CASE STUDY ON PULMONARY TUBERCULOSIS

DEMOGRAPHIC DATA OF THE PATIENT :

Name

: Mr. kailesh

Fathers /husbands name

: S/O Mr. Narottamlal

Age

: 31 years

Sex

: Male

Occupation

: auto drive

Religion

: Hindu

Address

: 196, shyam nagar, Bhopal

marital status

: Married

Diagnosis provisional

: tuberculosis

Final diagnosis

: pulmonary tuberculosis

Surgery if any

:No surgical intervention is done .

HISTORY TAKING :Present complain

:The patient is having present complain of ;

Severe dyspnoea on exertion even at rest also .

Cough with sputum
Chest pain due to excessive cough
Cold

Upper respiratory tract infection

Weakness , restlessness, weight loss
This all symptoms are persisting since 6yr but from last night it is in peak .

History of present illness : Since 3 month the patient is having problem of

breathlessness , cough, intermittent chest pain , he took treatment from dr. in the hospital
.the medications brought symptomatic relieve and he used to come for follow up but
since last 8days he developed severe dyspnoea due to congesion as well as during sleep
and he used to get up and sit for long time than it used to be relieved but last night the
symptoms were on peak and he was so uncomfortable because of that the relative brought
him in hospital and after consultation with doctor he was being got admit.
Past history

: he has no have any complaint of chronoc disease

Family history

: In his family no one is suffering from any major disease

condition neither any person died due to any disease .

Socio-economc status : He is from lower middle class family ,he has his own pakka
house which is having 3 rooms only and well ventilated , he disposes garbage outside the
house there is no particular place for disposing the garbage .he is very friendly and all
like to talk with him , he participate in all religious functions .

Family composition

S.No

Name of the

Age

Sex

member

Relation

Health

with the

status

patient
1.

Mr .kailesh

30 years

Male

Patient

Poor

2.

Mrs. Parwati

25 years

Female

Wife

Having
joint pain

3.

Pooja

2 years

Female

Daughter

Healthy

4.

munna

7 years

male

son

healthy

Personal history
Eating habits

:
:He is pure vegetarian , he usually takes light diet since he

developed this disease .He takes Roti, Dal, rice , any type of vegetable whatever is
available. Sometimes he take fruits , he does not keep fast .
Elimination pattern : He was having good bowel and bladder elimination pattern but
since the problem is more severe now the renal perfusion is also decreased and it is
affecting the bladder elimination .
Any abuse

: He used to smoke and sometimes he used to take alcohol but since

last 3 year he stopped taking all these things .

Life style

:He lives very simple lifestyles , he does not do any extra activity

like walking or any other exercise.

PHYSICAL EXAMINATION :
Height :

160 cm

Weight :

63 kg

VITAL SIGNS :
Temperature :
Pulse

99.8F
:

Respiration

Blood pressure :

42/mt.
44/mt.
130/70 mmhg per arterial blood pressure .

HEAD :
Scalp

No scar was seen but the scalp seems to be dry & having dandruff.

Face

Normal in shape , size and alignment ,a black mole was present on

chin .

Sinus area :

No tenderness present.

Nodes

No nodes are enlarged .

Cranium

Normal

EYES :
Visual acuity :
Visual field :

Normal
Clear,6/6

Ocular movement : Normal , moves to both sides as well as towards the up and
down .
Lids :

Eye Lides are normal no edema or inflammation is being detected .

Lacrimal glands :

The Lacrimal Glands are normal and secretes normally

Sclera :

pale

Cornea :

No Abnormality detected

Lens and media :

Normal , the image forms normally.

Fundus :

Normal

EARS :
External structure : Normal in alignment ,
Canal:

Normal , no discharge is seen

Tympanic membrane : Normal.

Hearing :

Normal , checked by tunic fork.

NOSE :
External structure : normal in alignment ,
septum :

No deviation seen

Mucus membrane : Moist , no inflammation seen .

Patency :

Good

Olfactory sense :

This was normal , checked by using some flavour

ORAL CAVITY :
Lips :
Buccal mucosa :
Gums :

Mildly cyanosed , cracked , dry .

Cyanosed and dry
Pale

Teeth :

Unhygienic , yellow stain was present .

Palates and uvula :

Normal

Tonsillar areas :

No enlargement detected

Tongue :

Cyanosed , dry ,

Floor :

Normal .

Voice :

No hoarseness was present .

Breath :

Dyspnoea present , the patient was on oxygen .

NECK :
General structure :

Normal in shape and size .

Trachea :

Present in central

Thyroid :

Normal , no enlargement seen

CHEST AND RESPIRATORY SYSTEM :

Chest shape:

Slightly heavy

Type of respiration : Thoraco- abdominal respiration was present .

Expansion :

It was fast .

General palpation : On palpation chest movement was present as well as apex impulse
5th intercostals space.

was felt on
Percussion :
Breath sound :

on percussion no air or fluid detected .

B/L +

CARDIOVASCULAR SYSTEM :
History :
1)Cardinal symptoms :
Dyspnoea
mild
Chest pain
irritated due
Cough

: There was presence of marked dyspnoea on exertion ,even with

exertion .
: It was not that evident but sometimes the client used to be
pleuritic chest pain
: He was having vigorous cough .\

Expectoration

: yes,expectoration was present .

Haemoptysis

:There was no presence of haemoptysis ,

Palpitation

:There was presence of slightly palpitation .

Syncopal attack

: 1 times he had Syncopal attack .

Build and nutrition

: He was averagely nourished .

Nails and conjunctiva : Nails were cyanosed .

Thyroid

: No enlargement detected .

Oedema

: There was no presence of oedema .

Skin

: The skin was pallor & brittle .

ABDOMEN AND INGUINAL AREAS :

Contour and tone : Good contour and good muscle tone .
Scars marks :
Liver

There is no scar marks detected .

Spleen :

Normal

Kidneys :
Bladder :

Normal

Hernias :

There is no hardness or swelling over the groin .

Masses :

No masses are felt on abdomen

Palpation :

On palpation no mass or any kind of hardness is felt , abdomen was

soft to touch .
Percussion :
Auscultation :

On percussion no fluid or gas collection detected .

On auscultation normal peristaltic movement heard .

GENITALIA AND AREA NODE :No such kind of nodes, abrasion or lesions seen.
RECTAL EXAMINATION :No rashes or any kind of abnormality detected.
MUSCULOSKELETAL SYSTEM :
Gait :

Normal

Upper extremities : Both are in normal alignment no extra digits are present and
cyanosis were

present on fingers .

Lower extremities: Both are in normal alignment .

Deformities :

No such deformities detected .

Range of motion :

He was so tired that could not perform the full range of

motion .

NERVOUS SYSTEM :
Mental status :

He was well oriented to date , place and time , even he was knowing
the reasons for admission in hospital .

Language

He has no problem in language , no sludge speech .

Motor co-ordination :

Motor co-ordination was good .

Lower extremities : Good tone of muscles , no rigidity detected and well co- ordination
present , there is presence of cyanosis .
s. no

Investigations

Normal value

Patients value

1.

Haemoglobin

11.5-15.5 gm.

15.2 gm

2.

W.B.C

4000-10000/cmm

22,100/cmm

3.

Packed cell vol.

37-45%

45 %

4.

Platelet count

1.5-4.0lacs/cmm

2.34 lacs /cmm

5.

Blood group

B positive

6.

R.B.S

70-140mg/dl

87 mg/dl

7.

SGOT

5-40 IU/L

32IU/L

SGPT

3-40 IU/L

47IU/L

EVALUATION

More

more

8.
9.

S. Bilirubin

0.2-1.2 mg/dl

0.46mg/dl

10.

Direct

Upto 0.3 mg/dl

0.30mg/dl

11.

Indirect

0.2-1.0 mg/dl

0.16mg/dl

12.

S. Creatinine

0.5-1.5mg/dl

0.9mg/dl

13.

S.na+

135-145meq/l

137 Meq/L

14.

S.K+

3.5-5 Meq/L

5.1Meq/L

15.

CL-

96-107 Meq/L

95 Meq/L

16.

S. Protein

6-8 gm/dl

5.8gm/dl

17.

S. Albumin

3.5-5 gm/dl

3.2gm/dl

18.

S.Globulin

2.5-3.5 gm/dl

2.6 gm/dl

19.

Bld. Urea

15-40 mg/dl

43mg /dl

20.

Hbsag

Negative

Negative

21.

HIV

Non-reactive

NR.

22.

Blood group

B positive

23.

PT test

15 sec.

24.

Control

13 sec.

25.

INR

1.11

more

more

URINE
ROUTINE
26.

Albumin

Nil

Trace

27.

Sugar

Nil

Nil

CHEST X-RAY :-The chest x- ray shows patchy, inflamed bronchioles, consolidation in
the lungs due to thick sputum. clouding appearance was observed.
Medial treatment : The patient was admitted in ICU and he was on oxygen therapy, the
medications which were being prescribed for him are listed below ;
INJ. Clavum I.V 1.2gm 8hourly

INJ. Aciloc 50mg I.V BD

INJ. Deriphyllin I.V 1 amp 8 hourly
INJ. Prednisone I.V 1 amp OD
INJ. Ibrufen 1apm I.M. BD
Tab Metagard CR 60mg 1 OD
Tab. Alupent 10mg 1 QID
Nebulise with Asthalin & Budecort 6 hourly
Syrup Mucinex 2t

Nursing

outcome

Implementation

Rationale

Evaluation

Assessment

diagnosis

Subjective data

Impaired gas

Patient breathing

Give comfortable

To extent lung

Now patient is feel

patient have complaint

exchange

pattern will be

position to the

surface.

better he have no

of breathing difficulty

related to

normal

patient.

objective data-

decrease lung

I observe patient

surface

complaint of breathing
difficulty.

Promote bed rest

Reducing 0xygen

breathing pattern and I

/limit activity & assist consumption

observe that patient

with self care

demands during

have breathing

activities as

periods of

difficulty and its come

necessary.

respiratory

under the first

compromise may

component of virgenia

reduce severity of

herson theory

symptoms.
Give the inhalation to
the patient.

It clean the airway

obstruction.

Instruct & encourage

patient to take deep

Deep breathing &

breathing & cough

coughing exercise

every hour

promote normal
breathing pattern.

Nursing diagnosis

outcome

Implementation

Rationale

Evaluation

Subjective data- my Chest pain related to Patient chest pain

Give comfortable

To proper lung

Expected outcome

patient have

position to the

extension

is completely meet

Assessment

disease condition

will be reduce

complain of chest

patient

pain

Objective data-

here
To provide comfort

Give continous bed

and rest to the

rest to the patient

patient.

Explain the

Proper coughing

coughing exercise.

pattern will reduce

I observe my
patient expression

the pain
Apply the chest

To remove

physiotherapy

coughing

Give the medicine

as by ordered

Nursing diagnosis

outcome

Implementation

Rationale

Evaluation

Subjective data-my

Vomiting related to

Patient vomiting

Give the

To provide

Patient feel good

patient have

drug induct

will be reduce

comfortable

comfortable and

now he have no

position to patient.

maintain sence of

complaint of

well being

vomiting

Assessment

complaint of
vomiting

Vomiting related to

Objective data-

disease process.

Instruct the patient

observe that patient

to avoid crowd of

Some time crowd

doing vomiting

relatives

may cause vomiting

infront of me

sensation

Give the antiemetic

as by ordered

Antiemetic to
prevent the
vomiting p

Subjective data

Alteration in

Patient sleep pattern Discourage large

This often change

my patient have

sleeping pattern

will be maintained

period of sleep

the client ususl

complaint about

related to prolonged

during day time

sleeping pattern

lack of sleep or

counghing

heavy ness in eyes.

Provide column and

Its induct to sleep

Objective data- I

quit environment to

observed by patient

the patient

condition and
consult with night

Remove the cause

To provide sleep

staff.

with is disturb to

pattern

sleeping pattern

Give the medicine

To induct sleep

asprescribed by
physician.

Nursing diagnosis

outcome

Implementation

Rationale

Evaluation

Subjective data-my

Imbalanced

Patient nutritional

Check the body

Note to changes in

Patient nutritional

patient have

nutrition less then

status will be

weight regularly

body weight

status is maintained

complaint of weight

body requirement

maintain

loss and lack of

related to frequent

Document clients

Useful in defining

hunger

anorexia.

nutritional status

degree/extent of

from admission and

problem &

history of vomiting/

appropriate choice

nausea

of intervention

Assess client

Helpful in

usually dietary

identifying and

Assessment

Objective data- I
observed that

Weight loss related

patient have lack of

to lack of interest to

interest of food he

food intake.

refused to take food

and he take interest

intake of food.

pattern like /dislike

specific need
consideration of

Monitor input and

individual

out put amount

preference may
improve dietary

Encourage to

intake

patient to take more

vitamins protein

To improve

diet

nutritional status &

promote weight loss

Nursing diagnosis

outcome

Implementation

Rationale

Subjective data- my

Knowledge

Patient knowledge

Assess client ability

Learning depends

patient have

deficiency related to

will be improved

to learn

on emotional and

complaint me about

misinterpretion of

regarding disease

his condition

information of lack

condition

He asked me
question regarding

Assessment

his condition

physical readiness
Provide interection

& is achieved at an

of information

specific written

individual pace

regarding disease.

information for
client

Written information
relieves client of the

Objective data I

Encourage client to

burden of having to

listen the patient

verbalize fear/

remember large

question

concerns

amount of
information.

Teach about disease

process and

Provides

medication

opportunity to
correct
misconceptions

Evaluation

inadequate finances
may affect coping
Teach about T.B.

with maintaining

transmission.

health.

To provide
knowledge about
transmission of
infection of T.B.