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nursing care Planpulmonary Tuberculosis

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nursing care Planpulmonary Tuberculosis
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  CASE STUDY ON PULMONARY TUBERCULOSIS DEMOGRAPHIC DATA OF THE PATIENT :  Name : Mr. kailesh Father’s /husband’s 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 member Age Sex Relation with the patient Health status 1 . Mr .kailesh 30 years Male Patient Poor 2. 3. 4. Mrs. Parwati Pooja munna 25 years 2 years 7 years Female Female male Wife Daughter son Having  joint pain Healthy 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 : 99.8®F Pulse : 42/mt. Respiration : 44/mt. Blood pressure : 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 : Normal Visual field : 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

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