CASE PRES - Q.I.

FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

NURSING PROCESS

SUBMITTED BY:

TABALNO, ELIZABETH S.TALAN, PRINCESS NEAH A.

BSN 134 – GROUP 134

SUBMITTED TO:

MR. LEONARDO DE GUZMAN III RN MANClinical Instructor

QUEZON INSTITUTE

SEPTEMBER 18, 2010

INTRODUCTION

This whole case study is about to discuss Pulmonary Tuberculosis (PTB). This

case will tackle about the disease, patient’s health, and nursing interventions.

Pulmonary tuberculosis is an infectious disease caused by slow- growing

bacteria that resembles a fungus, Myobacterium tuberculosis, which is usually spread

from person to person by droplet nuclei through the air. The lung is the usual infection

site but the disease can occur elsewhere in the body typically, the bacteria from lesion

(tubercle) in the alveoli. The lesion may heal, leaving scar tissue; may continue as an

active granuloma, heal, then reactivate or may progress to necrosis, liquefaction,

sloughing, and cavitation of lung tissue. The initial lesion may disseminate bacteria

directly to adjacent tissue, through the blood stream, the lymphatic system, or the

bronchi.

Most people who become infected do not develop clinical illness because the

body’s immune system brings the infection under control. However, the incidence of

tuberculosis (especially drug resistant varieties) is rising. Alcoholics, the homeless and

patients infected with the human immunodeficiency virus (HIV) are especially at risk.

Complications of tuberculosis include pneumonia, pleural effusion, and extrapulmonary

disease.

ANATOMY AND PHYSIOLOGY

Respiration is defined in two ways. In common usage, respiration refers to the

act of breathing, or inhaling and exhaling. Biologically speaking, respiration strictly

means the uptake of oxygen by an organism, its use in the tissues, and the release of

carbon dioxide. By either definition, respiration has two main functions: to supply the

cells of the body with the oxygen needed for metabolism and to remove carbon dioxide

formed as a waste product from metabolism. This lesson describes the components of

the upper respiratory tract.

The upper respiratory tract conducts air from outside the body to the lower

respiratory tract and helps protect the body from irritating substances. The upper

respiratory tract consists of the following structures:

The nasal cavity, the mouth, the pharynx, the epiglottis, the larynx, and the upper

trachea. The esophagus leads to the digestive tract.

One of the features of both the upper and lower respiratory tracts is the

mucociliary apparatus that protects the airways from irritating substances, and is

composed of the ciliated cells and mucus-producing glands in the nasal epithelium. The

glands produce a layer of mucus that traps unwanted particles as they are inhaled.

These are swept toward the posterior pharynx, from where they are swallowed, spat

out, sneezed, or blown out.

Air passes through each of the structures of the upper respiratory tract on its way

to the lower respiratory tract. When a person at rest inhales, air enters via the nose and

mouth. The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a

tube like structure that connects the back of the nasal cavity and mouth to the larynx, a

passageway for air, and the esophagus, a passageway for food. The pharynx serves as

a common hallway for the respiratory and digestive tracts, allowing both air and food to

pass through before entering the appropriate passageways.

The pharynx contains a specialized flap-like structure called the epiglottis that

lowers over the larynx to prevent the inhalation of food and liquid into the lower

respiratory tract.

The larynx, or voice box, is a unique structure that contains the vocal cords,

which are essential for human speech. Small and triangular in shape, the larynx extends

from the epiglottis to the trachea. The larynx helps control movement of the epiglottis. In

addition, the larynx has specialized muscular folds that close it off and also prevent

food, foreign objects, and secretions such as saliva from entering the lower respiratory

tract.

I. Biographic Data

Name: J. O. Gender: MaleAddress: #120 Ilang – Ilang St., Upang, Antipolo CityDate of Birth: December 31, 1962Place of Birth: AntiqueAge: 47 years oldMarital Status: MarriedName of Spouse: Rowena ObacReligion: Roman CatholicOccupation: Construction WorkerRoom and Bed #: 2BE – D12Chief Complaint: HemoptysisDiagnosis: Pulmonary TuberculosisAttending Physician: Dr. Arnold Ortiz

II. Nursing History

A. Past Health History

During his childhood, the patient doesn’t remember having any illness aside from fever and colds. The patient stated that he can’t remember anything about his immunization because he is young that time but according to him, he has an incomplete immunization. The patient has no known allergy. According to the patient, he had an accident and got an operation on his left hand last March 2009 because he was hit by broken bottle of perfume. According to the patient, he has not left the country during the past years.

B. Present Health History

The patient was admitted last September 10, 2010 with a chief complaint of Hemoptysis. Prior to admission, the client had a massive hemoptysis with chronic productive cough and yellowish phlegm. He was diagnosed to have Pulmonary Tuberculosis. “Nagtatabas kasi ako ng tiles, yun ang trabaho ko sa construction, hindi ko maiwasang malanghap yung dumi galing dito kaya ko daw nakuha ang sakit kong ito,” as verbalized by the client. “Nung pagkauwi ko ng bahay nung huwebes, uminom ako ng tubig tapos nasamid ako, bigla akong sumuka ng madame, akala ko tubig lang tsaka yung kinain ko yun pala may kasama ng dugo”, the patient added. “Tatlong hospital na ang pinagpa check-up-an ko, pare-pareho ang resulta, TB nga raw. Sabi nung isang doktor pumunta daw ako dito kaya dumiretso kami dito”, as verbalized by the patient.

C. Family History

The patient’s father and mother are both dead. The client stated that his

family has no herodofamilial diseases. According to the patient he is the only member of the family who has Pulmonary Tuberculosis due to his current occupation which is a construction worker.

III. Patterns of Functioning

A. Psychological Health

The patient’s education attainment is elementary undergrad, he only finished grade three. The patient verbalized that he is able to read and write. The patient added that he has difficulty in reading because of his poor eye sight. According to the client, he doesn’t have experience any change in smell, taste, touch and memory but sometimes he has difficulty in remembering things.

The client rates his health before as 8/10 because according to him he doesn’t easily get sick and can still perform daily activities but because of his current condition, the client rates his health as 5/10. According to the client, a healthy person eats three times a day, able to perform tasks of daily living without difficulty, and has no vices. The patient eats three times a day. He eats together with his co-worker during lunch and together with his family during breakfast and dinner. According to the client, the usual foods that they are eating are rice, vegetable, fish, and meat. According to the client he drinks a lot of water, he can consume 1 gallon per day of water. But when the patient admitted to the hospital, he said that he begins to lack his appetite and begins to loss some weight. “Wala akong ganang kumain dito dahil naninibago ako”, as verbalized by the patient. “Tsaka iba yung pagkain dito kumpara yung mga kinakain ko sa bahay”, added by the patient. “Grabe, sobra na nga ang ipinayat ko eh, hindi naman ako ganito kapayat dati para na nga akong buto’t balat”, patient verbalized. The client does not have a routine of physical examination because he and his family are not used to have a physical examination. The client also stated that he only visit the doctor when he is sick and he also added that sometimes instead of going to the doctor, he will consult to an “albularyo” or a quack doctor. His hygienic practices include bathing, washing hands, trimming nails, brushing teeth, and wearing slippers. “Pero ngayon yung mga dating nagagawa ko sa bahay di ko dito magawa kahit magtootbrush, lalo na ang pagligo dahil nanghihina ako”, as verbalized by the patient. “Buti na nga lang at nandiyan yung anak ko para pag may kailangan ako eh matutulangan niya ko kasi kung minsan kahit sa pag-ihi nahihirapan akong tumayo dahil hinang-hina ako”, added by the patient. The patient said that he smokes and drinks alcohol when he was not yet hospitalized. He consumes 5-7 sticks of cigarettes per day. The patient also said that he is not aware of the consequences he can get from smoking and drinking alcohol. “Masarap kasi pag umiinom at nagyoyosi, kahit papano nawawala yung problema ko tsaka natural naman sa mga lalake ang

may bisyo”, as verbalized by the patient. According to the patient there is an adequate lighting, space, water supply and ventilation in their home. The patient said that their house is just enough for his family. The patient also added that there are some vectors present in their home like mosquitoes and cockroaches. The patient is a construction worker in Sta. Mesa. He works 6 times a week and has a weekly salary of P2700 which is enough for his family.

The client defecates two to three times a day. The color of his stool is dark brown and has an aromatic odor. No recent environmental changes the client has undergone in his defecation pattern. The client voids at least three times a day. The color of his urine is color light yellow and has no odor. The client does not have any discomfort/ pain in his voiding activity and has no problem in controlling it.

Before hospitalization, the client sleeps for about 5 to 7 hours and takes naps. The usual time he’s going to sleep is about 9 to 10 in the evening, and he wakes up 4 or 5 in the morning. The patient takes nap every afternoon after lunchtime or during their break time in his work. According to the patient, he is satisfied with his sleep and rest; he doesn’t have any problems in regards to it. But when he was admitted to the hospital, the patient has only minimal time of sleeping because according to him, he is not comfortable in sleeping in the hospital together with other patients and he is easily disturbed by the noises of other patients. “Hindi ako makatulog ng maayos dito kasi yung iba ang ingay, ubo ng ubo”, verbalized by the patient. “Tsaka naninibago ako kasi ako yung tao na hindi nakakatulog kapag wala ako sa sarili kong kwarto”, he added.

According to the client, the language that he is using when he is at home, at work and with his friends is Tagalog. He communicates with his family and friends by talking and listening to them. His language is understandable, clear tone, exhibits thoughts, has logical sequence, makes sense and has sense of reality. The client describes himself as someone who is humble, caring and joyful. He stated that he does not have any physical defects. He is comfortable with the gender that he belongs because he can express himself and can relate with the same gender. The client has no problem or difficulty with his gender.

B. Socio-Cultural Patterns

The patient is already married. According to the patient, he is happy about his family. He has four children, 2 boys and 2 girls. The eldest is Rosel (20 y/o), the second is Jerwin (18 y/o), third is Jerome (15 y/o) and the youngest is Rolly (12 y/o). The patient said that he has a good relationship to his family, both to his wife and children. The patient is a construction worker in Sta. Mesa. He works 6

times a week and has a weekly salary of P2700 which is enough for his family. He’s wife only stays at home; she is the one taking care of their youngest child.

The client form of exercise is his work which is in a construction site. The client’s usual hobby is to watch television when he has no work. “Sa trabaho nauubos ang oras ko sa buong araw at kapag wala naman akong trabaho tumutulong ako sa pagtitinda kasama ang asawa ko,” as verbalized by the client. Before being diagnosed he has sufficient energy for completing a desired required activity. Most of the time the patient feels easily tired but immediately restores after resting. There is a sudden weight loss of the client after he was diagnosed to have PTB. He had a productive cough and frequently experience chest pain due to the dust that he inhales in the construction site. “Nahihirapan ako huminga talaga dahil sa plema, sobrang makapit at kung minsan ang hirap pa ilabas”, as verbalized by the patient.

According to the patient, their family is not having any major problems because they are not taking life seriously, they are always happy. The patient added that if they are having financial problem, they are getting money from 5-6. In his current condition, the patient said that they do not consider it as a major problem because according to him he will just be okay and will go out soon.

C. Spiritual Patterns

The patient’s religion is Roman Catholic. The patient goes to church every Sunday for a mass together with his family but sometimes he is just alone. The patient stated that it’s really important to maintain one’s health. According to the patient, his family doesn’t have any health beliefs and practices. The patient also stated that the most important person in his life is God, his family, and friends. The client sees himself in society as an individual that has a societal role to be done. According to the patient, an individual can be consider as a healthy person when he has the ability to carry out daily tasks; ability to interact successfully with people and within the environment; ability to manage stress and to express emotion appropriately; ability to learn and use information effectively for personal, family, and career development; ability to have owns moral, values, and ethics; ability to achieve a balance between work and leisure time and lastly the ability to promote health measures that improve the standard of living and quality of life in the community.

IV. Activities of daily living

ADL Before Hospitalization

During Hospitalization

Interpretation and Analysis

1. Nutrition The client eats home prepared foods and has a healthy appetite when eating at home.

The client’s diet changed due to his hospitalization; he has a disturb taste perception that leads to lack of appetite and does not eat the usual amount of food that he eats before because of the change in his environment.

The effects of drugs and hospitalization on nutrition vary considerably. They may alter appetite, disturb taste perception or interfere with nutrient absorption or excretion.

Kozier & Erbs Fundamentals of Nursing, 8th Edition, Volume two (pg. 1238)

2. Elimination The client voids at least three times a day and defecates two to three times a day.

There are few changes on the client’s defecation pattern and urination because of the presence of dirty CR on the hospital where he is staying.

Hospitalized clients may suppress the urge because of embarrassment about using a bedpan, because of lack of privacy or because defecation is too uncomfortable.


3. Exercise The client’s form of exercise is his work which is in a construction site.

The client no longer has any exercise because he is always on bed and

Many external factors affect a person’s mobility.

resting. He appears to be restless and according to the patient he can’t move because of body weakness.


4. Hygiene He takes a bath and does his hygienic routines every day.

The client’s hygienic practices is also affected by his hospitalization because he cannot do all of his hygienic routines every day.

Hygiene is a highly personal matter determined by individual values and practices.

Kozier & Erbs Fundamentals of Nursing, 8th Edition, Volume one (pg. 742)

5. Substance Use

He doesn’t use any substances like drugs, but smokes and drinks alcohol.

The patient is unable to smoke and drinks alcohol because of his hospitalization.

Addiction or physical or psychologic dependence on a substance, is related to properties of the substance, the individual user and the social network of the individual.

Kozier & Erbs Fundamentals of Nursing, 8th Edition, Volume one (pg. 396)

6. Sleep and Rest

He usually sleeps for 5 to 7 hours every day without disturbances.

He is now having sleep disturbances especially now that there are changes in his environment.

Hospital environments can be quite noisy and special care needs to be taken to reduce noise in the hallways and nursing care units.

Kozier & Erbs

Fundamentals of Nursing, 8th Edition, Volume two (pg. 1170)

V. PHYSICAL ASSESSMENT:

NORMS ACUTE FINDINGS INTERPRETATION AND ANALYSIS

General Appearance

1. Posture/Gait Relaxed, erect posture; coordinated movement; bouncy purposeful walk

Slouchy; less purposeful posture

Depressed or tired people are more likely to slouch. A less purposeful, shuffling gait often means the person is sad or discouraged. Certain gaits are associated with illness.Ref: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page 449)

2. Skin color Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive

Deep brown Skin color varies among races and individuals. Ref: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page 572)

3. Personal Hygiene/ Grooming

Clean, neat The client, upon inspection is clean and neat.

Within normal

4. Age appropriateness

Age is appropriate Age is appropriate Within normal

5. Verbal behavior Able to interpret their feelings or emotions by means of talking or saying words with simplicity, clarity, timing and relevance

answers to questions properly

Within Normal

6. Non-verbal behavior

Able to interpret their feelings or emotions by means of posture, gait, facial expressions, and gestures

Able to interpret their feelings or emotions by means of posture, gait, facial expressions, and gestures

Within normal

Measurements1. Temperature 36.5-37.5˚C 36.9˚C Within normal2. Pulse Rate 60-100 bpm 91 bpm Within normal3. Respiratory Rate 12-20 cpm 25 cpm Increased respirations

can be associated with illness

Ref: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page 570)

4. Blood Pressure 120/60 mmHg 110/70 mmHg Within normal5. Weight 52-58 kilos

(medium frame)44 kilos Weight is lower

compared to the normal weight of a 5’4” medium frame adult (male) which is 52-58 kilosRef: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page 573)

6. Height 5’4 ½ Within normal7. BMI 18.5 – 24.9 16.4 Underweight

AREA TO BE ASSESSED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION AND ANALYSIS

I. APPEARANCE AND MENTAL STATUSA. Body built, height, and weight (in relation to client’s age, lifestyle, and health)

Proportionate, varies with lifestyle

Body build is proportionate to age and lifestyle, stands 163 cm. and weighs 44 kilos

Within normal(Kozier and Erbs. Fundamentals of Nursing. 8th ed. p. 572)

B. posture and gait, standing, sitting, and walking

Relaxed, erect posture; coordinated movement

Slouchy, not coordinated movements, less purposeful posture

Depressed or tired people are more likely to slouch. A less purposeful, shuffling gait often means the person is sad or discouraged. Certain gaits are associated with illness.Ref: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page 449)

C. Over all hygiene and grooming

Clean, neat The client, upon inspection is clean and neat.

Within normal Ref: Fundamentals of Nursing, 8th edition by Kozier and Erb’s (page 462)

D. Body and breath odor No body odor or minor odor relative to work or exercise; no breath odor

Free from any foul body and breath odor

Within normal(Kozier and Erbs. Fundamentals of Nursing. 8th ed. p. 572.)

E. Signs of distress (in posture or facial expression)

No distress noted No distress noted Within normal

F. Obvious signs of health or illness

Healthy appearance Appears not healthy Illness can cause some alteration in general physical appearance. Ref: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page 449)

G. Attitude Cooperative Cooperative Within normal

H. Affect/mood (appropriateness of client’s response)

Appropriate to situation Responds to questions appropriately, correctly and relevantly

Within normal

I. Quantity and quality of speech

Understandable, moderate pace; exhibits thought association

Speech is soft but understandable and at a normal pace

Within normal

J. Relevance and organization of thoughts

Logical sequence; makes sense; has sense of reality

Answers make sense and in order

Within normal

II. INTEGUMENTARYA. SKIN1. Skin color Varies from light to deep

brown; from ruddy pink to light pink; from yellow overtones to olive

Skin color is dark brown Within normal. Skin color varies among races and individuals. Ref: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page 572)(Kozier and Erbs. Fundamentals of Nursing. 8th ed. p. 579.)

2.) Uniformity of skin color

Generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) in dark-skinned people

Evenly dark throughout the body except those areas being exposed to the sunlight

Within normal

3.) Presence of edema No edema Absence of edema or swelling

Within normal

4.) Existence of lesions Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions

The client has a scar on left arm.

Within normal

5.) Skin moisture Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temperature, and activity)

Dampness in skin folds such as in the areas of armpit ,palms of the hands, inguinal area, arms and legs

Within normal

B. NAILS

1.) Fingernail plate shape (its curvature and angle)

Convex curvature; angle of nail plate about 160°

Has a convex curvature of 160 degrees

Within normal(Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 583-584.)

2.) Fingernail and toenail Highly vascular and pink in light-skinned clients; dark-

Has brownish pigmentation Dark-skinned clients may have brown or black

bed color skinned clients may have brown or black pigmentation in longitudinal streaks

pigmentation in longitudinal streaks (Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 583-584.)

3.) Fingernail and toenail texture

Smooth texture Slightly thick Nail grows more slowly and thicken in elderly. (Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 583-584.)

4.) Presence of tissues surrounding nails

Intact epidermis Unimpaired cuticle; presence of tissues that are intact


III. HEADA. SKULL1.) Size, shape and symmetry of the skull

Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour

Normocephalic or rounded, is symmetrical, has smooth skull contour and is proportionate to the body


2.) Presence of nodules, masses, and depressions

Smooth, uniform consistence; absence of nodules or masses

No palpable nodules, messes or depressions, is smooth and uniform


B. SCALP1.) Inspect for color and appearance

Lighter than skin color Color is lighter than the skin; presence of dandruff

Dandruff is a condition characterized by itching and flaking of the scalp and may be complicated by the embarrassment it causes. Persistent, severe causes usually require medical attention, but daily brushing and shampooing with a medicated shampoo may be all that is needed to keep the scalp free of dandruff.Ref: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page 1014)

2.) Palpate for areas of tenderness

No tenderness Not tender Within normal (Kozier and Erbs. Fundamentals of Nursing. 8th ed. p. 585.)

C. HAIR1.) Evenness of growth, thickness, or thinness of hair

Evenly distributed and covers the whole scalp; maybe thick or thin

Curly; Uniformly distributed;

Within normal(Kozier and Erbs. Fundamentals of Nursing.

8th ed. p. 585.)

2.) Texture and oiliness over the scalp

Silky; resilient hair Silky; resilient hair Within normal(Kozier and Erbs. Fundamentals of Nursing. 8th ed. p. 585.)

D. FACEFacial features, symmetry of facial movements

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

Proportionate facial movements; symmetric nasolabial folds


IV. EYESA. EYEBROWSHair distribution, alignment, skin quality and movement

Symmetrical and in line with each other; maybe black, brown or blond depending on race, evenly distributed

Black; evenly distributed; symmetrically aligned


B. EYELASHESEvenness of distribution and direction of curl

Evenly distributed; turned outward

Evenly distributed; has a long, thick and slightly curled outward


V. EARSA. AURICLES1.) Color, symmetry of size, and position

Color same as facial skin; symmetrical; auricle aligned with outer canthus of the eye, about 10 degrees from vertical

Light in color same as the facial skin tone; symmetrical; auricle is leveled or aligned with the outer canthus of the eye


2.) Texture, elasticity and areas of tenderness

Mobile, firm, and not tender; pinna recoils after it is folded

Elastic, firm, not tender, pinna moves back after it was folded


VI. NOSE1.) Any deviations in shape, size, or color and flaring or discharge from nares

Symmetric and straight; no discharge or flaring; uniform color

Symmetric and straight; no discharge of flaring, uniform in color


2.) Presence of redness, swelling, growths and discharge of the nasal cavities

Mucosa pink; clear, watery discharge; no lesions

Mucosa is pinkish in color; clear; watery discharge and absence of lesions


3.) Nasal septum (between the nasal chambers)

Nasal septum intact and in midline

Nasal septum is intact and in midline alignment


X. THORAXA. POSTERIOR THORAX1.) Shape, symmetry, and comparison of anteroposterior thorax to transverse diameter

Anteroposterior to transverse diameter in ratio 1:2; chest symmetric

The chest is symmetry having a ratio of 1:2


2.) Spinal alignment Spine vertically aligned The spine alignment is straight or vertical

Within normal(Kozier and Erbs.

Fundamentals of Nursing. 8th ed. pp. 614-618.)

3.) Temperature, tenderness, and masses

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

There is no tenderness or masses upon doing the palpation; intact skin; even temperature on the posterior thorax


4.) Respiratory excursion assessment

Full and symmetric chest expansion

Restricted excursion Restricted excursion is associated with lung disorder(Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 614-618.)

6.) Posterior thorax percussion

Percussion notes resonate except over scapula; lowest point of resonance is at the diaphragm; percussion on a rib normally elicits dullness

Hyperresonance Hyperresonance may be associated with lung disorder(Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 614-618.)

7.) Posterior thorax auscultation

Vesicular and bronchovesicular breath sounds

Crackles and wheezes noted

Adventitious breath sound is associated with lung problem.Ref:Smeltzer, S., Bare, B. (2004). Medical-Surgical Nursing (10th ed.). Lippincott-Raven Publisher

B. ANTERIOR THORAX1.) Breathing patterns Quiet, rhythmic, and

effortless respirationsDyspnea noted Within normal

Ref:Smeltzer, S., Bare, B. (2004). Medical-Surgical Nursing (10th ed.). Lippincott-Raven Publisher

2.) Temperature, tenderness, masses

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

Skin is intact as well as in the chest wall; there is even temperature; no tenderness or masses noted upon palpation


3.) Respiratory excursion assessment

Full symmetric excursion; thumbs normally separate 3-5 cm

Fully symmetric; the thumbs normally separate and move outward and inward when the client asked to breath in and out; thumbs separate 4 cm


4.) Vocal fremitus palpation

Bilateral symmetry of vocal fremitus; fremitus is normally decreased over heart and breast tissue

The vocal fremitus is symmetrically bilateral but the fremitus usually decreased upon reaching the heart and the breast tissue


5.) Anterior thorax percussion

Percussion notes resonate down to the sixth rib at the

Flat sound is heard on the areas of heavy muscle and

Within normal(Kozier and Erbs.

level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over heart and the liver, and tympanic over the underlying stomach

bone; while resonance is heard down to the diaphragm; dull sound on the areas of the heart and liver and tympanic sound on the stomach or epigastric area

Fundamentals of Nursing. 8th ed. pp. 614-618.)

6.) Trachea auscultation Bronchial and tubular breath sounds


Adventitious breath sound is associated with lung disease.(Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 614-618.)

7.) Anterior thorax auscultation

Bronchovesicular and vesicular breath sounds


Adventitious breath sound is associated with lung disease.Ref:Smeltzer, S., Bare, B. (2004). Medical-Surgical Nursing (10th ed.). Lippincott-Raven Publisher

XI. CARDIOVASCULARA. AORTIC AND PULMONIC AREAS

No pulsations No pulse Within normal(Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 621-623.)

B. TRICUSPID AREA No pulsations; no lift or heaves

There is no pulsations, lift or heave


C. APICAL AREA Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL

There is visible pulsations specially on the point of maximal impulse in 5th LICS at or medial to MCL


D. EPIGASTRIC AREA Aortic pulsations Presence of aortic pulsations


E. CARDIOVASCULAR AREAS AUSCULTATION

S1: Usually heard at all sitesUsually louder at the apical areaS2: Usually heard at all sitesUsually louder at the base of the heartSystole: silent interval; slightly shorter duration than diastole at normal heart rate ( 60-90 beats/minute)Diastole: silent interval; slightly longer duration than systole at normal heart rates

S1: usually louder at the apical area and can be heard at all sitesS2: louder at the base of the heartSystole: silent interval and shorter duration than diastole at normal heart rateDiastole: silent interval; slightly longer duration than systole at normal heart rates S3: in client


S3: in children and young adultsS4: in many other adults

XV. ABDOMEN1.) Skin integrity Unblemished skin; uniform

colorNo blemishes; there is evenness in color


2.) Abdominal contour Flat, rounded (convex), or scaphoid (concave)

Slight deformity of abdomen

Due to incomplete uterine involution(Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 633-638.)

3.) Enlargement of liver or spleen

No evidence of enlargement of liver or spleen

There is no signs of an enlarged liver or spleen


4.) Symmetry of contour Symmetric contour Contour is symmetric Within normal(Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 633-638.)

5.) Abdominal movements associated with respirations, peristalsis or aortic pulsations

Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin persons at epigastric area

There is symmetry in movements due to respiration


6.) Vascular pattern No visible vascular pattern Absence of vascular pattern


7.) Bowel sounds, vascular sounds, and peritoneal friction rubs

Audible bowel sounds; absence of arterial bruits; absence of friction rub

Audible bowel sounds; absence of arterial bruits; absence of friction rub

Within normal (Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 633-638.)

8.) Several abdominal areas of the four quadrants

Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder

Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder


9.) Light palpation in the four quadrants

No tenderness,; relaxed abdomen with smooth, consistent tension

No tenderness; relaxed abdomen with smooth, consistent tension


XVI. MUSCULOSKELETAL SYSTEMA. MUSCLES1.) Muscle size and comparison on the other side

Proportionate to the body; even in both sides

Both sides are proportional to the body


2.) Contractures in the muscles and tendons

No contractures No contractures Within normalRef: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page

599)3.) Muscle tonicity Even and firm muscle tone Even and firm muscle tone Within normal

Ref: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page 599)

4.) Muscle strength 100% muscle strength Decreased muscle strength Decreased muscle strength may be associated with illnessRef: Fundamentals of Nursing, 5th edition by Carol Taylor; et al. (page 599)

B. BONES1.) Normal structures and deformities in the skeleton

No deformities No deformities noted in the skeleton


2.) Areas of edema or tenderness in the bones

Absence of edema or tenderness in bones

No edema or tenderness Within normal(Kozier and Erbs. Fundamentals of Nursing. 8th ed. pp. 640-641.)

C. JOINTS1.) Joint swelling No joint swelling, no

warmth, rednessAbsence of swelling and redness, and warmth


2.) Tenderness, smoothness of movement, swelling, crepitation, and presence of nodules

No tenderness, swelling, and nodules; smooth movements; minimal crepitus may be present but there should be no pronounced crepitation

No tenderness; swelling or nodules; has smooth movements; no crepitation and nodules


VI. Laboratory and Diagnostic Examination Results

Date Procedure Norms Result Interpretation and Analysis

September 13, 2010

URINALYSIS

Color Clear to Yellow

Yellow Normal. The patient’s urine color is yellow because he is drinking multivitamins.

Transparency Clear Slightly Turbid Deviation from normal. Cloudy urine or urine with a high level of sediment may be present in cases of urinary tract infection. The patient may be at risk of having a urinary tract infection.

Microscopic Exam

Red cells 0-3/HPF 3-4/HPF Deviation from normal. When a level of more than 3 RBC's are found, a disease condition is often present. One of the most common causes of RBC's in the urine is infection or inflammation of the urinary tract itself (i.e., cystitis). Trauma and several other conditions may also cause bleeding into the urine. This means that the patient may be at risk of having a urinary tract

infection. Pus cells Negative 1-2/HPF Deviation from

normal. When the WBC count in urine is high, it means that there is inflammation in the urinary tract or kidneys. This means that the patient may be at risk of having a urinary tract infection.

HEMATOLOGY

Hemoglobin Male: 140-180 g/L

126 g/L Less than normal. Low hemoglobin indicates anemia, severe hemorrhage hemolysis, cancer, kidney disease, and splenomegaly. This is because the patient is suffering from hemoptysis, and it may indicate that the patient may be at risk of having the said diseases.

Hematocrit 0.42-0.54 0.33Less than normal. A low hematocrit indicates anemia, hemorrhage, and leukemia. This is because

the patient is suffering from hemoptysis, and it may indicate that the patient may be at risk of having the said diseases.

Neutrophils 0.40-0.60 0.70 Above normal. High levels may indicate an active infection. This means that the patient may be at risk of having an infection or he has already an infection.

SPUTUM EXAMAppearance Absence of

bloodBloodstained Deviation from

normal. The sputum of the patient is stained with blood because the patient is suffering from hemoptysis so he is coughing up of blood.

Acid fast bacilli stain: (direct

smear)

Negative 1+ Deviation from normal. The sputum of the client is positive with acid fast bacilli.

FASTING BLOOD SUGAR

EXAM4.2-6.2 mmol/l 4.3 mmol/l Within normal.

VII. Medications

Generic/Trade Name

Dosage/ Frequenc

y

Classifi-cation

Indication Contra-indication

Side Effects Nursing Responsi-

bilitiesTrane-xamic acid (Hemos-tan)

500 mg 1 ampule IV

Cardio-vascular drugs

Control of hemorrhage in surgical and clinical cases. Hemostasis in traumatic injuries, post- extraction and other dental procedures.

Severe renal insufficiency. Patients with microscopic hematuria. Hypersensitivity to tranexamic acid.

GI disturbance, giddiness, hypotension, color vision disturbance.

Store the drug at room temperature away from sunlight and moisture.

Instruct the patient not to share the medication with others.

Instruct the patient that if he miss a dose, use it as soon as he remem-ber.

Cefuro-xime

750 mg every 8 hours

Anti-infective/ Antibiotic

Treatment of lower respiratory infections caused by strepto-coccus pneumoniae

Hypersensitivity to cephalos-porin.

Nausea, vomiting, headache, dizziness, lethargy

Give oral drug with food to decrease GI upset

Have Vit. K available in case hypo thrombi-nemia occurs

Discontinue if hyper-sensitivity reaction occurs

Instruct the patient to swallow the tablet whole, do not crust it

Instruct the patient some of it’s side effects

Multivitamins + Amino acid (Moriamin Forte) / Calcium Pantothenic

1 capsule OD

Multivitamins

Health maintenance for fatigue, decline in energy. Protein and vitamin deficiencies, malnutrition, adjuvant in the therapy of TB.

Hypersensitivity and malabsorption syndrome

Assess patient for signs of vitamin defi-ciency before and periodi-cally through-outtherapy. Assess nutritional status through 24 h diet recall. Determine frequency of consumption of vit rich foods

Butamirate citrate / Sinecod novartis or forte

1 tablet TID

Anti-cough

Acute cough due to variety of causes, especially dry cough, suppression of preoperative and postoperative cough in surgery and bronchoscopy. whooping cough.

Hypersensitivitv to Butamirate citrate or any of it is ingredients

Rash, nausea, diarrhea, vertigo

Instruct the patient that if the cough lasts for more than 7 days, ask a doctor for advice.

Instruct the patient about the side effects that he may experience while taking the drug.

X. Prioritized List of Nursing Problems

CUES NURSING DIAGNOSIS

RANK JUSTIFICATION

Subjective: The patients

chief complain is massive hemoptysis with chronic productive cough and yellowish phlegm

Exposure to dust due to his occupation which is a construction worker.

“Nagtatabas kasi ako ng tiles, yun ang trabaho ko sa construction, hindi ko maiwasang malanghap yung dumi galing dito kaya ko daw nakuha ang sakit kong ito,” as verbalized by the client.

“Nahihirapan ako huminga talaga dahil sa plema, sobrang makapit at kung minsan ang hirap pa ilabas”, as verbalized by the patient.

Ineffective Breathing Pattern related to decrease lung capacity

2 This is an actual, health-threatening problem. The client does not recognize this as an urgent problem that is requiring immediate intervention but considered this next to his priorities since it involves his breathing.

Discussion of this problem with the client requires a short period of time. Aside from educating the client regarding measures on how to attain or to have an effective breathing pattern, it is also required for the health care provider to evaluate whether the client has been applying his acquired knowledge into action. Thus, monitoring follows. The client has no knowledge about the measures or techniques need to be done to relieve his difficulty of breathing while the health care provider has adequate knowledge to address this problem. The health care provider is patient enough to help the patient know the different

Objective: + cough + DOB + Dyspnea Weak looking Restlessness

Measurement:Vital signs: BP- 110/70 mmHgTemp- 36.9CRR- 25 cpmPR- 91 bpm

measures/interventions needed to improve his breathing pattern. Financial resource of the client is not required. Assistance of the client’s partner to monitor and assist the patient may be required. Resolution of this problem may prevent or may help to solve the other identified problems.

Subjective: The patient’s

education attainment is elementary undergrad, he only finished grade three.

The patient said that he smokes and drinks alcohol when he was not yet hospitalized. He consumes 5-7 sticks of cigarettes per day. The patient also said that he is not aware of the consequences he can get from smoking and drinking alcohol.

“Masarap kasi pag umiinom at nagyoyosi, kahit papano

Knowledge Deficit about his condition prognosis and complications related to lack of information

7 Whenever the diagnostic label Deficient Knowledge is used, either the client is seeking health information or the nurse has identified a learning need.

nawawala yung problema ko tsaka natural naman sa mga lalake ang may bisyo”, as verbalized by the patient.

Objective: Lack of source

of information Frequent

questioning about his condition

Coughing without covering his mouth

Subjective: The patient chief

complain is massive hemoptysis with chronic productive cough and yellowish phlegm


Objective: Weak looking Restlessness Pale looking + cough

Ineffective Airway Clearance related to excessive mucus secretion as manifested by cough and presence of sputum

1 This is an actual problem which is according to Maslow’s Hierarchy Theory of Needs belonged to the physiologic needs specifically airway. This is health threatening because it involves the airway of the patient which is vital for life survival. The client wishes to prioritize this problem first rather than anything else identified. Resolution of this problem will facilitate readiness for learning to other health problems. This may also answer the client’s problem regarding to ineffective breathing pattern and other identified problems.

+ DOB Use of

accessory muscle while coughing

+ Yellowish phlegm

+ wheezes and crackles upon auscultation

Measurements:Vital signs:BP- 110/70 mmHgTemp- 36.9CRR- 25 cpmPR- 91 bpm

The client has insufficient knowledge of health maintenance while the health care provider has adequate knowledge that may address this problem. The client exhibits a little of health-seeking behavior while the health care provider is patient enough to teach and guide the client towards wellness.

There will be no other human resources that will be needed except for the health care provider and the client. For assistance and support, any member of the family may be included. Financial resources to sustain for medicines and compliance to some other health practices are also required. Discussing this problem to the client does not require too much of her time. However, a comfortable and well-ventilated place / area where the interventions / discussions will be done should be available. Usage of other resources such as visual aids and recreational materials are up to the health care provider’s preference. Visual

aids, and other teaching equipments / orientation should be done in appropriate with the client’s development and situation.

Subjective: “Yung mga

dating nagagawa ko sa bahay di ko dito magawa kahit magtootbrush, lalo na ang pagligo dahil nanghihina ako”, as verbalized by the patient.

“Buti na nga lang at nandiyan yung anak ko para pag may kailangan ako eh matutulangan niya ko kasi kung minsan kahit sa pag-ihi nahihirapan akong tumayo dahil hinang-hina ako”, added by the patient.

Objective: Weak looking Unable to stand Assisted by his

son Dirty nails on

fingers and toes Not well-

groomed Dirty physical

appearance

Self care deficit related to body weakness

6 Muscle disused associated with prolonged bed rest can contribute to complications of immobility like unable to manage one’s own self. An important aspect of care is the prevention of these complications.

Subjective: The client rates

his health as 5/10.

“Nung pagkauwi ko ng bahay nung huwebes, uminom ako ng tubig tapos nasamid ako, bigla akong sumuka ng madame, akala ko tubig lang tsaka yung kinain ko yun pala may kasama ng dugo”, the patient added.

“Wala akong ganang kumain dito dahil naninibago ako”, as verbalized by the patient

“Tsaka iba yung pagkain dito kumpara yung mga kinakain ko sa bahay”, added by the patient.

“Grabe, sobra na nga ang ipinayat ko eh, hindi naman ako ganito kapayat dati para na nga akong buto’t balat”, patient verbalized.

Altered Nutrition: less than body requirement related to loss of appetite as manifested by loss of weight

3 This is an actual, health-threatening problem. The client does not recognize this as an urgent problem that is requiring immediate intervention but considered this third to his priorities since it involves the patient’s nutrition.Discussion of this problem with the client requires a short period of time. Aside from educating the client regarding measures on how to attain a balanced nutrition, it is also required for the health care provider to evaluate whether the client has been applying his knowledge into action. Thus, monitoring follows. The client has no knowledge about the measures on how to attain balanced nutrition while the health care provider has adequate knowledge to address this problem. The health care provider is patient enough to help the patient know the different measures/interventions needed. Financial resource of the client is maybe required especially in meal

Objective: Small body

frame Weak looking Pale conjunctiva

and mucous membrane

Dry skin Evidence of lack

of available food

Measurement:Weight: 44 kgHeight: 5’4 1/2BMI: 16.4

planning of nutritious foods needed for his condition. Assistance of the client’s partner to monitor and assist the patient may be required.

Subjective: When he was

admitted to the hospital, the patient has only minimal time of sleeping because according to him, he is not comfortable in sleeping in the hospital together with other patients and he is easily disturbed by the noises of other patients.

“Hindi ako makatulog ng maayos dito kasi yung iba ang ingay, ubo ng ubo”, verbalized by the patient.

“Tsaka naninibago ako kasi ako yung tao na hindi

Sleep disturbance related to change in the environment

4 Multiple factors contribute to sleep deprivation, including noise level. Studies have shown by the World Health Organization that when men were deprived of sleep, the experience major imbalances in carbohydrate metabolism and hormone levels. The researchers concluded that lack of sleep has an effect similar to an accelerated aging process.

nakakatulog kapag wala ako sa sarili kong kwarto”, he added.

Objective: Presence of

dark circles around the eyes or eye bags

Weak looking Restlessness The patient is

yawning A little bit

irritable

Subjective: “Yung mga

dating nagagawa ko sa bahay di ko dito magawa kahit magtootbrush, lalo na ang pagligo dahil nanghihina ako”, as verbalized by the patient.

“Buti na nga lang at nandiyan yung anak ko para pag may kailangan ako eh matutulangan niya ko kasi kung minsan kahit sa pag-ihi nahihirapan akong tumayo dahil hinang-hina ako”, added by the patient.

Activity intolerance related to body weakness

5 Muscle disused associated with prolonged bed rest can contribute to complications of immobility. An important aspect of care is the prevention of these complications

Objective: Weak looking Unable to stand Assisted by his

mother Anxious

behavior Pessimistic

XI. Nursing Care Plan

Cues Nursing Diagnosis

Health Implication

Goal & Objective

Intervention Rationale Evaluation

Subjective: The

patient chief complain is massive hemop-tysis with chronic productive cough and yellowish phlegm

“Nahihirapan ako huminga talaga dahil sa plema, sobrang makapit at kung minsan ang hirap pa

Ineffective airway clearance related to excessive mucus secretion as manifested by cough and presence of sputum

Pulmonary tuberculosis is an infectious disease caused by slow- growing bacteria that resembles a fungus, Myo-bacterium tuberculosis, which is usually spread from person to person by droplet nuclei through the air. The lung is the usual

Goal:By September 19, 2010 the client will be able to have an effective airway clearance.

Objectives:After 1 hour of nursing interven-tion, the client will be able to:

have a clear airway clearance and able to exhibit

Adminis-tered medication, oxygen and suction if needed as

Oxygen will help to relieve respiratory distress.REF:Nursin

After the nursing intervention, the client was able to have an effective airway clearance as manifested by normal RR, absence of pallor and cyanosis, and clear lungs upon auscultation.

ilabas”, as verbalized by the patient.

Objective: Weak

looking Restless

ness Pale

looking + cough + DOB Use of

accessory muscle while coughing

+ Yellowish phlegm

+ wheezes and crackles upon auscultation

Measurements:Vital signs:BP- 110/70 mmHgTemp - 36.9CRR- 25 bpmPR- 91 cpm

infection site but the disease can occur elsewhere in the body. Typically, the bacteria from lesion (tubercle) in the alveoli. The lesion may heal, leaving scar tissue; may continue as an active granuloma, heal, then reactivate or may progress to necrosis, liquefaction, sloughing, and cavitation of lung tissue. The initial lesion may disseminate bacteria directly to adjacent tissue, through the blood stream, the lymphatic system, or the bronchi.

Most people who become

at least 3 signs of effective airway:

1. Normal RR

2. Lungs clear to auscul-tation

3. Absence of pallor and cyanosis

prescribe by Doctor.

Monitor respiratory status q4: rate, depth, effort, skin color, mucous mem-branes. Monitor also the level of conscious-ness.

Maintain proper position such Fowler’s or semi-fowler’s position and change

g Diagnosis reference manual Sixth Edition by Sparks and Taylor page 33.

Suctioning helps in the removal of mucous secretions and sputum in the lungs.REF:Nursing Care Plans Third Edition by Gulanick page 211.

Monitoring will identify progress toward or deviations from goal. Ineffective Airway Clearance leads to poor oxygenation, as evidence by pallor, cyanosis, lethargy and drowsiness.REF:Fundamental of Nursing by

infected do not develop clinical illness because the body’s immune system brings the infection under control. However, the incidence of tuberculosis (especially drug resistant varieties) is rising. Alcoholics, the homeless and patients infected with the human immunodeficiency virus (HIV) are especially at risk. Complications of tuberculosis include pneumonia, pleural effusion, and extra-pulmonary disease.

Expecto-rate or clear secre-tions readily.

position every 2 hours.

Encourage patient to increase fluid intake (1500 – 2000 mL/day).

Administer analgesics.

Barbara Kozier vol I page 227.

Gravity allows for fuller lung expansion by decreasing pressure of abdomen and diaphragm and enhancing drainage of/ventilation to different lung segments. REF:Fundamental of Nursing by Barbara Kozier vol I page 227.

It helps liquefy secretions and ensure proper hydration and improve secretion clearance.REF:Nursing Diagnosis reference manual Sixth Edition by

Client’s sputum will be normal.

Monitor and document the amount and characteristics of sputum. Observe for signs and symptoms of infection.

Sparks and Taylor page 35.

It improves cough when pain is inhibiting effort.REF:Nursing Diagnosis reference manual Sixth Edition by Sparks and Taylor page 35.

Its gauge the effectiveness of the therapy and detect possible respiratory infection. It’s also ascertain status and note progress, promote timely intervention, and to examine and report changes in color and amount.REF:Nursing Diagnosis reference

manual Sixth Edition by Sparks and Taylor page 35.


Health Implication

Goal & Objective


Subjective: The

patients chief complain is massive hemoptysis with chronic productive cough and yellowish phlegm

Exposure to dust due to his occupation which is a construction worker.

“Nagtatabas kasi ako ng tiles, yun ang trabaho ko sa

Ineffective Breathing Pattern related to decrease lung capacity

The risk of TB is a higher in older people who have close contact with a newly diagnosed TB patient, those who have TB before, gastrec-tomy patients, and those affected with diabetes mellitus. The aging process weakens the immune system, further increasing the likelihood of tubercular infection in

Goal:By September 19, 2010 the client will be able to have an effective breathing pattern.

Objectives:After 1 hour of nursing interven-tion, the client will:

Promote good respiratory function

Monitor respiratory status, including vital signs, breath sounds, and skin color.

Respiratory status assessment helps gauge the patient’s severity and whether it’s progressing.REF:Fundamental of Nursing by Barbara

After the nursing intervention, the client was able to have an effective breathing pattern as manifested by normal RR.

construction, hindi ko maiwasang malanghap yung dumi galing dito kaya ko daw nakuha ang sakit kong ito,” as verbalized by the client.


Objective: + cough + DOB +Dyspne

a Weak

looking Restless-

ness

older adults.

Promote

Administer oxygen therapy as ordered.

Monitor ABG levels and oxygen saturation as ordered.

Place the patient in semi-fowlers position and place

Kozier vol I page 227.

To provide relief from symptoms of hypoxemia and hypoxia.REF:Nursing Diagnosis reference manual Sixth Edition by Sparks and Taylor page 33.

ABG levels and continuous pulse oximetry measures the blood’s oxygen content and are good indicators of the lung’s ability to oxygenate the blood.REF:Fundamental of Nursing by Barbara Kozier vol I page 227.

To increase

Measurements:Vital signs:BP- 110/70 mmHgTemp- 36.9CRR- 25 bpmPR- 91 cpm

comfort the diaphragm in proper position to contract.

Collect sputum samples as ordered.

chest expansion and to alleviate dyspnea.REF:Nursing Diagnosis reference manual Sixth Edition by Sparks and Taylor page 35.

To monitor the progress of the disease and treatment.REF:Nursing Diagnosis reference manual Sixth Edition by Sparks and Taylor page 35.


Health Implication

Goal & Objective


Subjective: The client

rates his health as 5/10.

“Nung pagkauwi ko ng

Altered Nutrition: less than body requirement related to loss of appetite as

Adequate nutrition is necessary to meet the body’s demands. Nutritional status can

GOAL: After 5 hours of nursing interven-tion, the client will be able to

After the nursing intervention, the client was able to have sufficient knowledge

bahay nung huwebes, uminom ako ng tubig tapos nasamid ako, bigla akong sumuka ng madame, akala ko tubig lang tsaka yung kinain ko yun pala may kasama ng dugo”, the patient added.

“Wala akong ganang kumain dito dahil naninibago ako”, as verbalized by the patient

“Tsaka iba yung pagkain dito kumpara yung mga kinakain ko sa bahay”,

manifested by loss of weight

be affected by disease or injury states (e.g., gastrointestinal [GI] malabsorption, cancer, burns); physical factors (e.g., muscle weakness, poor dentition, activity intolerance, pain, substance abuse); social factors (e.g., lack of financial resources to obtain nutritious foods); or psychological factors (e.g., depression, boredom). During times of illness (e.g., trauma, surgery, sepsis, burns), adequate nutrition plays an important role in

have sufficient knowledge on proper nutrition regarding on his current condition.

Objectives:After 1 hour of nursing interven-tion, the client will be able to:

state what is proper nutrition in his own words

state the impor-tance of proper nutrition

discuss the definition of proper nutrition

discuss the importance of proper nutrition

Nutritional counseling includes providing information about proper nutrition. (Fundamentals of Nursing by taylor, 5th

edition, page 1260)

Nutritional counseling includes providing information about proper nutrition. (Fundamentals of Nursing by

on proper nutrition regarding on his current condition.

added by the patient.

“Grabe, sobra na nga ang ipinayat ko eh, hindi naman ako ganito kapayat dati para na nga akong buto’t balat”, patient verbalized.

Objective: Small

body frame

Weak looking

Pale conjunctiva and mucous membrane

Dry skin Evidence

of lack of available food

Measurement:Weight: 44 kgHeight: 5’4

healing and recovery. Cultural and religious factors strongly affect the food habits of patients. Women exhibit a higher incidence of voluntary restriction of food intake secondary to anorexia, bulimia, and self-constructed fad dieting. Patients who are elderly likewise experience problems in nutrition related to lack of financial resources, cognitive impairments causing them to forget to eat, physical limitations that interfere with preparing food,

explain briefly what food pyramid is all about and how it can help him in his current condition

state the recom-mended food pattern that is appli-cable in his current condition

state the impor-tance of meal planning

Discuss about the Food Pyramid

discuss the recommended food pattern that is applicable in his current condition

Discuss the importance of meal planning

taylor, 5th

edition, page 1260)

Food Pyramid assists in making sure to offer variety of the recommended foods. (Maternal and Child Health Nursing, 5th

edition by Adelle Pillitteri, page 893)

Meals should be served on right amount regularly to meet the nutritional requirements. (ABC’s of Nutrition by Pataunia page 71)

Carefully planned meals deliver sufficient amount of all the vital

½ (164 cm)BMI: 16.4

deterioration of their sense of taste and smell, reduction of gastric secretion that accompanies aging and interferes with digestion, and social isolation and boredom that cause a lack of interest in eating.

create a meal plan based on the recommended food pattern suitable for her condition

create variety of meals everyday to meet the nutritional require-ments needed for his condition, consider-ing also the budget of the family

have an adequate knowledge of the proper

Assist the client in creating a meal plan

Guide the client in creating variety of meals that suits their budget

nutrients. (ABC’s of Nutrition by Pataunia page 71)

Carefully planned meals deliver sufficient amount of all the vital nutrients. (ABC’s of Nutrition by Pataunia page 71)

Encourage a variety of foods from each food groups in amount suited for the client's appetite and needs. (ABC’s of Nutrition by Pataunia page 71)

nutrition about his current condition

CASE PRES - Q.I.

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