Primary Koch’s Infection

by: Dann Louie Z. Praxides

Introduction Tuberculosis (TB) is a potentially fatal contagious disease that can

affect almost any part of the body but is mainly an infection of the lungs. It is caused by a bacterial microorganism, the tubercle bacillus or Mycobacterium tuberculosis. Although TB can be treated, cured, and can be prevented if persons at risk take certain drugs, scientists have never come close to wiping it out. Few diseases have caused so much distressing illness for centuries and claimed so many lives.

Tuberculosis was popularly known as consumption for a long time. Scientists know it as an infection caused by M. tuberculosis. In 1882, the microbiologist Robert Koch discovered the tubercle bacillus, at a time when one of every seven deaths in Europe was caused by TB. Because antibiotics were unknown, the only means of controlling the spread of infection was to isolate patients in private sanitoria or hospitals limited to patients with TB—a practice that continues to this day in many countries. The net effect of this pattern of treatment was to separate the study of tuberculosis from mainstream medicine. Entire organizations were set up to study not only the disease as it affected individual patients, but its impact on the society as a whole. At the turn of the twentieth century more than 80% of the population in the United States were infected before age 20, and tuberculosis was the single most common cause of death. By 1938 there were more than 700 TB hospitals in this country.

Objectives: OBJECTIVES As a Nurse: a. To gain knowledge about the case of my patient, Primary

Koch’s infection. b. To impart knowledge to the significant others about her case. c. To provide quality and effective nursing interventions to the

patient. d. To encourage the client and her significant others to comply

with the nurses’ and doctors’ health teaching and interventions.   To the Patient: a. To know, understand and accept important matters about her

condition. b. To cope up with her present condition. c. To help obtain timely recovery. d. To help her to learn the important things about PKI.

Patient Profile Name: PrincessAddress: Mercedes, Camarines NorteAge: 8 years old.Weight: 18.1 kgs.Nationality: FilipinoReligion: Roman CatholicOccupation: Student.Date of admission: 08-14-2011Time of admission: 4:50 p.m.Birthday: April 13, 2003Blood Type: “O”

Review of systemHead: rounded and symmetrical absence of

nodules, proportion to the body Scalp: white in color, no lumps, no lesion,

no tenderness, with dandruff Hair: white in color, wavy and evenly

distributed, oily, Eyes: eyebrows symmetrically aligned;

equal movementPupillary size of 3, pupil is blackNo discharge, lids close symmetrically,

symmetrical eyebrows.With slight periorbital puffiness noted.Ears: auricle aligned with outer canthus of

the eye not tenderSticky brownish cerumen

Nose: not tender, no lesion symmetric and straight with discharges (yellowish in color in appearance)

Nasal septum intact and midline Pharynx: soft, moist pale lips and buccal mucosa

Mouth: dry mucous membrane. Neck: aligned symmetrically with the body. Respiratory: RR: 35 c/min. Skin intact; uniform temperature Crackles sound upon auscultation Extremities: No presence of edema Skin: Pallor No lesion, no abrasion, moisture in skin folds and

axillae Poor skin turgor

History of present illnessDate of Admission: 08-14-2011

Attending Physician: Dra. Labarro

Chief Concern: Hemoptysis

Admitting Diagnosis:Primary Koch’s Infection

HISTORY OF PAST ILLNESSES

A. Childhood Illnesses 1. Cough 2. Colds 3. Fever   B. Medication History 1. Uses OTC meds Paracetamol (Biogesic) – Fever 2. Herbal Medicine Lagundi – colds C. Immunization Fully vaccinated as verbalized by the mother

of the client.

HISTORY OF FAMILY ILLNESSES Father:Cesar Recurrent colds, Cesar’s father died because

of PTB Has PTB.

Mother: Amelia Hypertension

PERSONAL HEALTH HISTORY Allergies: No known allergies on foods and drugs.

Injuries/ Accident in the past: Patient had not experience injuries or accident in the past.

Family health history: Experienced Hypertension and PTB

Home and Environment: Resides at Mercedes Camarines Norte

Source of Income: Producing and Selling dried fish.

Gordon’s Functional Health PatternHEALTH PERCEPTION PATTERN -”nabigla po ako ng pag ubo ko,

may dugong kasama, sinabi ko kagad kay mama, at dinala po ako dito sa hospital, pero ngayon di ko na po iniisip kasi may gamot na po ako’’.

NUTRITIONAL METABOLIC PATTERN

-”madami po ako kumain dati, nakakaisang pinggan po ako, katulad lang po dito, madami pa din po ako kumain. ”

ELIMINATION PATTERN -”parehas lang po ako kung

gano kadalas umihi at mag dumi nung nasa bahay pa po ako”.

ACTIVITY -EXERCISE PATTERN -”naglalakad po ako tuwing

umaga papuntang school”.SLEEP PATTERN -”nang nasa bahay po ako,

maayos po akong nakakatulog, pero ngayon po dito po sa hospital nahihirapan po ako matulog kasi po mainit at di po ako sanay”.

COGNITIVE PERCEPTUAL PATTERN

-” ‘di ko po alam kung bakit umubo po ako ng dugo,”.

SELF-PERCEPTION PATTERN -”siguro po ay may sakit din po

ako, katulad ni papa, kaya umubo din po ako ng may dugong kasama”.

VALUE-BELIEF PATTERN -”nagsisimba naman po kami

nila mama kapag sabado ng umaga, pero ngayon po, hindi na po kami nakakapag simba”

LABORATORY RESULT HEMATOLOGY August 15, 2011 Hct 0.37 0.36 – 0.48 WBC 12.1 x 109/L 5 – 10 x

109/L

Differential Count Lymphocyte 0.25 0.20 – 0.40 Neutrophil 0.75 0.25 – 0.70 Platelet Count 154 150 – 450

x 103/l

Type O+

URINALYSISAugust 15, 2011

Chemical Findings Color: Yellow Transparency: clear Spec. Gravity: 1.032Microscopic Findings Pus Cells: 1-2 Epithelial: Few RBC: 0-2

Anatomy and Physiology Anatomy In humans, the trachea divides into the two main bronchi that enter

the roots of the lungs. The bronchi continue to divide within the lung, and after multiple divisions, give rise to bronchioles. The bronchial tree continues branching until it reaches the level of terminal bronchioles, which lead to alveolar sacs. Alveolar sacs are made up of clusters of alveoli like individual grapes within a bunch. The individual alveoli are tightly wrapped in blood vessels and it is here that gas exchange actually occurs. Deoxygenated blood from the heart is pumped through the pulmonary artery to the lungs, where oxygen diffuses into blood and is exchanged for carbon dioxide in the hemoglobin of theerythrocytes. The oxygen-rich blood returns to the heart via the pulmonary veins to be pumped back into systemic circulation.

Human lungs are located in two cavities on either side of the heart. Though similar in appearance, the two are not identical. Both are separated into lobes by fissures, with three lobes on the right and two on the left. The lobes are further divided into segments and then into lobules, hexagonal divisions of the lungs that are the smallest subdivision visible to the naked eye. The connective tissue that divides lobules is often blackened in smokers. The medial border of the right lung is nearly vertical, while the left lung contains a cardiac notch. The cardiac notch is a concave impression molded to accommodate the shape of the heart.

Each lobe is surrounded by a pleural cavity, which consists of two pleurae. The parietal pleura lies against the rib cage, and the visceral pleura lies on the surface of the lungs. In between the pleura is pleural fluid. The pleural cavity helps the lubricate the lungs, as well as providing surface tension to keep the lung surface in contact with the rib cage.

Lungs are to a certain extent 'overbuilt' and have a tremendous reserve volume as compared to the oxygen exchange requirements when at rest. Such excess capacity is one of the reasons that individuals can smoke for years without having a noticeable decrease in lung function while still or moving slowly; in situations like these only a small portion of the lungs are actually perfused with blood for gas exchange. Destruction of too many alveoli over time leads to the condition emphysema which is associated with extreme shortness of breath. As oxygen requirements increase due to exercise, a greater volume of the lungs is perfused, allowing the body to match its CO2/O2 exchange requirements. Additionally, due to the excess capacity, it is possible for humans to live with only one lung, with the other compensating for its loss.

The environment of the lung is very moist, which makes it hospitable for bacteria. Many respiratory illnesses are the result of bacterial or viral infection of the lungs. Inflammation of the lungs is known as pneumonia inflammation of the pleura surrounding the lungs is known as pleurisy.

Vital capacity is the maximum volume of air that a person can exhale after maximum inhalation; it can be measured with a spirometer. In combination with other physiological measurements, the vital capacity can help make a diagnosis of underlying lung disease.

The lung parenchyma is strictly used to refer solely to alveolar tissue with respiratory bronchioles, alveolar duct and terminal bronchioles. However, it often includes any form of lung tissue, also including bronchioles, bronchi, blood vessels and lung interstitium.

Non respiratory functions In addition to their function in respiration, the lungs also: Alter the pH of blood by facilitating alterations in the partial

pressure of carbon dioxide. Convert angiotensin I to angiotensin II by the action of angiotensin-

converting-enzyme. May serve as a layer of soft, shock-absorbent protection for

the heart, which the lungs flank and nearly enclose.

PathophysiologyPredisposing Factors: Precipitating

Factors:

- Age -Occupation

-Immunosuppressant -Repeated close contact with

-- prolonged corticosteroid infected persons

therapy -recurrence of infection

-systemic infection

-- HIV or aids infection

Exposure or inhalation of droplet nuclei

Tubercle bacilli invasion in the apices of the lungs or near the lower

lobes.

Arrest of a phagosome which result to bacilli replication.

Necrotic degeneration begins

(production of cavities filled with cheese-like mass of tubercle bacilli, dead WBC’s, necrotic lung tissue)

Drainage of necrotic materials into the tracheobronchial tree.

(coughing, formation of lesions)

Primary Infection

(the original outbreak of an illness against which the body has had no opportunity to build antibodies)

Lesions may calcify and forms scars and may heal over a period of time.

Tubercle Bacilli immunity develops

(2-6 weeks after infection)

(maintains in the body as long as living bacilli remains in the body)

Acquired immunity leads to further growth of bacilli and development of active infection.

(An infection that is currently producing symptoms or in which the causative organism of the disease is rapidly

reproducing)

Signs and symptoms:

Pulmonary Symptoms: General Symptoms:

-dyspnea -fatigue

-non productive cough or -anorexia

productive cough -weight loss due to NV.

-Hemoptysis -low grade fever with chills and

-Chest pain sweats often at night.

-Chest tightness

-Crackles may be present on

auscultation.

With medical interventions: Without medical interventions:

-early detection of the dse. -reactivation of the tubercle

-multi-antibacterial therapy. Bacilli (due to repeated

-TB DOTS exposure to infected individual

-BCG vaccination immunosuppresion) 2 o infxn.

Severe occurrence of

lesions in the lungs

No recurence: Recurrence:

Cavitation in the lungs

Good prognosis Bad prognosis occurs.

Active infection is spread

throughout the body

systems. (infiltration of

tubercle bacilli in other

organs.

»TB of the bones

»Pott’s disease

»Renal TB

Severe occurrence of infection

Bad prognosis

Death

Medical management

Ampicillin 500 mg. q 6o

Action:

Destroys bacteria by inhibiting bacterial cell wall synthesis during microbial multiplication.

Indication:

-respiratory tract, skin and soft tissue infection

-bacterial meningitis

-GI or urinary tract infection

-endocarditis

-N. gonnorrhoeae infections

-prophylaxis for sexually transmitted disease.

Contraindications:

Hypersensitivity to penicillin.

Precautions:

Use cautiously in patient with severe renal insufficiency.

Adverse reaction:

CNS: lethargy, hallucinations, anxiety, confusion and dizziness.

GI: nausea and vomiting, diarrhea, abdominal pain.

Respi: wheezing, dyspnea, hypoxia.

Patient teaching:

-instruct patient to immediately report sign and symptoms of hypersensitivity.

-advise patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of fluids.

Discharge summaryM- Multi Vitamin C 5mL ODE- encouraged to do simple exercise like

walking when going to the school.-encouraged the client to participate minimally in ADL.

T- Advised patient/SO’s to strictly adhere to the therapeutic regimen-advised to avoid inhaling smokes came from their source of income.-advised patient and SO to cover their mouth whenever they are coughing or sneezing.-advised to have adequate rest and sleep.

O- instructed the patient to came back after 1 week for follow up check up.

D- -advised to eat nutritious foods rich in vitamin C such as fruits and vegetables.

-advised to increase oral fluid intake of the client.

S- Encouraged to tighten her faith to God and worship Him.

NCPAssessment:

S- “nahihirapan po akong huminga” as verbalized by the client.

O- RR: 35 c/min.

- with yellowish colored nasal secretions.

-Crackle sound upon auscultation.

Diagnosis:

Ineffective airway clearance related to retained secretions.

Planning:

After 1-3 hours of nursing interventions the client will be able to expectorate secretions and alleviate difficulty of breathing

Interventions:

» monitor client’s respiration rate for baseline data

» encourage deep breathing and coughing exercise to the client to maximize lung expansion.

» advised to increase oral fluid intake to liquefy secretions.

» positioned the client on moderate high back rest to maximize lung expansion.

» auscultated breath sounds to ascertain client’s status and note progress of nursing interventions.

» advised to take foods rich in vitamin c such as fruits and vegetables and avoid foods rich in sugar like candies and pastries because sugar attracts microorganism.

» advised to have adequate rest and sleep.

» administer meds prescribed by the physician.

Evaluation:

After 1-3 hours of nursing interventions the client was able to expectorate secretions and alleviate difficulty of breathing.

RR: 28 c/min.

Assessment:S- “parang pagod po ako at palaging

nauuhaw” as verbalized by the client.O- poor skin turgor

-with dry skin and mucous membrane noted.-mild weakness noted.-PR: 120 b/min.

Diagnosis:Fluid volume deficit related to nausea and

vomiting secondary to frequent coughing.

Planning:Within the shift of nursing interventions the

client fluid volume will be maintain at functional level.

Interventions:

-assess vital signs for baseline data and comparison.

-properly regulated IVF of the client.

-advised the SO to prepare beverages and foods high in fluid content.

-advised to increase oral fluid intake.

-advised to wear loose clothing.

-advised to used hypoallergenic soap to the client to maintain skin integrity and prevent excessive dryness.

-encouraged to apply lotions to moisturize the client’s skin.

Evaluation:

Within the shift of nursing interventions the client fluid volume will be maintain at functional level as evidence by stable vital sign, moist mucous membrane and good skin turgor.

PR: 100 b/min.

Assessment:S- “mabilis po akong napapagod at parang

nawawalan po ako ng lakas” as verbalized by the client.

O- slow movement and reaction upon interaction.-drowsiness noted-unable to do simple activity such as feeding herself.

Diagnosis:Fatigue related to weight loss secondary to

vomiting.

Planning:Within the shift nursing interventions will

participate in various nursing interventions and will report improve sense of energy.

Interventions:

-assisted on changing position.

-encouraged the client to do whatever possible activity she can such as walking, self care or self feeding to give sense of energy.

-encouraged the client to assist the client whenever he wants to go to the rest room or to walk, this can help her to feel sense of energy.

-advised to perform activities in gradual motion to avoid injury.

-advised to eat nutritious foods, like foods rich in vitamin C such as fruits and vegetables, also give foods rich in protein such as fish and lean meats and serve foods rich in carbohydrates such as rice to have adequate energy.

-advised to have adequate rest and sleep to regain energy and avoid fatigue.

Evaluation:

Within the shift nursing interventions the client participated in various nursing interventions and report improve sense of energy as verbalized by “nagagawa ko nang kumain ng magisa at maglakadlakad”