Case Study Ptb

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Case Study Ptb

  1. 1. Pulmonary Tuberculosis Nursingcasestudy.blogspot.com
  2. 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. 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. 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.
  5. 5. E. Familial History Telesporo Eugenia Cia, 75 Chavez 65 Deceased Deceased Carlito, 75 Flusofi Junior, 44 Josephi Gaudiocio, Blencio, Litsilda, da, 48 Eufemia, ne, 42 40 38 50 46 PTB Arsenio, 50
  6. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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