DESH BHAGAT UNIVERSITY

CASE PRESENTATION
ON
PULMONARYT
UBERCULOSIS

SUBJECT- ADVANCE NURSING PRACTICE

SUBMITTED TO: SUBMITTED BY:

ASSISTANT PROF. MR. JASPREET KAUR
PUNEET GILL M.Sc. NURSING 1ST YEAR
FACILTY OF NURSING MEDICAL SURHICAL
DESH BHAGAT UNIVERSITY NURSING
DESH BHAGAT UNIVERSITY
 IDENTIFICATION DATA
• Name : Mr. Gautam Kumar

• Age : 32 yrs

• Gender : Male

• Address : punjab

• I.P.D no : 593657893

• CR.no : 274598

• Marital status : Married

• Religion : Hindu

• Occupational status : shopkeeper

• Date of admission : 24/03/2023

• Time of admission : 4pm

• Bed no : 21

• Ward : Chest and T.B ward

• Dr. Incharge : Dr.

• Diagnosis : Pulmonary tuberculosis

• CHIEF COMPLAINTS:
Mr. Gautam Kumar, 35 years old admitted in the hospital with the chief complaints of
Coughing with sputum since 1month
Chest pain since 2 weeks
Loss of appetite and since 1 week
Fever since 1 week
 • PAST MEDICAL HISTORY
Mr. Gautam kumar has past medical history of pneumonia 1 year back and was
hospitalized but no history of diabetes mellitus, hypertension.
PRESENT MEDICAL HISTORY:
Patient was having prolonged coughing with sputum production since 1 month back
when he developed the chest pain, fever and breathing difficulty, associated with loss
of appetite and weight loss. The patient was admitted in Chest and T.B ward.
• PAST SURGICAL HISTORY
Mr. Gautam kumar does not have any past surgical history.
• PRESENT SURGICAL HISTORY : no surgical procedure is performed
• FAMILY HISTORY:
✓ Any hereditary disease : no hereditary disease is present
✓ Any communicable disease : Not significant

• FAMILY COMPOSITION:

Sr. Name Age Gender Education Occupation Marital Relation Health

no status with client status
1. Mr. Gautam 32 yrs Male 12th pass Shopkeeper married Patient Pulmonary
tuberculosis
2. Mrs. Rani 28 yrs Female 10th pass Housewife Married Wife Healthy

2. Mr. Ramdev 89 yrs Male Uneducated unemployed married grandfather healthy

3. Mrs.Gyanwati 75yrs Female Uneducated Housewife Married grandmother Healthy

4. Mr. sewak lal 55yrs Male 5th PASS Shopkeeper Married Father Healthy

5. Mrs. reema 50 yrs Female Uneducated Housewife Married Mother Healthy

6. Ms.renu 7yrs female 2th educated student daughter healthy

standard
FAMILY TREE

Mr. Ramdev (grandfather) Mrs. Gyanwati ( grandmother)

Mr. Sewak lal (father) Mrs. Reema (mother)

Mr. Gautam (Patient) Mrs. Rani (wife)

Ms. Reenu( daughter)

• KEY WORDS: Male-

Female-
Patient-
• SOCIO ECONOMIC HISTORY:
✓ Bread winner Mr. Ramdev
✓ Income 20,000/month
✓ Type of house Pakka house
• ENVIRONMENTAL HISTORY:
✓ Drinking water supply
✓ Environmental sanitation proper
✓ Waste/ excreta disposal adequate
✓ Electricity proper
• PERSONAL HISTORY:
✓ Dietary pattern non vegetarian
✓ Sleeping pattern disturbed
✓ Life style proper
✓ Language Hindi
✓ Relationship with others good
 PHYSICAL EXAMINATION:

• GENERAL APPEARANCE:

✓ Look : Anxious
✓ Orientation : well oriented
✓ Consciousness : conscious
✓ Nourishment : malnourished
✓ Body built : thin
✓ Speech : clarity
✓ Mental status : cooperative
✓ Activity : dull
• POSTURE:
✓ Body curves : no lordosis or kyphosis is present
✓ Movement : decreased
✓ Height : 4 feet 8 inch
✓ Weight : 52 kg
• VITAL SIGNS:
✓ Temp : 102.2 *F
✓ Pulse : 74/mt
✓ Respiration : 22/mt
✓ B.P. : 110/90 mmHg
• INTEGUMENTARY (SKIN):
✓ Colour : pallor
✓ Moisture : normal
✓ Temperature : warm
✓ Texture : dry
✓ Turgor : normal
✓ Vascularity : normal
✓ Lesions : no macule or papule present

• HAIR AND SCALP:

✓ Distribution : evenly distributed
✓ Colour : black and brown
✓ Appearance : good
✓ Scalp : clean
✓ Thickness : thick

• NAILS:
✓ Colour : pink
✓ Thickness : normal
✓ Shape : curve
• HEAD :
✓ Position : normal
• EYES:
✓ Position and alignment : symmetrical
✓ Eye brows : equally distributed
✓ Eye lids : no edema, lesions present
✓ Conjunctiva : normal
✓ Sclera : normal
✓ Cornea : no irregularity present
✓ Pupil : reacts to light
✓ Lens : normal
✓ Visual acuity : normal
✓ Discharge : not present
• EARS:
✓ Shape and size : symmetrical
✓ Discharge : not present
✓ Hearing acquity : proper
• NOSE:
✓ External nares : normal
✓ Mucosa : normal
✓ Discharge : not present
✓ Nasal septum : midline
✓ Sinuses : adequate
• MOUTH AND PHARYNX:
✓ Cleft lip or cleft palate : not present
✓ Teeth : evenly distributed
✓ Tongue : whitish
✓ Throat and pharynx : normal
• NECK:
✓ Lymph nodes : enlarged
✓ Thyroid glands : normal
✓ Trachea : middle
• CHEST:
✓ Thorax : symmetrical
✓ Thorax expansion : inspiration and expiration normal
✓ Hearts sound : normal heart sound S1, S2 (No added sound)

• BREAST:
✓ Nipple : normal
 ✓ Discharge : not present

• ABDOMEN:
✓ Inspection : No scar of prior surgery. Umbilicus inverted.
✓ Palpation : Guarding, right iliac mass is fossa is palpable,
✓ Percussion : rebound tenderness
✓ Auscultation : bowel sound present but hypoactive
• GENITAL AREA (MALE):
✓ Penis : normal
✓ Scrotum : normal
✓ Inguinal ring and canal : normal
• MUSCULOSKELETAL SYSTEM:
✓ Range of motion : restricted
✓ Muscle tone and strength : stiffness present
• NEUROLOGICAL SYSTEM:
✓ Level of consciousness : alert
✓ Behaviour : normal
✓
• INVESTIGATIONS:
SR.NO INVESTIGATION NORMAL VALUE PATIENT VALUE REMARKS
1. Haemoglobin 13-18g/dl 14.2g/dl NORMAL
2. haematocrit 40-54% 52% NORMAL
3. MCV 82-100fL 94fL NORMAL
4. MCH 27-32pg 32pg NORMAL
5. RBC 4.5-6.0 cells/mcL 5.57 cells/mcL NORMAL
6. WBC 4,5-11.0*109/L 21.2*109/L INCREASED
7. Neutrophils 40-75% 87.3% INCREASED
8. lymphocytes 15-45% 7.4% DECREASED
9. monocytes 2-10% 5.3% NORMAL

• MEDICATIONS:

Sr.no Drug name Dose Route/Frequency action

1. Inj. Amikacin 5mg I/V-BD Antibiotic
2. Inj. Emset 4mg I/V-BD Antiemetic
3. Inj. pantop 1amp I/V-BD Antacid
4. Inj. lasix 1amp I/V-OD Diuretics
• NURSING DIAGNOSIS:

✓ Acute chest pain related to prolonged coughing as evidence by patient facial

expression.
✓ Ineffective airway clearance related to bronchial secretion as evidence by dyspnea.
✓ Risk of infection related to decrease immune response as evidence by poor personal
hygiene.
✓ Fluid volume deficient related to inadequate fluid intake as evidence by weakness.
✓ Loss of appetite related to disease and its treatment as evidence by patient weight loss
✓ Anxiety related to hospitalisation and treatment regimen as evidence by patient
verbalisation.
✓ Insomnia related to acute pain at surgical site as evidence by patient restless.
✓ Knowledge deficit related to disease condition and its treatment as evidence by patient
as many questions.

INTRODUCTION
Tuberculosis is one of the most prevalent infection of human beings and contributes
considerably to illness and death around the world. It is spread by inhaling tiny
droplets of saliva from the cough or sneezes of an infected person. It is a slowly
spreading chronic granulomatous bacterial infection, characterized by gradual weight
loss.

DEFINITION
Tuberculosis is the infectious disease primarily affecting lung parenchyma is most
often caused by mycobacterium tuberculosis, it, may spread to any part of the body
including meninges, kidney, bones and lymph nodes.

ANATOMY OF LUNGS
➢ The lungs are the major organs of the respiratory system, and are divided into sections,
or lobes. The right lung has three lobes and is slightly larger than the left lung, which
has two lobes.
➢ The lungs are separated by the mediastinum. This area contains
the heart, trachea, esophagus, and many lymph nodes. The lungs are covered by a
protective membrane known as the pleura and are separated from the abdominal
cavity by the muscular diaphragm.

➢ With each inhalation, air is pulled through the windpipe (trachea) and the branching
passageways of the lungs (the bronchi), filling thousands of tiny air sacs (alveoli) at
the ends of the bronchi. These sacs, which resemble bunches of grapes, are surrounded
by small blood vessels (capillaries). Oxygen passes through the thin membranes of the
 alveoli and into the bloodstream. The red blood cells pick up the oxygen and carry it to
the body's organs and tissues. As the blood cells release the oxygen they pick
up carbon dioxide, a waste product of metabolism. The carbon dioxide is then carried
back to the lungs and released into the alveoli. With each exhalation, carbon dioxide is
expelled from the bronchi out through the trachea.

PHYSIOLOGY OF LUNGS
➢ The lungs are the foundational organs of the respiratory system, whose most basic
function is to facilitate gas exchange from the environment into the bloodstream.
Oxygen gets transported through the alveoli into the capillary network, where it can
enter the arterial system, ultimately to perfuse tissue.

➢ The respiratory system is composed primarily of the nose, oropharynx, larynx, trachea,
bronchi, bronchioles and lungs. The lungs further divide into individual lobes, which
ultimately subdivide into over 300 million alveoli. The alveoli are the primary location
for gas exchange. The diaphragm is the primary respiratory muscle and receives
innervation by the nerve roots of C3, C4, and C5 via the phrenic nerve. The external
intercostals are inspiratory muscles used primarily during exercise and respiratory
distress.

PATHOPHYSIOLOGY
Due to etiological factors

entry of microorganism through droplet nuclei

bacteria transmitted in the alveoli through airways

deposition and multiplication of bacteria

Bacilli are also transported to other parts of the body via blood stream and phagocytosis by
neutrophils and ,macrophils

Pulmonary tuberculosis
 CLINICAL MANIFESTATION
S.NO BOOK PICTURE PATIENT PICTURE
1. Productive coughing Present
2. Night sweating Present
3. Low grade fever Present
4. Hemoptysis Absent
5. Malaise Present
6. Weight loss Present
7. Fatigue Present
8. aneroxia Present
9. irritability Present
10. weakness Present

DIAGNOSTIC EVALUATION
S.NO BOOK PICTURE PATIENT PICTURE
1. History collection Done
2. Physical examination Done
3. X-Ray the X-Ray shows that the upper
lobe is infiltrated and lymph
node involvement.
4. Ultrasound
5. CT-Scan Absent
6. Sputum culture Patient positive for M.
tuberculosis
7. Plueral needle biopsy Not significant
8. Blood test WBC count Neutrophils are elevelated
9. Montoux test Positive
10. The QuantiFERON –TB Gold Positive
test (QFT-G)

MANAGEMENT
MEDICAL MANAGEMENT:
S.NO BOOK PICTURE PATIENT PICTURE
1. Antibiotics Done

2. Anti pyretic drugs done

 3. Anti tuberculine drugs:
First line drugs
Isoniazid (H) • Rifampicin done
Second line drugs:
Amikacin • Capreomycin •
Ethionamide

NURSING MANAGEMENT:
➢ The nurse should instructs the patient about correct positioning to facilitate
drainage and to increase fluid intake to promote systemic hydration
➢ The nurse should teach the patient that TB is a communicable disease and
taking medications is the most effective means of preventing transmission.
➢ The nurse must plans a progressive activity schedule that focuses on increasing
activity tolerance and muscle strength and a nutritional plan that allows for
small, frequent meals.
➢ The nurse should carefully instructs the patient about important hygienic
measures including mouth care, covering the mouth and nose when coughing
and sneezing, proper disposal of tissues, and handwashing.
➢ Initiate AFB isolation immediately, including the use of a private room with
negative pressure in relation to surrounding areas and a minimum of six air
changes per hour.
➢ Place a covered trash can nearby or tape a lined bag to the side of the bed to
dispose of used tissues.
➢ Be alert for adverse effects of medications.

HEALTH EDUCATION
✓ Educate patient and relative that tuberculosis is spread by airborne droplets. Protect
others by covering your mouth when coughing, laughing or sneezing, wash hands
often.
✓ Ask client to avoid smoking and consumption of alcohol and tabacco use.
✓ Advise the patient to maintain proper hygiene.
✓ Tell the patient to take nutritious diet and avoid oily and spicy food.
✓ Advise the client to take medications regularly as prescribed by the doctor.
✓ Advise the patient to take adequate rest
✓ Tell the client to inform doctor if any discomfort or discharge is present and to take
follow up check -up as prescribed.
✓ Explain to the patient about importance of treatment regimen as required for full
course of therapy to prevent re infection.
 ✓ Explain the patient about the isolation in order to prevent the disease to spread to
others.
✓ Explain the patient about proper disposal of sputum by burring in soil for
preventing the disease spread.

SUMMARY
➢ The lungs are the major organs of the respiratory system, and are divided into sections,
or lobes. The right lung has three lobes and is slightly larger than the left lung, which
has two lobes. The lungs are separated by the mediastinum. This area contains
the heart, trachea, esophagus, and many lymph nodes. The lungs are the foundational
organs of the respiratory system, whose most basic function is to facilitate gas
exchange from the environment into the bloodstream.

➢ Tuberculosis is the infectious disease primarily affecting lung parenchyma is most

often caused by mycobacterium tuberculosis, it,may spread to any part of the body
including meninges, kidney, bones and lymph nodes. Sign and symptoms of
tuberculosis include coughing, weight loss, hemoptysis fatigue anorexia etc.
diagnostic test involve X-Ray, CT-Scan, MRI, Sputum culture montoux test TB gold
test.it can be treated with anti- tuberculin drugs and DOTs therapy.

FLORENCE NIGHTINGALE ENVIRONMENTAL THEORY

• Florence nightingale was born on may 12, 1820, much attention has been to the “
calling” that Nightingale recorded in her diary in 1837, when she wrote that “God
spoke to me and calling me to his service”.
• Florence nightingale began her nursing training in 1851 in Germany, she is considered
as the first nursing theorist.
• International nurses day, May 12 is observed in respect to her contribution to nursing.
• She died on 13 august 1910.
• According to nightingale, if nurses modify patients environment according to her
canons of environment, she can help patient in recovery. Hence nightingale provided a
basis for providing holistic care to the patient and it is still applicable today.
• Nightingale believed healthy surrounding were necessary for proper nursing care and
healing. Environment was the main focus of nightingale theory. Environment was
defined through the “concept of ventilation, warmth, light cleanliness, diet and noise.

NIGHTINGALE THEORY APPLICATION

• My patient Mr. Gautam, 32 years old admitted in male surgery ward with the
diagnosis of pulmonary tuberculosis, to make him comfort and reduce the anxiety, I
have applied Florence Nightingale Environmental nursing theory.
S.NO MAJOR CONCEPT PATIENT CONCEPT
1. Ventilation and warming Patient is staying in well ventilated area,
and warmth is provided to the patient

2. Light and noise Patient stays in well illuminating lights is

present and patient was feeling
uncomfortable with the noise the noise
has been reduced by instructing the staff
of the ward.
3. Cleanliness of rooms walls Well painted and clean room is provided
to the patient so that patient can feel relax
and comfortable in the room.

4. Health of house/ area Patient is staying in the environment

where everyone is trying to cooperate
with patient so it is good to improve the
health status of client.
5. Bed and bedding Patient is resting in the bed, where proper
bedding is provided to the patient to feel
comfortable.
6. Personal cleanliness Patient personal cleanliness is quit poor
and not maintained properly. So some
instruction has been provided to the
patient for personal hygiene.
7. Chattering hopes and advises Psychological support and advise has
been provided to the patient, thus patient
can feel relax.
8. Taking food Patient is taking semi solid food i.e
daliya, dal. Patient is eating simple diet
that is not spicy.
9. Observation and petty Patient observed carefully for checking
management the benefits on adverse reaction of any
medical management. Patient is closely
observed for psychological and cognitive
status.