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CASEPRESENTATION:
LungAdenocarcinoma
Submitted by:
Mariz Mae S. BoligaoElaine Therese M. Cabacang
Maridee P. Dimagna-ongJulie C. Hubilla
Phea Lenny C. NambatacCarl Stephen B. PerezCharlene Marie A. Raya
BSN-RUBY
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PATIENTS DATA
Personal Data:
Patients Name: Beachin BaratoAge: 65 years oldGender: FemaleBirth date: December 11, 1942Address: Davao CityNationality: FilipinoReligion
[Domination]:
Christianity [Roman Catholic]
Civil Status: Married
EducationalAttainment:
High School Graduate
Occupation: Retired High School Teacher for 10 yearsWeight: 62 kilograms
Clinical/ Admitting Data:
Date of admission: July 2, 2009Time of admission: 9:30 amHospital: Davao Medical School Foundation Davao City
[1604730]Ward [Room & Bed
Numbers]:
H244
Attending Physician: Dr. Allan P. Arreola
Chief complaint: Difficulty breathingAdmitting and Final
Diagnosis:
Left Massive Pleural Effusion secondary to Lung
CAVital signs on
admission:
Temperature:
Pulse Rate:
Respiratory Rate:
Blood pressure:
36C Degrees Celsius
87 Beats per Minute
23 Cycles per Minute
130/ 90 mmHg
Chest Tube Thoracostomy
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Surgical Procedure
Done: *Pre-operation Diagnosis: Massive left pleural effusionsecondary to lungcancer
*Surgeon: Dr. Lei
*Anesthesiologist: Dr. Barinaga
Source of
information:
Patient; Patients daughter-in-law; Husband
FAMILY BACKGROUNDAND HEALTH HISTORY
HEALTH BACKGROUND
A. Family Background
Beachin Barato (not her real name), 65 years old was born in
Misamis Occidental, on December 11, 1942. She spent majority of her
childhood there but was separated with her family during the Philippine-
Japanese war. In fact, she does not know who her real parents and siblings
are. She acquired formal education up to high school while living in an
orphanage. She met her current husband, Mr. Optimus Prime (engineer), who
is from Davao, in Misamis. Optimus Prime was working as an engineer in
Misamis when they met. The couple decided to marry in Davao, where the
family of Optimus Prime can witness the wedding and provide support to the
couple, who are still starting out as a young family.
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The couple has three children, all of which are boys. Their sons got
formal education in Davao City National High School. Moreover, all are
college graduates in different universities and colleges. Mr. Optimus Prime
had a stable job working as an engineer and was their main source of
income. Beachin Barato was a devout Catholic, joining church organizations
and becoming an active member in their mission of enriching their faith,
while recruiting others along the way, as Beachin Barato remarked. This
provided her good experience to be a teacher of Religion in Davao City
National High School for 10 years.
Beachin Barato has nine grandchildren, three for each sons. She only
has two granddaughters. Beachin Baratos sons have become successful in
their chosen professions, thus they had the means to afford good education
for their children. Her eldest son, Bumble Bee, is a manager at a
telecommunications company. He has two sons in college while her youngest
daughter is still in high school. Her second son, Ironhide, is now working in
Pampanga as an engineer for the DPWH. His three sons are still in high
school. The third son, Jetfire is currently working as a manager at an oil
company. He has two sons and a daughter. The eldest is in high school while
the younger children are in grade school.
B. History of Past Illness
The past illnesses that the patient has encountered in the past
were not significant. Only common minor illnesses such as fever, flu, and
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hyperacidity were experienced by the patient in her lifetime. She did not
experience severe, yet common diseases such as dengue and measles. Also,
she has no diabetes mellitus. She has no history of food and drug allergies or
hypersensitivities. She and the entire family, according to her, do not smoke.
Also, consuming alcoholic beverages was something she did not do. A
notable health condition that she experienced is bronchial asthma. She
coped with asthma by finding a comfortable position during asthma attacks
and she did not take any medications because those were not available yet.
Her asthma subsided when she was about 40 years old. A significant disease
that she encountered (and is still encountering) later on in her life is
hypertension. She was diagnosed after getting her routine blood pressure
checkup. The doctor advised her to avoid salty and fatty foods and she was
also given medicine, specifically amlodipine besylate- Norvasc.
Medications she took in her lifetime were not numerous, according to
her. In fact, she said she hardly ever took medications. Paracetamol was
always her first choice whenever she encounters fever and colds. She also
took some Neozep and mefenamic acid in her lifetime. Also, the patient
noted that she had to comply with taking Norvasc for her hypertension.
C. Present Health History
The patients hypertension is now held at bay by doing follow-up visits
to the doctor, asking for advices and of course, compliance with medications.
She also minimized eating her favorite food, which is pork, for the sake of
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improving her hypertensive state. She is currently in a pre-hypertensive
state with a blood pressure of 130/90 mmHg. The doctors first impression
with her hypertension was that she was in Stage 2, thus we can say that her
condition has significantly improved.
The patients lung cancer was diagnosed when she was having an
onset of difficulty of breathing for three days when she was on a vacation in
Pampanga last May 2009. As the days went by, she noticed a progression of
dyspnea. Initially, she thought that her asthma had recurred, which
prompted her to seek consultation on June 2009. After a series of diagnostic
procedures, she was then diagnosed of having lung cancer. The cancer was
classified as adenocarcinoma, or a cancer originating in the mucus producing
glands in the lungs. It is known to be the most common cancer in lifelong
non-smokers.
On July 2, 2009, upon receiving the chest x-ray result, her physician,
Dr. Arreola, ordered a STAT chest tube thoracostomy. Dr. Lei performed the
procedure with the help of Dr. Barinaga as the anesthesiologist.
DEFINITION OF COMPLETEDIAGNOSIS
MASSIVE PLEURAL EFFUSION secondary to LUNG
CANCER
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Pleural effusion, a collection of fluid in the pleural space, is rarely a primary
disease process but is usually secondary to other diseases. Normally, the
pleural space contains a small amount of fluid (5 to 15 ml), which acts as a
lubricant that allows the pleural surfaces to move without friction...
Bronchogenic Carcinoma is the most common malignancy associated with
pleural effusion.
Lung cancer arises from a single transformed epithelial cell in the
tracheobronchial airway. A carcinogen binds to cells DNA and damage it. This
damage results to cellular changes, abnormal cell growth, and eventually a
malignant cell. As damage DNA passed on to the daughter cells, the DNA
undergoes further changes and becomes unstable. With accumulation of
genetic changes, the pulmonary epithelium undergoes malignant
transformation from normal epithelium to eventual invasive carcinoma.
(Kelly, 1997)
Cited on medical-surgical nursing vol. 1 (2000)By: Suzanne C. Smeltzer and Brenda G. Bare
PHSYICAL ASSESSMENT
Date of Assessment: July 4, 2009
Time of Assessment: 5:25 pm
Location of Assessment: Davao Medical School Foundation Hospital
Vital Signs
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Temperature : 36 degrees CelsiusPulse Rate: 87 Beats per MinuteRespiratory
Rate:
23 Cycles per Minute---
RapidBlood Pressure: 130/90 Millimeter per
Mercury
General Survey
During assessment, the patient was eating on bed. There is a chest tube
connected to a chest tube drainage installed on the surgical site located at the 6 th
and 7th intercostal space of the left lung. Patient is awake, conscious, coherent, and
oriented to time, place, person and reason for admission. She is calm and
responsive. The patient has an endomorph type of body; with a height of 158.49
centimeters or 62.4 inches and with a weight of 62 kilograms or 136.4 pounds.
Patient had already done her general and oral hygiene and was dressed
appropriately for the occasion.
Skin
Her skin color is normal, appears thin and translucent, dry and flaky over the
extremities. Skin lost its elasticity and takes longer to return to its natural shape
after being tented between the thumb and finger. The palms and the soles are
calloused. Wrinkles appear on the skin of the face and neck. Freckles are also noted
on the back of the hand. Incision site is 2 cm on the lateral thorax on the 6 th and 7th
intercostal space of the left lung and the compact dressing appears to be fixed. Hair
is black, thin and fine textured but not evenly distributed on the scalp. No infection
or dandruff noted. Scalp is free of lesions. The hair of the eyebrows is coarse. Nails
are pink, firm with capillary refill of 2 seconds and without lesions or clubbing.
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Head
Head is symmetrical, rounded normocephalic with smooth skull contour
positioned at midline and erect with no lumps or ridges. Facial movements are
symmetrical and patient is able to perform different kinds of facial expression
effortlessly and without any obstructions.
Eyes
Patient uses corrective lenses when reading. Eyebrows are symmetrically
aligned and with equal movement with no presence of flakes, scars, or lesions.
Darkened skin around the orbit of the eye is noted. Skin folds of the upper lids are
more prominent, and the lower lids sag. Eyes are dry and lusterless and iris appears
pale with brown discolorations. Conjunctivas of the eye are also pale. Pupil reaction
to light and accommodation is normally symmetrically equal, 2mm in size diameter.
Both eyes are coordinated; move in unison and with parallel alignment.
Ears
The color of patients ears is the same as her facial skin. The left and the
right pinna are symmetrical and are aligned with the inner canthus of the eye.
There is no foul smelling serous or purulent discharges noted. External canal is
normally clear with minimal dry cerumen. The earlobe is elongated and the skin of
the ear is dry and less resilient. Upon palpation, auricles are mobile, and non-
tender; pinna recoils after it is folded. The patient was able to hear normal voice
tones and is able to hear ticking in both ears, as whispered same words on both
ears with correct responses.
Nose
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The nose is symmetric, straight, and uniform in color and no discharges or
flaring noted. Air moves freely as the patient breathes through the nares. Nasal
mucosa is pink, clear and no lesions noted. Nasal septum is intact and in midline.
Upon palpation, no tenderness noted.
Mouth
Lips are dry, cracked and pale in color and with symmetry in contour. Patient
is wearing dentures and has an incomplete set of teeth. Gums are pinkish in color,
dry and firm with yellow discoloration of the enamel and dental carries was noted
on both lower right and lower left of the teeth. The tongue is normally in midline
and was able to move freely, and the base has prominent veins. The patient is able
to swallow with no difficulty.
Pharynx
The patients uvula was located along the midline. The mucosa was pinkish in
color and no lesions or ulcerations noted. The tonsils were pink and smooth, no
discharges or inflammation noted.
Neck
Neck can perform any range of motion without discomfort and with equal
muscle strength as the patient turns his head from left to right; up and down; and
circular motion. Trachea was located centrally in the midline of the neck, spaces are
equal on both sides, and no deviation noted on any part. No lymph nodes noted on
any of the areas of the neck. Thyroid gland is not visible upon inspection. No lymph
nodes palpated
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Chest and Lungs
The patients thoracic curvature is accentuated , her chest was not
symmetrical due to the surgical site and the spine was vertically aligned from the
neck to the buttocks. There was a full and symmetric chest expansion. The
anteroposterior diameter of the chest widens because of barrel-chested
appearance. Upon auscultation, no adventitious sounds can be heard.
Heart
The patients precordial area is flat; there was no lift or heaves. The point of
maximal impulse was located at the fifth left intercostals spaces or along the breast
line in line with the nipples. During palpation, the patients carotid artery produces
full pulsations with thrusting quality.
Breast and Axilla
Patients breasts were even. Skin was smooth and uniform in color with the
abdomen. During palpation, there were no tenderness, masses or nodules noted
with the patients axillary, subclavicular and supraclavicular lymph nodes. There
were also no discharges in the patients nipples. Breast is noted to be saggy in
contour and in shape as a sign of breastfeeding and child birth.
Abdomen
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Patients abdomen is round, with silver white striae, symmetric contour, and
no evidence of enlargement of liver or spleen. Abdominal wall is slacker and
thinner. The patients abdominal girth measures 34 inches or 74.8 centimeters. Skin
returns quickly to its original shape when picked up between two fingers and
released. Growling sounds noted with fifteen (15) bowel sounds per minute. No
areas of tenderness or palpable organs noted upon palpation. Patient defecates
once a day, every morning.
Genitor-Urinary
The patient declined to assess her genitals. However, according to the client
there were no discharges and pain during urination.
Back and Extremities
Patients peripheral pulses were symmetrical, strong, within normal rate,
regular in rhythm at 24 beats per minute. The patients nails took 2 seconds for the
capillary refill. The nails were pinkish in color. Edema was not noted on the patients
upper extremity and lower extremities. There are bilateral warmth on both arms
and legs of the client.
The patient was able to perform range of motion without any discomfort,
swelling, deformity, or nodule on her upper and lower quadrants and on both upper
and lower extremities. Weakness and pain were noted at the upper left extremity of
the patient near the incision or surgical part. There is no missing finger or bone
enlargement on the hands and wrists.
The back is also symmetrical with the spinal cord aligning from the neck
down to the buttocks. There were no deformities or abnormalities on the bone such
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as scoliosis, osteoporosis and alike to be noted. There are also no lesions and the
like noted on the back. Skin color at the back and the extremities are similar with
the rest of the body. Hip joints and thighs can perform range of motion without any
discomfort.
ANATOMY AND PHYSIOLOGY
The lungs are a pair of cone-shaped breathing organs in the chest. The lungs
bring oxygen into the body as you breathe in. They release carbon dioxide, a waste
product of the bodys cells, as you breathe out.
Each lung has sections called
lobes. The left lung has two lobes,
while the right lung is slightly larger and
has three lobes. Two tubes called
bronchi, lead from the trachea (windpipe)
to the right and left lungs. These
bronchi are sometimes also
involved in lung cancer disease process.
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Tiny air sacs called alveoli and small tubes called bronchioles make up the inside
of the lungs. A thin membrane called the pleura covers the outside of each lung and
lines the inside wall of the chest cavity. This creates a sac called the pleural cavity. The
pleural cavity normally contains a small amount of fluid that helps the lungs move
smoothly in the chest when you breathe.
Lung Cancer
Cancer of the lung, like all cancers, results from an abnormality in the
body's basic unit of life, the cell. Normally, the body maintains a system of checks
and balances on cell growth so that cells divide to produce new cells only when
needed.
There are two main
types of lung cancer, non-
small cell lung cancer and
small cell lung cancer. First
is the Non-small Cell Lung
Cancer. NSCLC accounts for about 80% of lung cancers.
There are different types of NSCLC, including 1. Squamous cell carcinoma (also
called epidermoid carcinoma). This is the most common type of NSCLC. It forms in
the lining of the bronchial tubes and is the most common type of lung cancer in
men. 2. Adenocarcinoma. This cancer is found in the glands of the lungs that
produce mucus. This is the most common type of lung cancer in women and also
among people who have not smoked. 3. Bronchioalveolar carcinoma. This is a rare
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subset of adenocarcinoma. It forms near the lungs' air sacs. Recent clinical research
has shown that this type of cancer responds more effectively to the newer targeted
therapies, and 4. Large-cell undifferentiated carcinoma. This cancer forms near the
surface, or outer edges, of the lungs. It can grow rapidly.
The second type of lung cancer is the Small cell Lung Cancer. SCLC accounts for
about 20% of all lung cancers. Although the cells are small, they multiply
quickly and form large tumors that can spread throughout the body. Smoking
is almost always the cause of SCLC.
Adenocarcinoma
Like other cancers, adenocarcinoma is the growth of abnormal cells. These
cancerous cells multiply out of control and form a tumor. As the tumor grows, it
destroys parts of the lung. Eventually, the tumor's abnormal cells can spread
(metastasize) to other parts of the body, including the local lymph nodes in the
chest and the central portion of the chest, called the mediastinum; the liver; the
bones; the adrenal glands; and other organs, including the brain.
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When lung cancer metastasizes, the tumor in the lung is called the primary
tumor, and the tumors in other parts of the body are called secondary tumors or
metastatic tumors. Tumors are dangerous because they take oxygen, nutrients, and
space from healthy cells, thus leading to the destruction of the healthy and normal-
functioning cells in our body
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DIAGNOSTIC EXAM
COMPLETE BLOOD COUNT WITH PLATELET COUNT
Date ExamNormal
ValueRationale
Result
of
Patient
Clinical
SignificanceNursing Responsibilities
Hemoglobin 120 160
g/dL
The test that
measures the
amount of
hemoglobin
per liter of
blood
122
g/dL
Normal 1. Discuss and explain the procedure
and purpose of the test.
2. Inform the patient that no fasting is
needed.
3. Assess the patient for any factor that
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Date ExamNormal
ValueRationale
Result
of
Patient
Clinical
SignificanceNursing Responsibilities
July 2,
2009
will probably affect the results of the
test.
4. Make sure patient is well hydrated.
Dehydration elevates the test results.
5. If patient is connected to IVF, make
sure that the blood is not taken from
the arm connected to the IVF.
Hemodilution causes false decrease of
the test results.
6. After the puncture, assess the site
for bleeding or bruising.
Hematocrit M: 42-
52%
F: 37-
47%
The test
measures the
percentage of
RBC in the
total blood
volume
35% Normal
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Date ExamNormal
ValueRationale
Result
of
Patient
Clinical
SignificanceNursing Responsibilities
7. If patient is under treatment from an
infection, inform the patient that the
test will be repeated to monitor
progress.
8. Any abnormality noted will be
reported to the physician.
WBC count 0.5-10
X10^9/L
The test
measures all
leukocytes
present in 1
cubic
millimeter of
blood.
13.6 X
10^9/L
HIGH:
Conditions thatcause high WBCvalues include
infection,inflammation,damage to bodytissues, severephysical oremotional stress(such as a fever,injury, orsurgery), burns,kidney failure,lupus,tuberculosis,rheumaoidarthritis,
malnutrition,leulemia, anddiseases such ascancer.
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Date ExamNormal
ValueRationale
Result
of
Patient
Clinical
SignificanceNursing Responsibilities
Monocyte 2 10% Monocytes
have
phagocytic
action. It
removes dead
or injured
cells, cell
fragments,
and
microorganis
m. This test is
done to
diagnose anillness such as
inflammatory
diseases.
2% Normal
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Date ExamNormal
ValueRationale
Result
of
Patient
Clinical
SignificanceNursing Responsibilities
Eosinophils 1 8%
Eosinophils
initiate
allergic
responses and
act against
parasitic
infestation.
The test is use
to diagnose
worm
infestation.
2% Normal
RBC count 4.0-5.0X
10^12/L
The test
measures the
circulating
RBCs in 1
cubic
millimeter of
blood.
4.73X
10^12/
L
Normal
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Date ExamNormal
ValueRationale
Result
of
Patient
Clinical
SignificanceNursing Responsibilities
Thrombocyt
es
150-
300X
10^9/L
The test
measures the
amount of
platelets that
are important
for blood
clotting.
290
X10^9/
L
Normal
Lymphocyte
s20-40%
The test
meaures the
percentage of
the principal
component of
the bodysimmune
system.
20% Normal
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PROTHROMBIN TME
Date ExamNormal
ValueRationale
Result
of
Patient
Clinical
Significanc
e
Nursing Responsibilities
July 2,
2009
Prothrombi
n time
12-15
seconds
The
prothrombin
time is the
time it takes
plasma to clot
after addition
of tissue
factor. This
measures the
quality of the
extrinsic
pathway (as
well as the
common
pathway) of
coagulation.
12.4
second
s
Normal
1. Discuss and explain theprocedure and purpose of thetest.
2. Assess the patient for anyfactor that will probably affectthe results of the test.
3. Check to see if the patient istaking any medications that mayaffect test results. Thisprecaution is particularlyimportant if the patient is takingwarfarin, because there are anumber of medications that caninteract with warfarin to increaseor decrease the PT time.
4. After the procedure,there mustbe routine care of the areaaround the puncture mark. Applymoist warm compresses on thearea around the puncture mark.
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Date ExamNormal
ValueRationale
Result
of
Patient
Clinical
Significanc
e
Nursing Responsibilities
5.Apply pressure for a fewseconds and the cover the woundwith a bandage.
6. Inform the patient that theremight be mild dizziness and thepossibility of a bruise or swellingin the area where the blood wasdrawn.
International
NormalizedRatio
0.81.2
The test is toknow if there
is a high
chance of
bleeding or
high chance
of blood clot.
0.07 Normal
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DRUG NAME ACTION INDICATION CONTRAINDI-CATION
ADVERSEREACTION
NURSINGRESPONSIBILTIES
DATEORDERED:FEB.13 2011GENERICNAME:NEBULIZATONWITHSALBUTAMOL +IPRATROPIUMQ 8 1 AMP.BRAND NAME:ACTIVENTDOSAGE ANDFREQUENCY:1NEB. 1AMPEVERY 8HOURS.
CLASSIFICATION:SYMPHATOMIMETICS
>STIMULATESBETA2RECEPTORS OFBRONCHIOLESBY INCREASING
THE LEVELS OFCAMP WHICHRELAXESSMOOTHMUSCLES TOPRODUCEBRONCHODILATION.
> RELIEFANDPREVENTIONOFBRONCHOSPASM INPATIENTSWITHREVERSIBLEOBSTRUCTIVE AIRWAYDISEASE ORCOPD>INHALATION AND
TREATMENTOF ACUTEATTACK OFBRONCHOSPASM
>HYPERSENSITIVITY TO ASALBUTAMOL,ALSO TOATROPHINEAND ITSDERIVATIVES.>CARDIACARRHYTHMIAASSOCIATED W/
TACHYCARDIACAUSED BYDIGITALISINTOXICATION.
>FINESKELETALMUSCLE
TREMOR, LEGCRAMPS,PALPITATIONS,
TACHYCARDIA,HYPERTENSION, HEADACHE,NAUSEA,VOMITING,DIZZINESS,HYPERACTIVIT
Y, INSOMNIA,
>ASSESS CARDRESPIRATORYFUNCTION: BHEART RATE ARHYTHM ABREATH SOUND>MONITOR FEVIDENCE ALLERGICREACTIONS APARADOXICALBRONCHOSPASM
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.
DRUG NAME ACTION INDICATION CONTRAINDICATION
ADVERSEREACTION
NURSINGRESPONSIBI-LITIES
Date
Ordered:
Feb.13 2011
Generic
Name:
Dexamethas
one 250 g IV
q8
Brand Name:
Decilone
Dosage and
Frequency:
Classificatio
n:
Hormones
and related
drugs.
>Syntheticglucocorticoidw/ marked
anti-inflammatoryeffect becauseof its ability toinhibitprostaglandinsynthesis,inhibitmigration ofmacrophages,leukocytesandfibroblasts atsites of
inflammation,phagocytosisand lysosomalenzymerelease. It canalso cause thereversal ofincreasedcapillarypermeability.
>Respiratorydiseases
>systemic fungalinfection: IMinjection use in
idiophaticthrombocytopenicpurpura:
>Thromboembolism or fat embolism;thromboplebitis;
necrotizingangiitis; cardiacarrhythmias orECG changes.
>vertigo
> headache
>Impared woundhealing
>visual acuity
>thoat irritation
> Obtain pt.history of underlying
conditionbeforetherapy.
>Assess forpossible druginducedadversereaction.
>Monitorrenal statusand function.
>Assessmental status:
Affect, mood,behavioralchanges.
>Assess ptsand familysknowledge ondrug therapy.
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DRUG NAME ACTION INDICATION CONTRAINDICATION ADVERSEREACTION
NURSINGRESPONSIBI-LITIES
Date Ordered:
Feb. 13, 2011
Generic Name:
Nebulizaton
with
salbutamol +
IPRATROPIUM
q 8 1 amp.
Brand Name:
Atrovent
Classification:
Anticholinergic
s
Chemically relatedto atropine, it
antagonizes theeffect of acetylcholine. Itcauses a local andsite specificbronchodilatationby preventing theincrease inintracellular cyclicguanosine mono-phosphate whichproduced by theinteraction ofacetylcholine w/
the muscarinicreceptors of thebronchial smoothmuscles.
Acuteexacerbations
of chronicobstructivepulmonarydisease(COPD). Usedin conjunctionw/ beta-adrenergicstimulant foracuteasthmaticattacks.
Hyper sensitivity tosoya lecithin or related
food products. Atropineor any anticholinergicderivates.
Dryness ofmouth,
throatirritation orcough.
>Assess patientscondition before
and after drugtherapy. Monitorpeak expiratoryflow.
>Monitor forevidence of allergic reactions,paradoxicbronchopspasm.
>Assess pt andfamilysknowledge ondrug therapy.
>Inform pt. thatdrug is noteffective fortreatment of acutebronchopspasm
>Teach pt. theproper way ofdrugadministration.
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NURSING CARE PLAN
Patients Name: Beachin Barato Age: 65 years old
Chief Complaint: Difficulty of Breathing Attending Physician: Dr. Allan P.Arreola
Gender: Female Shift: 3-11
Diagnosis: Massive pleural effusion secondary to lung cancer. Date: July 2, 2009
Room No.: 4C 444 to 244
DateandTime
Cues Nursing Diagnosis Need(s)
Objective(s) ofcare
Interventions Evaluation
July3,
2009at
5:00pm
Subjectivecues:
Verbalizeddifficulty inbreathing.
Objectivecues:-Rapid
breathing
-Respiratory
rate: 23cycles per
minute- O2
saturationof 65%
Impaired gasexchange related todisease process as
evidenced bydyspnea.
(R) The presence ofpleural fluid (a
complication of lungcancer wherein
pleural fluid collectsin the pleural space
as a result of irritationor obstruction of thevenous drainage by
the tumor), mayhinder adequate lung
expansion, and itcauses the pleural
membranes (essentialfor diffusion of gases)
to compress thus
ACTIVI
TY
EXERCISE
Within 3 hoursof nursing care,the patient will
experienceimproved gasexchanged asevidenced by:
a. Improvedoxygenation (within
88%-100% O2saturation
) andabsence
ofrespiratory distress.
b. Statement of
acceptabl
Independent:
Monitor vital signs.(R)To evaluate
degree ofcompromise.
Assess lung sounds,respiratory rate and
effort and use ofaccessory muscles.(R) Respiratory rate
less than 12 or morethan 24 or use of
accessory musclesindicate distress.Diminished lungsounds indicate
possible poor airmovement andimpaired gas
exchange.
Observe skin and
July 3, 2009 at7:30pm
GOAL PARTIALLYMET.
Within three hoursof nursing care, the
patient statedacceptabledyspnea.
Nakakahinga naako ng mas maayos
kaysa kanina. Inaddition, the
patient participatedin treatment
regimen, such asbreathing exercises.
However, thepatient still has
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affecting gasexchange.
Source:William, L. Hopper, P.
(2007) UnderstandingMedical SurgicalNursing: Third Edition.
Philadelphia: F. ADavis.
edyspnea.
c. Participation in
treatmentregimen(breathin
gexercises)
within thelevel ofability.
mucous membranesfor cyanosis. (R)
Cyanosis indicatespoor oxygenation.
Oral mucousmembrane cyanosis
indicates serioushypoxia.
Monitor for confusion
or changes in mentalstatus. (R) A change
in mental statusindicates impaired
gas exchange.
Elevate head of bedor help the patientlean on over bedtable. (R) Uprightposition helpspromote lung
expansion.
Encourage adequaterest and limit
activities within
clients level oftolerance. Promote a
calm and restfulenvironment. (R)
Helps limit oxygenneeds/consumption.
Dependent:
Monitor for ABG prn.(R) PaO2 < 80
mmHg, PaCO2 >45mmHg or SaO2