1

P.O BOX: 875, BAMENDA.

MOTTO: HOPE IS THE KEY

SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS

FOR THE AWARDS OF HIGHER NATIONAL DIPLOMA (HND) IN

NURSING

April 2018

A CASE STUDY REPORT ON TUBERCULOSIS IN AN HIV POSITIVE CARRIED OUT DURING AN INTERNSHIP AT THE MBENGWI DISTRICT HOSPITAL FROM 8 DECEMBER 2017

TO 8 JANUARY 2018

SUPERVISED BY:

Dr Mfonfu Daniel

PRESENTED BY:

TUNGA HILDA ANNE

REPUBLIQUE DU CAMEROUN --------------------------- PAIX-TRAVAIL-PATTIE ---------------------------------- MINISTERE DE L’ENSEIGNEMENT SUPERIEUR ---------------------------- DIRECTION DE L’ENSEIGNEMENT SUPERIEUR PRIVE ---------------------------------------

REPUBLIC OF CAMEROON ----------------------------- PEACE-WORK-FATHERLAND ------------------------------------- MINISTRY OF HIGHER EDUCATION --------------------------------- DEPARTMENT OF PRIVATE EDUCATION -----------------------------------

2

CERTIFICATION

This is to certify that, this report was written and presented by Tunga Hilda

Anne of the department of Nursing at Capitol Higher Institute of Health

Sciences and Beauty Therapies Bamenda as a partial fulfillment of the

requirement for the award of a Higher National Diploma (HND).

Student_______________________Signature____________ date_________

Supervisor_____________________Signature____________ date_________

Dean of studies ________________Signature____________ date_________

President of Jury _______________ Signature____________ date__________

3

DEDICATION

I dedicate this piece of work to the Almighty God who gave me the grace to

be alive to become what I am and to allow me do this work.

4

ACKNOWLEDGEMENT

I acknowledge all those who supported me spiritually, academically, morally,

socially, financially and materially.

My supervisor Dr.Mfonfu for the time he sacrificed to read and correct

this work.

My parents and my children; Bradley, Nuela, Bryan and Braddel. Also

Nuela and Randy for their educational motivation and financial

support.

Madame Fozing Helen, Madame Apo Gladys, Mr.Asaah K Fombi for

their advice.

The Capitol Higher Institute of Health Sciences and Beauty Therapies

for making me to be what I am today.

My lecturers for the knowledge they have transmitted to me.

The staff of Mbengwi District Hospital, especially those of the

UPEC/TB unit who cooperated when I was carrying put this case

study.

All my friends who supported me in one way or the others.

5

List of Tables

Table 1: Table showing the staffing of the MDH.................................................9

Table 2: Daily drug chart.................................................................................19

Table 3: daily drug chart....................................................................................19

Table 4: daily drug chart...............................................................................19-20

Table No_5: Nursing care plan 1-19/12/17.......................................................23

Table No_6: Nursing care plan 1-20/12/217.....................................................23

Table No_7: Nursing care plan 1-21/12/17..................................................23-24

Table No_8: Nursing care plan 1-22/12/17.......................................................24

Table No_9: Nursing care plan 1-23/12/17.......................................................24

Table No_10: Nursing care plan 1-25/12/17.....................................................25

Table No_11: Nursing care plan 1-26/12/17.....................................................25

Table Number- 12: Vital Signs..........................................................................26

6

List of Abbreviations

CMO Chief Medical Offices

CRA Community Relay Agent

DOA Date of Admission

DOD Date of Discharge

G.S General Supervisor

Km Kilometer

MDH Mbengwi District Hospital

SRN State Registered Nurse

SRN/RH State Registered Nurse in Reproductive Health

TB Tuberculosis

IWC Infant Welfare Clinic

NA Nursing Assistant

HIV Human Immune Virus

ANC AntenatalClinic

IVD Intravenous Direct

SPPTB Sputum Positive Pulmonary Tuberculosis

SNPTB Sputum Negative Pulmonary Tuberculosis

EPTB Extra Pulmonary Tuberculosis

DOTs Directly Observed Treatment Short Course

RHEZ IsoniazidRifampicinPyrazinamideEthambuto

RHE Rifampicin Isoniazid Ethambuto

S Streptomycin

MD Medical Doctor

7

Table of Content

CERTIFICATION………………………………………………………..........2

DEDICATION……………………………………………………………........3

ACKNOWLEDGEMNTS………………………………………………..........4

LIST OF TABLES……………………………………......................................5

LIST OF ABBREVIATIONS……………………………………………........6

TABLE OF CONTENTS…………………………….......................................7

CHAPTER ONE - INTRODUCTION…………………………….............8-11

CHAPTER TWO - REVIEW OF LITERATURE ON THE CASE…...12-16

CHAPTER THREE-PRESENTATION OF CASE……………….........17-26

CHAPTER FOUR - REVIEW OF MEDICATIONS ……………..........27-30

CHAPTER FIVE - TUBERCULOSIS IN AN HIV ADULT……….......31-32

CHAPTER SIX – CONCLUSION……………………………….............33-34

REFERENCE …………………………….................................................34

8

CHAPTER ONE - INTRODUCTION

1.1 Definition of the case

The HIV virus itself doesn‟t kill. It weakens the immune system by destroying

CD4 cells, which usually defend against infection. Most people will remain

healthy for many years after contracting HIV. Only after around five to ten

years, when the virus has severely damaged the immune system, do people

progress to the next stage – AIDS.

AIDS is diagnosed when a defined set of clinical conditions are found in a

person infected with HIV. These conditions are mostly infections that occur

because the immune system is unable to fight them – so called „opportunistic

infections‟. TB is one of the most common „opportunistic infections‟ in people

with HIV.

Tuberculosis is an infectious and contagious disease caused by a microorganism

called mycobacterium tuberculosis or Kock‟s bacilli. It is one of the most killer

diseases because of the advent of HIV /AIDs. HIV infection increases the

prevalence rate of tuberculosis.

1.2 Motivation

I was motivated by the fact that the case was a roaming patient moving from

hospital to hospital without the diagnosis of tuberculosis in HIV. He came from specialised hospitals in Yaoundé to a district hospital in Mbengwi where he was diagnosed of pulmonary tuberculosis.

General objective (goal):

Successfully manage the case of Tuberculosis in an HIV adult as a member of

the medical and nursing team; and to submit the report of this case study in

partial fulfilment to obtain the HND in nursing.

.

1.3 Specific objectives

a) Identify the patient

b) Describe the circumstances of arrival of the patient

c) Admit the patient

d) State the provisional diagnosis on admission, state source

e) Administer any emergency medications

f) Clerk/Assess the patient

g) Administer the medications prescribed by the medical officer, monitor

and record side effects on the patient

h) Establish daily drug chart

9

i) State results of confirmatory diagnostic tests

j) Develop and implement nursing care plans

k) Describe the evolution of the patient and vital signs

l) Revue the medications administered

m) Write the discharge summary

n) Identify positive findings, weaknesses; make recommendations; make

conclusions

1.5. Presentation of the Mbengwi District

The MDH is a reference hospital of Mbengwi health district; it is located some

20km South of Bamenda town and belongs to the Mbengwi Urban Area. It is

made up of 6 buildings with 30personnel and 45beds. Its average daily

consultation at the outpatient is 20patients. The staffing of the hospital is

distributed as follows;

Table 1: Table showing the staffing of the MDH

Staff Number

CMO 01

Medical doctors 01

General supervisor 01

Laboratory staff 04

Ward nurses 05

Maternity 06

1.6. Description of the TB unit of MDH

The TB unit of MDH is a small building located at the old stoned

building. It is made up of three rooms. It has a capacity of 6beds.

These units function with 6personnel, 2 HND, 3NA and 1cleaner.

1.7. General Objective

The main objective is to treat and follow up HIV patients suffering

from tuberculosis.

1.8. Specific Objectives

To create good nurse patient relationship.

Ensure comfort and reassurance for rapid recovery.

Follow up of HIV/TB patient

10

Follow up exposed infants.

Provide psychological preparation before treatment

Provide free TB medications

Provide care to the patients admitted for a disease condition.

Participate in the training of student nurses

Ensure the management of the waste

Ensure the cleanliness of the units.

1.9. Activities of the service

Activities were carried put in 3shifts. We have 2days shift and

2night shift. The day shift starts from 7:30-1:30pm and from

6:30pm-7:30am.

During each shift, a shift report was written which state the health

condition of patients, number of admissions, number of Discharges,

transfers, treatments administered number if death and material

handed over.

1.10. Activities of the day shift

Reading of the night shift report and handling over

General cleaning, dusting of equipment and objects in the service.

Welcome and admit patient

Making up patients bed

Monitor vital signs

Cleaning of instruments and sterilizing them

Assisting during Doctor‟s rounds

Administer patient medications

Give counselling to patients

Write shift duty report and handling over the day shift.

The day shift was done by a ward charge that is an N.A. and assisted

by ol SRN

1.11. Activities of the night shift

Reading of the day shift report and taking over

Monitory the patients

Welcome and admit patients

Clean materials

11

Monitor vital signs and record it

Writing of shift duty report

Handing over to day nurses

1.12. Activities of the night shift

The duty rooster of the unit gives information about the various

nurses working in the service including their night, and day shifts and

also they are off.

These nurses alternate in three shift; 20days and 02nugth shift and

except the ward charge who work on Monday to Fridays with the

assistant who are usually off duty on Saturdays, Sundays and public

Holidays. The cleaner works every morning except weekends in the

morning. Nurses on duty do their rounds before the medical Doctor‟s.

This is done every day. Doctors are called on phone to intervene in

case of emergency during weekends. The ward charges can also

interne during weekend when there is a severe case.

The other nurse work in the morning, the following day in the

afternoon, the following day in the night and goes off for 2days before

resuming duty.

12

CHAPTER TWO - REVIEW OF LITERATURE ON THE CASE

2.0 Causes

Tuberculosis is an infectious and contagious disease caused almost

exclusively by Mycobacterium tuberculosis or Koch‟s bacillus.

Mycobacterium africanum is a variant of M. tuberculosis and has

been found in 10% of tuberculosis patients in Yaounde and the West

Province according to surveys carried in 1995 in Yaounde and 1998

in the West Prorvince.

2.1 Clinical Features (Signs and Symptons)

Tuberculosis should be suspected in a patient who presents with

cough, with or without sputum production that has lasted for at least

3weeks. But with an HIV patient, current cough is a call for concern.

This cough may be accompanied by haemoptysis (blood stained

sputum), chest pain, difficulties in breathing and generalize

symptoms such as loss of weight and appetite, night sweats,

tiredness and fever.

Tuberculosis can also be suspected if the chest X-ray of the patient

shows images suggestive of disease, e.g. cavities in lungs.

13

2.2. Pathophysiology The immunological effect of HIV is manifested

especially on immunity at the cellular level, the part of the immune

system responsible for the response against the tubercle bacillus. The

diminished immunity brought about as a result of the HIV infection

reduces the capacity of the individual to contain the TB infection and

to prevent a new infection or re-infection of micro bacterium.

TB is transmitted by air through an infected person. The interaction

between HIV/TB is bi-directional because mycobacterium

Tuberculosis increases the replication of HIV in vitro and active TB

14

Accelerates the evolution of the HIV infection is HIV positive TB

patients. The presence of active pulmonary TB or extra pulmonary

TB in an HIIV positive patient is indicative of an imminent Aids

phase (National tuberculosis control programme-Cameroon)

2.3. Diagnosis

Sputum microscopic examination is the basic test to be carried out. It

consists in the examination of the patient‟s sputum under the

microscope after it has been stained by the ZienhlNeelsen technique.

The laboratory examinations that are performed are;

Acid flaccid bacilli (ZienhlNeelsen test)

Gene expert

Chest X-ray

Biospsy

2.4. Treatment

The internationally accepted strategy for TB control is known as

DOTS (Directly Observed Treatment, Short Course) and involves

five components:

1. Sustained political and financial commitment

2. Case‐detection through quality‐assured bacteriology

3. Standardized treatment with supervision and patient support

4. An effective drug supply and management system

5. Monitoring and evaluation system and impact measurement5

(Interagency coalition on AIDS and Development-Canada TB/HIV

CO-INFECTION, www.icad-cisd.com)

New cases of tuberculosis are treated with a standardize 6 months

therapeutic regimen. Relapses, treatment failures and retreatment are

managed with a standardize 8 months retreatment regimen. Drugs

are available in district hospitals and approved centres. The health

centre under the supervision of the district health team ensures the

follow - up of the treatment initiated at the district hospital.

The treatment of choice includes the following;

RHEZ dose 20 -25mg/kg body weight in adults used in the

intensive phase for 2 months.

RH dose 20 -25mg/kg body weight in adults used in the

continuation phase 6 months

15

After which a series of sputum control has to be done at 2nd

month of

treatment, 5th

of treatment and 6th

month of treatment.

For cases of relapses, re-treatment cases are managed with the following

choices of drugs.

RHEZ dose 20 -25mg/kg body weight in adults used in the

intensive phase for 3 months.

RHE dose 20 -25mg/kg body weight in adults used in the

continuation phase from 4 to 8months

After which a series of sputum control has to be done at 3nd

month of treatment,

8th

of treatment.

2.5. Complication

HIV/TB is a deadly duo since the disease suppresses the immune

system and give rise to other opportunistic infection.

2.6. Prognosis

It is fatal

2.7. Prevention

TB should be suspected to all HIV cases with current cough

Encourage health centres to identify and refer suspected cases

All TB suspects be identified and screen for TB.

All sputum positive cases be put on treatment

The standardize treatment regimen make sure they are applied

The patient for intensive phase should be isolated

Increase the level of sensitization of the disease in the general

population

Early diagnosis and treatment

2.8. Defining Nursing Care Plan

A nursing care plan is described as all the activities that involve in the

patients from the arrival, management and the evolution of the

patient. These include;

16

The physical presentation of the patient

The past medical history

The present medical history

Laboratory investigation

Treatment

2.9 Nurses’ responsibilities in the administration of drug

The nurse must respect the seven rights of drug administration also

known as the seven rules.

- The right patient

- The right drug

- The right dose

17

CHAPTER THREE-PRESENTATION OF CASE

3.1. Presentation of the patient

The patient is an adult man suffering from HIV/ TB

3.1.1. Demograhic Identity of the case on Admission

Name of the patient: N J

Age: 56 years

Sex:male

Address: mile 19 Mbengwi

Occupation: Engineer

Nationality: Cameroonian

Religion: Christain

Ward: Private 3

Bed Number: bed1

Blood Group: “O+”

DOA: 9/12/2017

3.1.2. Describe the conditions of arrival of the patient at the

hospital/ward and all of what was done to him/her before

admission

The patient was supported into the ward and vital signs monitored.

Physical examination was done by the doctor, lab investigation was

requeted. The doctor requested about how he feels, he then

complained of cough, severe weight loss, night sweat and fever for

two months.

3.1.3. Provisional diagnosis by MD

Pulmonary tuberculosis

3.1.4. Patient past medical history

Age: 56

No of children: 0

18

Serology statue: positive

Diagnosed of HIV in 2014

Patient was a roaming patient as he move from one hospital to other

he was not being diagnose for TB

Treatment type: on tenolamnevir at l‟hopitaljamot Yaoundé before

coming to Mbengwi

Hb: 3.2 G/D

MP: Negative

VDRL: non reactive

Urine: protein and glucose not seen

TPHA: negative

CD4: 61cells

AFB: 3+++

3.1. Past Surgical history

He has never had TB before

Past surgical history

He has never been operated upon

Social history

He does not drink nor smoke

3.2. Family History

No TB found in any of the family members

3.3. Social History

The patient does not drink alcohol or smoke

Physical assessment (vital signs) - TOC, BP, Body weight, pulse,

Respiration, Bowel, Urine, Vomitus, Intake

Temperature:40.2oc

BP:110\70mmhg

19

Body weight:51kg

Pulse:116b\min

Respiration:26c\m

Bowel:normal stool

Urine:urinates 3 times daily(normal)

Vomitus:nil

Intake:fruits only

Table 2: Daily drug chart

Time drug dose route frequency remarks Identity

of nurse

Name of medication

Morning ceftriazone 1g IVD 12hrly served Hilda

Noon Paracetamol 900mg IVD 8hrly served Hilda

Evening gentamycine 80mg IM 12hrly served Hilda

Table 3: Daily drug chat

Time drugs dose route frequency remarks Identity

of nurse

Name of Medication

Morning RHEZ

Ceftriazone

inj

Pyridoxine

gentamycine

3tabs

1g

5mg

80mg

Oral

IVD

Oral

IM

Daily

12hrly

Daily

12hrly

Served

Served

Served

served

Hilda

Hilda

Hilda

Hilda

Noon Ampicilline

paracetamol

1g

900mg

IVD

IVD

8hrly

8hrly

Served

served

Hilda

Hilda

Evening Ceftriazone

Gentamycine

Tenolamefir

1g

80mg

600mg

IVD

IM

oral

12hrly

12hrly

daily

Served

Served

served

Hilda

Hilda

Hilda

Table 4: daily drug chart

Time Drugs dose route frequency remarks Identity

of nurse

Name of medication

Morning RHEZ

Ceftriazone

inj

3tabs

1g

Oral

IVD

Daily

12hrly

Served

Served

Hilda

Hilda

20

3.4. Patients on Admission

Consulted by doctor an adult male age of 56years with cough

(productive), weight loss, night sweat and fever

3.5. Vital sign on admission

Temperature: 40.2oC

Weight: 51kg.

Respiratory rate: 90 cycles/min.

Pulse: 140 beat/min.

3.6. Physical examination

Colored conjunctions

Abdominal pains

Numbness of the lower limbs

3.7. Diagnosis

Pulmonary tuberculosis

3.8. Laboratory examination

Mp –negative

Full blood count

HB 32g/d

WBC 9.6*10^3/mm

CRP:+++

Neutrophils 58%

Eosinophils 00%

Basophils 00%

Lymphactytes 62%

Pyridoxine

Gentamycine

5mg

80mg

Oral

IM

Daily

12hrly

Served

served

Hilda

Hilda

Noon Ampicilline

Paracetamol

1g

900mg

IVD

IVD

8hrly

8hrly

Served

served

Hilda

Hilda

evening Ceftriazone

Gentamycine

Tenolamefir

1g

80mg

600mg

IVD

IM

oral

12hrly

12hrly

daily

Served

Served

served

Hilda

Hilda

Hilda

21

3.9. Specific management of patient with drugs

09/12/17

Transfuse 2pints of whole blood

Ceffriazone injection 1g*2*7/7

Ampiccilline injection 1g 1vail*3*7/7

Gentamycine injection 80mg

Paracetamol injection 300mg

900mg tiding 3/7

10/12/1

1. RHEZ 3 tablets daily at 5am

2. Ceflriczone injection1g bd*7/7

3. Ampicilline injection(1vial tid *7/7)

4. Gentamycine injection song 1amp bd*5/7

5. Paracytamolinjection300mg(900mg tid*3/7)

6. Pyridoxine 1tab daily x 30 days

11/12/17

1. RHEZ 3tabs daily at 5am

2. Cefriazone injection 80mg 1g bd*5/7

3. Centa injection 80mg(1amp bd*5/7)

4. Paracetamol injection 300mg(900mg tid *3/7)

5. Ampicelline1g(1tid*7/7)

6. TB control

12/12/17

1. RHEZ 3 tabs daily at 5am

2. Cefriazone injection 1g(1g bd*7/7)

3. Gestamycine injection 80m(80mg bd*5/7)

4. Ampicelline injection 1g(1g tid*7/7)

13/12/17

Continues antibiotics(RHEZ 3 tabs daily at 5am

14/12/17

22

Continues antibiotics 1g(RHEZ 3 tabs daily

5am)

15/12/17

Continues ceffriazone 1g (RHEZ 3 tads daily at

5am

16/12/17

Amoxicalline tabs 1 tid *1g

Relay with orals antibiotics

17/12/17

1. Amoxicalline tabs 500mg (1tib 7/7)

2. Ranferon capsule (1 bd * 30/7)

3. RHEZ tab 3 tabs daily at 5am

18/12/17

1. Continue RHEZ

2. Continue Ranferon

3. Amoxicilline tabs

4. Pyridoxine

19/12/17

Continue RHEZ

Continue Ranferon

Continue Amoxicilline

Pyridoxine 25mg daily

20/12/17

1. Continue RHEZ

2. Continue Amoxiciline

3. Continue Pyridoxine

4. Continue Ranferone

23

Table No_5: Nursing care plan 1-19/12/17: Need: Need to eat soft and easily

digested food

Nursing diagnosis: Activity intolerance related to lack of energy and inability to

eat

Objectives Nursing

intervention.

Rationale Evaluation.

Patient will eat

soft and easily

digested food

Educate the carrier

of the type of food

Adequate

information on how

to prepare the food

will improve

nutrition

Goal was met.

The patient

was able to eat

Table No_6: Nursing care plan 1-20/12/217: Need: need to have normal

temperature

Nursing diagnosis: Hyperthermia (38.6c/ related to disease condition

Hyperthermia (38.6c/ related to disease condition

Objectives Nursing

intervention.

Rationale Evaluation.

Client temperature

will be within

normal range of

36.2c-37.2c in

2hours after

nursing

intervention

Reduce

patients

clothing

Improve

ventilation in

the room

Administer

paracetamol

as prescribed

Monitor temperature

Reduce

clothing,

allow free air

to pass

through the

and heat loss

by convection

Paracetamol has

anti-pyretic property

which reduces

patient temperature

Temperature

dropped from

40.2c to normal

value 36.8c

Table No_7: Nursing care plan 1-21/12/17: Need: need to sleep

Nursing diagnosis: Altered sleep pattern related to exhaustion and manifested

by agitation

24

Objectives Nursing

intervention.

Rationale Evaluation.

Patient will sleep

8hours daily

within the time

stay in the hospital

Advise patient to

sleep on demand

Sleeping on demand

will improve pattern

of sleeping and

calming the patient

Patient slept

for more than

12hours

Table No_8: Nursing care plan 1-22/12/17: Need: need to breathe normaly

Nursing diagnosis: Altered breathing (90cycle/min/related to infection as

manifested by nasal abdominal muscle in breathing

Objectives Nursing

intervention.

Rationale Evaluation.

Patient will

have a

breathing rate

of 40-6

cycles/min/in

12hours

-Assess patient

respiratory track

to keep it open

-Give Ampicillin

Gentamycin as

prescribed

-Place the patient

in a lateral

position

-To know if there is any

variation of respiration rate

-Ampicilli, Cerfriazone,

Gentamycin reduces

infection and decreases

respiration track infection

Putting patient in the lateral

position will give room to

expand freely give room to

expand freely

Goal was met

as in 24hours,

the respiratory

rate was

without the use

of accessory

muscles

Table No_9: Nursing care plan 1-23/12/17: Need: need to breathe normaly

Nursing diagnosis: Altered nutrition less than body requirement related to the

ability to feed

Objectives Nursing

intervention.

Rationale Evaluation.

Patient will eat

4squamitts

meals for

6hours for

6days

-Educate the patient

on nutrition

Give drugs as

prescribed

-To know if there is any

variation of respiration rate

-Ampicilli, Cerfriazone,

Gentamycin reduces

infection and decreases

Monitor urine

output 12hourly

25

respiration track infection

Putting patient in the lateral

position will give room to

expand freely give room to

expand freely

Table No_10: Nursing care plan 1-25/12/17: Need: need to be calm

Nursing diagnosis: Knowledge deficit on the prognosis and management of the

disease

Objectives Nursing intervention. Rationale Evaluation.

Patient will

state the

cause, signs

and symptoms

-Educate the patient on nutrition

-Give drugs as prescribe

Reassuring the patient carrer

-Education concerning the

treatment and outcome of the

disease

Answering and questioning the

patient to clarify doubts.

Reassurance

will make the

patient gain

information on

the disease.

Anxiety was

relieved as the

career was calm

Table No_11: Nursing care plan 1-26/12/17: Need: need to have knowledge

Nursing diagnosis: Anxiety of the patient carer related to unknown outcome of

the patient‟s disease

Objectives Nursing

intervention.

Rationale Evaluation.

Patient will

state the cause,

signs and

symptoms and

prognosis in

two days

-Educate the

patient on the

cause, prognosis,

treatment and

outcome

Reassurance will make the

patient gain information on

the disease.

Patient could

give the cause,

signs, treatment

and outcome of

the disease

26

Table Number- 12: Vital Signs

Date Period TOC BP Body

Weigh

t

Pulse

b/c

Respiration Bowel Urine Vomitus Intake

9/12/

17

Morning 40.2 116/76 61kg 116 26c/m Nil 500cc Nil Fruits

Evening 38.5 120/80 61kg 120 24c/m Nil 350cc Nil Fruits

10/12

/17

Morning 39.1 125/85 60kg 122 22cm Nil 250cc Nil Fruits

Evening 38.2 115/70 60kg 120 24cm Twice 300cc Nil Fruits

11/12

/17

Morning 36.5 120/70 58kg 122 22cm Once 250cc Nil Fruits

Evening 36.9 118/70 58kg 120 22cm Nil 150cc Nil Nil

12/12

/17

Morning 37.5 120/60 57kg 118 20cm Nil 250cc Nil Pap

Evening 37 115/70 57kg 116 20cm Nil 150cc Nil Pap/fr

uits

13/12

/17

Morning 36.5 120/70 56kg 113 18cm Nil 200cc Nil Fruits

Evening 36 120/80 56kg 112 18cm Nil 200cc Nil Pap

27

CHAPTER FOUR - REVIEW OF MEDICATIONS

4.1. MEDICATION 1

1. (RHEZ) / 4(RH)

Composition

The regimen comprises a combination of Rifampicin- Isoniazid-

Pyrazinamide (RHEZ) taken daily for 2 months followed by a

combination of Rifampicin- Isoniazid taken daily for 4 months

that is a total duration of 6months of continuous treatment.

Indication

Initial Intensive Phase

The drugs: a fixed dose combination (4-FDC) of Rifampicin-

Isoniazid –Ethambutol- Phyrazinamid is least one (once a day on

an empty stomach in the morning at least one hour before eating)

under the strict supervision of the health personnel.

Contra – Indications

Patient with hypertitis (jaundice)

Respiratory Distress

Purpura, acute haemolytic anaemia

Kidney failure, shock.

Abdominal pain and nausea.

An erythematous skin and / or itches and / or rash.

Dosage

Adults dose: 20 – 25 mg/ kg body weight

Children dose: 5 – 10 mg –kg body weight

Side Effects

28

The side effects of anti – tuberculosis drugs can be classified into

two categories: Minor and major side effects.

Minor side effects only cause sight discomfort. They however,

have to be taken into consideration as they can lead to the

abandonment of treatment by a patient who painfully supports the

side effects and who on feeling better, may no longer see the need

to follow up such treatment for so long a time. It is therefore

important to watch out for these symptoms, modify the treatment to

diminish or clear them away; but above all convince the patient to

continue treatment.

Major side effects can constitute a serious threat on the patient‟s

life. It is therefore necessary to be vigilant so as to anticipate

prodromal signs of the major side effects on time and so refer the

patient with such symptoms to a competent health care institution.

4.2. MEDICATION 2

2. CEFTRAXONE

Composition

Each vial contained ceftriaxone Sodium equivalent to 250mg, 500mg

or 1g

Indication

It is indicated for the treatment of lower respiratory tract infection,

urinary and billiary tracts infection, abdominal infection, pelvis

infection, skin infection, soft tissues, bone and joint infections,

,meningitis and pre-operative prophylaxis of infections.

It was indicated to treat the opportunistic infection in the client

Contra- indication

It is indicated in patients with known allergy to Cephalosporrin class

of antibiotics.

Client did not present any contraindication

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Dosage

Adults and children over 12 years: 1-2g once daily. It may be raised

to 4g

Infants and children below 12years: 20-80mg/kg once daily.

For the client, the dose was 1g twice daily

4.3. MEDICATION 3

3. Gentamicin

Each ampoule contains a solution of Gentamicin Sulphate equivalent

to 10mg, 20mg and 40mg per ml

Indication

It is used in case of bacteriaemia, septicemia, urinaru tract infection,

severe chest infection

It was used to treat severe chest infection in the client

Dosage

In children up to 12 years 6mg/kg in 24hours

In infant up to 2weeks: 30mg/kg 12hourly

Adult: 160mg daily may be used.

The dosage for the client was 80mg 12 hourly

Precautions

In case of impairment of renal function

Side Effects

Nephrotoxicity, ototoxicity, nausea, vomiting and headache

No side effect was observed on the client

4.4. MEDICATION 4

4. Paracetamol

Each ampoule contains a solution of paracetamol 300mg and 600mg

per 2meals

15

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Indication

It is used in case of hyperpyrexia

It was used on the client

Dosage

In children up to 12years: 300mg in 8hourly

In adult above 12years: 900mg 8hourly

The dosage for the client was 900mg 8hourly

4.5. MEDICATION 5

5. Pyridoxine

It is indicated for allergy reaction of anti tuberculosis drug

This patient was on pyridoxine 1tablet daily

4.6. Side effects observe on the case and management of them of the

above medications

No side effect was identified.

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CHAPTER FIVE – DISCHARGE SUMMARY

TUBERCULOSIS IN AN HIV ADULT

5.1. Diagnosis on Admission

TB in An HIV client

5.2. Diagnosis on Discharge

-pulmonary TB and added to his previous HIV condition.

5.3. Treatment received

RHEZ, Ceftriazone, Gentamycine, Paracetamol and Pyridoxine

5.4. Response to Treatment

Treatment was favourable

5.5. Home Treatment

They include;

RHEZ: 3 tablets daily at 5:00am

Pyridoxine: 1 tablet daily at 9:00am

Tenofovir, Lamivodine, Efavirence: 1 tablet at 7:00pm

5.6. Appointment Date

Client was advised to return to the hospital on the 5th of January

2018.

5.7. Follow Up (Appointment by telephone if appointment is not

respected)

The follow up of this patient is done by the use of a telephone if

appointment is not respected but this client respected his

appointment.

5.8. Advice on Discharge

Patients were discharge and advised on the following;

Advised to take medications on time

Patient encouraged to eat a balance diet

To respect subsequent appointments

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To come back to the hospital quickly if signs of complications

before the day of follow up

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CHAPTER SIX- CONCLUSION

6.1 Positive Findings

The client adhered to treatment

No major side effect was identified in the client during the

treatment

Client was satisfied because treatment was free of charge

Client was satisfied because hospitalization was free of charge

Client was satisfied because laboratory follow up was free of

charge

Adequate psychosocial workers who spent most of their time

counselling their patients

His medication was being serve by the health staff on duty

6.2. Difficulties Encountered

There include;

Difficulty of the patient career to master the nursing intervention

Difficult financial constrain

Difficulties to tolerate the side effects of drugs

Poor nutrition

Difficulties to accept his/her condition

6.3. Solutions

There include;

The same information is given to the client several times,

assurance was done by asking questions to ensure that he /she has

mastered.

The manager of the hospital should provide financial mines and

also train Tuberculosis staff on how to use it.

Pre/post treatment counselling has always been enforced

6.4. Recommendations

Family members should be well sensitize on the condition of the

client

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A proper fund be instituted for TB/HIV clients

6.5. Conclusion

TB/HIV patients should be treated according to guide line described

by World Health Organization (WHO). Reinforcement of counseling

during treatment is always very necessary.

6.6 References

There include;

National Tuberculosis Control Programme (Manual for Health

Personnel) 2006 Edition.

Past Reports of Madam Fozing Helen on Neonatal Sepsis 2015

session.

Past Report of Nji NuelaAnyenon Graphic Designs 2016 session.