 979)
3. Exercise Cleaning their house is the only Deep breathing and coughing The patient performs deep
activity she considered as her exercises are advised and breathing exercise as instructed
exercise. She does not have performed. The patient has by the nurse.
routine exercise. However, she decreasing function as the
is aware that her activity is not disease progresses.
enough, and she recognizes the
importance of having regular
exercise. She loves to listen to
radio programs usually in the
afternoon.
When after all the chores are
done she will rest and watch
television.
36. 4. Hygiene Patient takes a bath every day, Not applicable
brushes her teeth once a day.
She wears slippers while inside
their house. She feels that her
hygienic practices are adequate,
and she feels clean and neat.
There is body odor noted.
5. Substance Patient is a non-smoker and The patient doesn’t use any The patient does not use any
Use denies use of illicit drugs. She prohibited substances like addictive substances. Illicit drugs
does not drink alcohol. alcohol, cigarettes and illicit are strictly prohibited in the
drugs. hospital premises, even cigarette
smoking and alcohol drinking.
6. Sleep and Sleeping is important to her. She Not applicable
Rest is experiencing intermittent sleep
disturbance because according
to her she feels difficulty of
breathing and cough. She takes
a nap in the morning from 8 am
to 11 am. She sleeps together
with her husband. The patient
regularly sleeps at 8:00pm and
wakes up at 1:00 pm. She feels
that her sleep and rest is
inadequate because of her
conditions.
7. Sexual She dresses appropriately, Not applicable
Activity based on her gender. She still
has regular menstruation. She is
engage in sexual activity to her
husband only. Presently she is
still active in her sex life
37. I. Patients Concept about Health, Illness and Hospitalization
HEALTH ILLNESS HOSPITALIZATION
The patient believes that being healthy is For the patient, an individual is weak and The patient looks at hospitalization as
being strong, does not experience any eats little amount of food. the last recourse when one has an
sickness and energetic. illness. For the patient, it is the place
where an individual is being treated from
- Health is defined as a state of -Is a disease, sickness or the condition of severe cases.
complete physical, mental and social being in a poor health, either physically or - Placement of an individual in a hospital
well-being and not merely the absence mentally. (Blackwell’s Nursing for observation, diagnostic test, or
of disease or infirmity. WHO definition Dictionary) treatment for some diseases.
(Blackwell’s Nursing Dictionary)
J. Laboratory and Diagnostic Examination
DATE PROCEDURE NORMS RESULT INTERPRETATION and ANALYSIS
Sept. 19, 2008 Hemoglobin 120-160g/L
Hematocrit 0.38-0.40 g/L
RBC count 4’2-5.4x 1012 per
liter
WBC 5-10x109/L
Neutrophils 81.3%
Lymphocytes 10.2%
Basophils 0.1%
Monocytes 7.5%
Eosinophils 0.9%
Platelets 150-450x109/L
Fasting Blood Sugar 70-110 mg/dl
Urinalysis
Creatinine 44.2-106.08 umol/L
Na 135-145mmol/L
K 3.6-5.5mmol/L
38. Sputum Test/AFB Negative
• Electro Cardiogram
• Chest X-ray
The patient had undergone chest x-ray upon admission. The film shows presence of infiltrates
or clouds. The right is smaller than the left lung, particularly the lower lobe of the right lung.
K. Impression/Diagnosis
Dr. San Jose, the patient’s attending physician, who diagnosed the disease as Pulmonary
tuberculosis. This diagnosis is supported by the pathognomonic signs that manifested by the patient. These
include intermittent fever in the afternoon, difficulty of breathing, coughing, weight loss and chest pain. This
diagnosis is supported by the following diagnostic exam such as Culture and Sensitivity of the sputum and
chest x-ray.
L. Course in the Ward
The patient was accompanied by her husband and her children. While waiting for the doctor, she was
placed in a wheel chair.
DATE MEDICAL PROCEDURES/ORDERS NURSING ASSESSMENT and FUNCTION
September 19, - History taking Upon admission:
2008 - Physical assessment -GCS E4 V5 M6
- Neurological Assessment - Vital signs BP- 90/70 mmHg, CR: 84 bpm, RR: 36
- Chest-x-ray cpm, T-31.5 C
- IVF of PNSS 1 liter 20 gtts/min to run for 12 hours. - IV insertion done at the right arm, infusing well.
- Medications -Due meds given
• Nausil 1 ampule TIV stat, then every 6 hours. - X-ray result obtained.
• B complex 2 ampules TIV stat - History taking
• Cefuroxime 500 mg/Cap - Physical assessment done
• Theophylline 1 cap TID - Neurologic assessment done
• Salbutamol and Guiafene Sin + tab TID PO -crackles noted upon auscultation.
- Diet as Tolerated with aspiration precaution. 2:40 AM
