CasePres Pneumothorax

UNIVERSITY OF MAKATICollege of Allied Health Studies

J.P. Rizal Extension, West Rembo, Makati City

Spontaneous PneumothoraxIn Partial Fulfillment of the Requirements in

Medical and Surgical Nursing I

Presented by:

Aloba, Kenosis P.De Asis, KennethGenerao, Ginalyn

Lupango, JessaOlino, Rustia Caren

Oliveros, Juan MiguelOrillaneda, Jean

Pasco, John CarloSale, Rhechell C.Sulangi, Angela

Introduction

INTRODUCTION

Six members of the group have handled the case, “Spontaneous Pneumothorax” during their duty at the General Ward of Ospital ng Makati last May 7 to May 8, 2012. The group has noticed Mr. E. T. L. among other patients because they believe that a lot of people are still unaware about the condition, how it occurs and how it is managed. Only few studies were made about spontaneous pneumothorax. Little information was also provided even on books and on the internet. Our group wanted to expand and share what we have learned about this study. For us to come up with a better study, our group has interviewed several health care providers such as a doctor, a nurse, and a respiratory therapist. Mr. E. T. L. was conscious and coherent throughout the interview and assessment, so he was able to express all of his concerns.

This study mainly focuses on the proper assessment, diagnosis, plan of care, and intervention for spontaneous pneumothorax. It also gives on the understanding of the disease process in relation to the patient’s medical history.

Pneumothorax (pl. pneumothoraces) is an abnormal collection of air or gas

in the pleural space that separates the lung from the chest wall, and that may interfere with normal breathing. It occurs when the parietal or visceral pleura are breached and the pleural

space is exposed to positive atmospheric pressure.

Normally, the pressure in the pleural space is negative. This negative pressure is required to maintain lung inflation. When either of them is breached, air enters the pleural space and the lung or a portion of it collapses. The types of pneumothorax include simple, traumatic, and tension pneumothorax.

A simple, or spontaneous, pneumothorax may occur in an apparently healthy person in the absence of trauma due to rupture of an air-filled bleb, or blister, on the surface of the lung, allowing air from the airways to enter the pleural cavity. The spontaneous pneumothorax is either a primary or a secondary pneumothorax.

Primary Spontaneous Pneumothorax is the air in the pleural space without preceding trauma and without underlying clinical or radiologic evidence of lung disease.

Secondary Spontaneous Pneumothorax occurs in patients with underlying pulmonary structural pathology. Air can enter the pleural space via distended, damaged, or compromised alveoli. It may present with more serious clinical symptoms and sequel due to comorbidity. Pneumothorax can also develop as a result of underlying lung diseases, including cystic fibrosis, chronic obstructive pulmonary disease (COPD), lung cancer, asthma, and infections of the lungs.

A Traumatic Pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or from a wound in the chest wall. It may result from a blunt trauma (e.g. rib fractures), penetrating chest or abdominal trauma (e.g. stab wounds or gunshot wounds), or diaphragmatic tears.

Open Pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Such injuries are called sucking chest wounds due to the rush of air producing a sucking sound. Not only does the lung collapse, but the structures of the mediastinum (heart and great vessels) also shift toward the uninjured side with each inspiration and in the opposite direction with expiration. This is called the mediastinal flutter or swing.

A tension pneumothorax occurs when air is drawn into the pleural space from a lacerated lung or through a small opening or wound in the chest wall. Relief of tension pneumothorax is considered an emergency measure.

The risk factors that a person is more likely to develop pneumothorax include: sex (occurs more in males than females, 4:1 ratio), age (20-40 yrs), tall and thin body built, history of smoking, change in atmospheric pressure, previous history of pneumothorax, family history, underlying chronic lung disease (e.g. emphysema, asthma, tuberculosis, pneumonia, cystic fibrosis and lung cancer), medical procedures (e.g. Thoracentesis), and mechanical ventilation.

Symptoms of a pneumothorax include chest pain that usually has a sudden onset. The pain is sharp and may lead to feelings of tightness in the chest. Shortness of breath, rapid heart rate, rapid breathing, cough, and fatigue are other symptoms of pneumothorax. The skin may develop a bluish color due to decreases in blood oxygen levels. Rapid, shallow and asymmetric respirations may be observed. Hyperresonance upon chest percussion and diminished or absent breath sounds, and decreased tactile fremitus on the affected lung field are evident.

Number of incidences:

According to the Stockholm study of worldwide frequency of pneumothorax 2011, one of the largest epidemiologic studies performed, pneumothorax occurs in 18 per 100,000 men and 6 per 100,000 women per year. The study also showed that COPD was the primary cause of pneumothorax development. About 22 of 45 patients with COPD develop pneumothorax. Recurrence will occur in about 30% of primary and 45% of secondary pneumothorax. It often occurs within 6 months, and usually within 3 years.

OBJECTIVES

General objective:

The study conducted by our group aims to acquire sufficient knowledge of the disease process, how it develops and its management. Another objective is to gain full awareness of the medical procedures done during hospitalization. The study also serves to aid us in formulating possible Nursing Care Plans for patients with Pneumothorax. It will help us apply the knowledge and skills gathered from this case to other cases that will be encountered in the future.

Specific objective:

Student-centered:

To conduct a research regarding the patient’s condition. To discuss the underlying problem of our chosen case and give a clear view of

it. To be able to provide a comprehensive nursing history to identify the cause of

Spontaneous Pneumothorax To enhance our nursing skills in identifying and classifying signs and symptoms

of the patient with Spontaneous Pneumothorax. To hone us to become competitive nurses in the future. To be able to execute the effective nursing interventions that may help

promote the well being of the patient and decrease risk for further complications.

To assess the patients’ response to the treatment and evaluate the effectiveness of the nursing care given.

To review the Anatomy and Physiology of the system related to the disease. To be aware of the pathophysiology of the disease.

Client-centered:

The patient will become aware of his existing condition and the different treatment modalities that are available to him.

For the client to realize factors that contributes to his disease and how he can modify these factors.

For the client to assist himself during discharge by health teaching contributed by the nurse.

For the client to turn towards the preventive behavior to avoid recurrence of the present condition in the future.

Health History

Patient’s ProfileName: Mr. E. T. L.Sex: MaleAge: 36 years old.Civil Status: MarriedNationality: FilipinoBirth date: August 26, 1975 Birth Place: Valenzuela CityAddress: Guadalupe, MakatiReligion: Roman CatholicEducational Attainment: High School GraduateOccupation: Bag seller at the Guadalupe market

Patient’s ProfileDate and time of admission: May 6, 2012 8:15 AMMode of admission: General wardAdmitting Diagnosis: Spontaneous PneumothoraxPreoperative Diagnosis:

Massive Pneumothorax Left Secondary to Ruptured Bleb vs IdiopathicOperation Performed:

‘E’ Chest Tube Thoracostomy, LeftPostoperative Diagnosis:

Massive Pneumothorax, Left, Secondary to Ruptured Bleb vs Idiopathic

Informant: Patient

Percentage Reliability: 90%

Chief Complaint

“Dalawang linggo na akong nahihirapang huminga,”

History of Present Illness 2 weeks Prior to Admission, the client experienced difficulty of

breathing and had a fever of 38.1®C. He was given a tepid sponge bath by his wife and took a tablet of Paracetamol 500mg for his fever. After 1hour, his temperature went down from 38.1®C to 37.7®C. His fever persisted for 2 days. The client took Salbutamol 4mg for his difficulty of breathing during the night and was able to fall asleep.

1 week and 4 days prior to Admission, the difficulty of breathing still persisted. The client used water steam inhalation and his wife did chest clapping on his back. He still took Salbutamol 4mg, but only once per day. The symptoms were relieved only for a short time.

There was persistence of symptoms. No improvement or progression was stated

History of Present Illness2 days Prior to Admission, the client went to an OPD at Polymedic Clinic

for consult and was advised for admission. The client decided to stay at home against medical advice.

1 day Prior to Admission, 8pm, the client was sent to the emergency room at OSMAK with difficulty of breathing and was diagnosed of impending thyroid storm. Oxygen was administered at 4L/M via nasal cannula. Intravenous Fluid of D5LR was also administered to the patient. Patient was then sent home.

At home, the client experienced chest pain and shortness of breath. Hence, he went back to the emergency room at 1:27am, the next day, and was scheduled for an Emergency Chest Tube Thoracostomy on the left lung.

Past Medical HistoryThe client stated that he had received complete immunization during childhood. He

was also never admitted to any hospitals in the past. He has no known allergies. The client also has no history of injuries or falls. He has no history of any type of pneumothorax. He goes to clinics for a check-up whenever he is feeling unwell. No recent travel was also made.

DATE DIAGNOSIS HOSPITAL INTERVENTION MEDICATIONS

5 yrs old Bronchial Asthma None Self medication Salbutamol

2005 Goiter due to Hyperthyroidism

Manila Doctor’s Hospital

Unmanaged Was only compliant with medications from yr 2005-2008.Unrecalled

Family Medical History

Family Medical History

Interpretation: The father and grandfather of Mr. E. T. L. died of emphysema. That means that he is at risk of developing emphysema. His uncle on the father side and younger sister are asthmatic. His mother and aunt are hypertensive and diabetic. His uncle on the mother side is also known to be diabetic. The eldest sister was also diagnosed of goiter

Personal and Social HistoryThe client and his wife are bag sellers for 3 years with their

own stall at the Guadalupe Market. Their gross income is 20,000/month. He is a high school graduate at Bangkal High School in Makati City.

The client lives in his own house, together with his wife and mother. His house is a bungalow style with two bedrooms. He stated that their environment is clean and has enough space for all of them. They didn’t have any children.

The client started smoking at 15 years old and smokes at least half a pack of cigarettes per day and also drinks alcohol occasionally.

Physical Assessment

Physical AssessmentDATE AND TIME: May 7, 2012 9:00am – 11:00am

General appearance: (+) facial grimace Conscious and coherent

Thin body figure Cooperative and responds appropriately to

every question asked at moderate pace and as long as he can tolerate.

Anthropometric measures: Height: 172.72 cm

Weight: 54.4kg BMI – *18.2 (Normal values are 18.5-25)

Vital signs: Temperature: 37.3 CRespiratory rate: 27 cpmPulse rate: 105 bpmBlood pressure: 130/80 mmHg

ORGAN/BODY PARTS METHODS USED FINDINGS SIGNIFICANCESkin Inspection

Palpation*Hematomas on antecubital and radial surface on both arms(-) cyanosisDark complexionIntact skinGood skin turgor

*Hematomas are due to blood samples taken

Head Inspection Normocephalic(-) Head injury (-) Tenderness(-) Lesions

Normal

Hair Inspection (-) hair parasites(-) dandruffsHair is evenly distributed

Normal

Face Inspection Normal facial movements Normal

Eyes Inspection PERRLA:Pupils are equal and round, left eye 3 mm reactive to light and right eye 3 mm reactive to light, good accommodation noted.*slightly protruding eyes*Dark circles around the eyes

* Eye protrusion is one of the signs of hyperthyroidism*Possible sleep deprivation

ORGAN/BODY PARTS METHODS USED FINDINGS SIGNIFICANCEEars Inspection

Watch tick testPalpation

Bilaterally equal in size (-) lesions (-) discharge(-) redness(-) bleedingAble to hear sounds on both earsPinna is firm, non tender and no pain

Normal

Nose: Inspection Symmetric and straight(-) discharges(-) nasal flaringWith O2 administered at 4L/min via nasal cannula

NormalO2 Therapy is used to benefit patient by increasing the supply of O2 to the lungs and thereby increasing the availability of O2 to the body tissues

Mouth: Inspection *(+) dental carries*Absence of teeth on upper mandibleUniform and pinkish tongue with no lesion, Moist pink buccal mucosa

There could be difficulty in mastication.

Neck: InspectionPalpation

Symmetric and head centered(+) swollen lymph nodes(+) Lump on the neck

There could be presence of infectionThere is thyroid enlargement

ORGAN/BODY PARTS METHODS USED FINDINGS SIGNIFICANCEUpper Extremities Inspection

PalpationWith IV contraption on R metacarpal infusing PNSS 1L x 40cc/min*20.5cm mid-upper arm circumferenceEqual pulses (+) tachycardia

*Normal value of MIUC in adult males is ≥23cm. This shows decreased amounts of fat and muscle mass in the arms

Nails: InspectionPalpation

(-) Pail(-) IndentationsCapillary refill less than 3 seconds

Normal

Thorax and lungs: InspectionAuscultationPercussionPalpation

With CTT one-way drainage system inserted on the 5th ICS, LMA lineRR = 27cpm(+) difficulty of breathing(+) dry cough(+)chest wall retraction(+) use of accessory musclesDiminished breath sounds and pleural rub on left lungHyper resonance on left lungTactile fremitus decreased on left lung

*To remove air in the pleural space*Patient is having problems with oxygenation*Air in the pleural space dampens the transmission of sounds and vibration.

Heart InspectionAuscultation

(-) visible pulsationNo heart murmurs auscultated over aortic, pulmonic, tricuspid and mitral area.Normal heart rate and regular rhythmHR = 105bpm(+)Tachycardia

Heart compensates to increase oxygenation

ORGAN/BODY PARTS METHODS USED FINDINGS SIGNIFICANCE

Abdomen InspectionAuscultationPalpation

(-)swelling(+) bowel sounds(-) palpable masses and no tenderness.

Normal

Genito-urinary Inspection No swelling, no lesions noted

Normal

Lower Extremities InspectionPalpation

Legs bilaterally symmetric, no ulcerations noted.*(+) limited ROM*(+) body malaiseEqual pulses (+) tachycardia

*Due to weakness

Nails: InspectionPalpation

(-) Pail(-) IndentationsCapillary refill less than 3 seconds

Normal

Review of SystemsSYSTEM CUES INTERPRETATION SIGNIFICANCE

General “Medyo nanghihina pa ako.”

(+) body malaise Body weakness is attributed to the present condition

Skin/Integumentary System

“May konting sakit sa mga parte na pinagkuhaan ng dugo

(+) Tenderness Tenderness is due to puncture of skin from obtaining blood specimen.

EENTEarsEyesThroat

“Pantay ang pandinig ko.”“Parehas malinaw ang paningin ko.”“Nahihirapan akong lumunok,”

Is able to hear on both earsIs able to see on both eyesDifficulty in swallowing

Normal NormalBrought about by thyroid enlargement

SYSTEM CUES INTERPRETATION SIGNIFICANCE

Respiratory System

“Hirap akong huminga.”“Masakit yung sa gilid ng dibdib ko, parang tinutusok tusok.”

DOBPain on the Left lateral chestP – Exacerbates when coughing and moving.Q- Stabbing painS- 6/10R – Radiates to the left shoulderT – 5-10 sec

Due to escape of oxygen into the pleural space.

Cardiovascular System

“May oras na mataas ang bp ko.”

↑BP ↑BP is due to increased force of cardiac contractility and the body’s attempt to increase tissue perfusion and oxygenation

Gastrointestinal System

“Hindi naman ako nagtatae”“Nagsuka ako kanina dahil sa sama ng pakiramdam ko.”

(-) DiarrheaVomiting Attributed to present condition

SYSTEM CUES INTERPRETATION SIGNIFICANCE

Genitourinary System

“Regular ang ihi ko, normal ang color at hindi rin masakit umihi.”“Wala akong mga almoranas”

Normal

Musculoskeletal System

“Madali akong mapagod.”

(+) muscle weaknessLimited ROM

Weakness is attributed to present condition and limited ROM

Neurologic “Di naman ako ulyanin.”

Is able to communicate

Normal

Gordon’s Functional Health PatternBefore hospitalization During hospitalization

Health perception and Health Management pattern

Client seeks medical consultation every time he feels that there is something abnormal with his health. He normally takes over the counter drugs when he experiences a cough or cold.

Client is adherent to the treatment regimen

Nutritional and metabolic pattern

He is fond of eating salty and fatty foods.

He eats what the dietary department serves. On low salt and low fat diet.

Elimination pattern He defecates at least 2 times a day and urinates at least 6 times a day.

Client uses a urinal to urinate. He has not made any bowel movement since hospitalization.

Activity-exercise pattern

He plays badminton every day.

Is unable to ambulate due to presence of CTT.

Sleep-rest pattern Has lack of sleep. Has more difficulty of sleeping.

Before hospitalization During hospitalizationCognitive perpetual pattern

The client can hear clearly. Cognitive and alert.

The client can hear clearly. PERRLA.

Self-perception and self concept pattern

Confident and he has a good outlook on the way things are happening.

The client still has a positive outlook.

Role relationship Is satisfied with family, work, and social relationships

He cannot perform his roles as of the moment.

Vices Drinks alcohol occasionally and smokes half a pack of cigarettes per day.

Is unable to do vices in the hospital setting

Sexual pattern Is satisfied with sexual relationship

None

Coping/ Stress Tolerance

Client manages stress listening to music

Client handles stress of condition by practicing a regular breathing pattern.

Value – Belief Client prays often for good health.

Client often reads the bible.

Medical and Nursing Diagnosis

Medical Diagnosis:

Spontaneous Pneumothorax

Nursing Diagnosis:1. Ineffective breathing pattern related to decreased lung expansion.2. Impaired gas exchange related to decreased lung expansion

secondary to air accumulation in the pleural space.3. Acute Pain related to impaired pleural integrity4. Disturbed sleep pattern related to interruptions from therapeutic

regimen, monitoring and other generated awakening and excessive stimulation.

5. Activity intolerance r/t muscle weakness and fatigue6. Risk for trauma related to dependence on chest tube drainage

system.7. Risk for falls related to generalized weakness.8. Risk for deficient fluid volume related to treatment regimen.9. Risk for constipation related to changes in level of activity.10. Risk for prone behavior related to lack of knowledge about the

disease.

Laboratory Exams

Hematology – May 6, 2012Component Result Normal Value Interpretation Analysis

Hemoglobin

Hematocrit

WBC count

RBC count

16.8

0.52

15.9

5.8

14-18 g/L

0.40-0.54

4-11 x10ˆ g/L

5.0-6.4

Normal

Normal

Increased

Normal

Insight: Usually, elevated WBC is an indicator of infection. But in some cases with inflammation or trauma such as spontaneous pneumothorax, it may also lead to increase WBC even without infection.

Component Result Normal Value Interpretation Analysis

Differential count:

Eosinophils

Neutrophils

Segments

Lymphocytes

Monocytes

0.01

0.71

0.16

0.4

0.02-0.04

0.50-0.70

0.20-0.40

0.02-0.05

Decreased

Increased

Decreased

Increased

Low eosinophil level is usually not a cause for concern and is actually quite common.

Neutrophil is body’s primary defense against bacterial infection and physiologic stress. ↑neutrophils may indicate presence of infection

Low lymphocyte counts may occur in normal individuals. . A low value doesn’t necessarily mean a decrease in protection against viruses.


Platelet count

PT

% activity

INR

Activated PTT

202

16.3 secs

57.0%

1.52

48.0 secs

150-450 x10ˆ g/L

10.4-14.05

73-127%

0.88-1.21

30.4-41.2

Normal

Slow

Decreased

Increased

Slow

The prothrombin time can be prolonged as a result of deficiencies in vitamin K, warfarin therapy, malabsorption In addition, poor factor VII synthesis (due to liver disease) or increased consumption (in disseminated intravascular coagulation) may prolong the PT.

In chronic liver disorders, an increasing INR indicates progression to liver failure. The INR does not increase in mild hepatocellular dysfunction and is often normal in cirrhosis.

Probable coagulation factor deficiency (e.g. hemophilia).

Nursing implications: Assess for fatigue, dietary deficiencies and V/S. Assess fluid balance and respiratory status.

Clinical Chemistry – May 7, 2012 2:50pm

Component Result Normal Value InterpretationAnalysis

Sodium Potassium Chloride Calcium, IonizedCalcium, TotalMagnesiumPhosphorus

134 mmol/L

4.3 mmol/L

97 mmol/L1.08 mmol/L1.88 mmol/L0.63 mmol/L1.68 mmol/L

135 – 148 mmol/L

3.5 – 4.5 mmol/L

98 – 107 mmol/L1.12-1.32 mmol/L2.15-2.55 mmol/L0.66-0.99 mmol/L0.81-1.58 mmol/L

Decreased

Normal

DecreasedDecreasedDecreasedDecreasedIncreased

Contributory factor to lethargy and

muscle weakness

Due to potassium deficiency

Reason of prolonged QT interval in the

ECG and ↓PT

Tends to cause low serum calcium concentration


Glucose (fasting) Cholesterol TriglyceridesHDL -cholesterolLDL – cholesterol

6.84 mmol/L

2.73 mmol/L

0.83 mmol/L0.51 mmol/L1.66 mmol/L

4.1 - 5.5 mmol/L

1. 5.2 mmol/L

0.0 – 2.3 mmol/L0.9 – 1.45 mmol/L0.0 – 2.59 mmol/L

Increased

Normal

NormalDecreased

Normal

May predispose the client to DM

May predispose the client to

development of CAD


Blood Urea Nitrogen

Serum creatinine

3.9 mmol/L

60 mmol/L

2.1-7.1 mmol/

45-104 mmol/L

Normal

Normal

BUN is affected by hydration, hepatic

metabolism of protein and reduced GFR

↑BUN indicates kidney damage, ↓GFR

↑serum Crea indicates nephron

damage, ↓GFR

Blood Chemistry – May 7, 2012

Nursing implications: Assess kidney function and check Input and Output.* Mr. E. T. L. as indicated in his blood chemistry is having a normal renal function.

Stool Exam – May 6, 2012Macroscopic Examination:

Color:Consistency:Gross Evidence of:>WBC>RBC Remarks:

Light BrownSoft

0-3/HPF0-2/HPF

No intestinal Parasites seen

Urinalysis – May 6, 2012Component Result Interpretation

MACROSCOPIC EXAM:

Color Transparency

SugarProtein

pHS.G. MICROSCOPIC EXAM:WBCRBCEpithelial CellsCrystalsBacteria

Dark Yellow

Slightly Hazy

N (-)+2

6.01.025

0-2/ HPF1-3/ HPF

FEWAmorphous

Urates / Phosphates: Occasional

FEW

Dehydration is the most common condition that can produce yellow urine. Normal urine is transparent. Normal turbid urine includes precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria.

Equivalent to 100mg/dl. >2+ in concentrated or dilute urine indicates significant proteinuriaNormal pHNormal S.G.

NormalNormal

Renal epithelial cells normally appear in the urine in small numbers.

Normal

Normal

Chest X-ray – May 6, 2012TYPE: In-patient Examination:

Remarks:

– Department of Medicine – General Ward

Chest

-Follow up chest x-ray after a few hours shows complete re-expansion of the left lung with no evidence of pneumothorax-Left sided CTT seen in place.

Electrocardiogram Test (ECG) – May 6, 2012ABNORMAL FINDINGS INTERPRETATION

Poor R progression

ST-T abnormality (Ant, Lat)

Negative T (Inf)

Right axis deviation

QT prolongation

Clockwise rotation

Atrial Fibrillation- Noise or baseline drift is present ( V1, V6)

Increase the magnitude of the voltage in the leads from V1 to V4

Ventricular conduction abnormalities and rhythms originating in the ventricles.

Represents ventricular repolarization rhythms originating in the ventricles.

congenital heart condition wherein the electrical conduction of the heart is greater than +105 degrees. Between +90 degrees and +180 degrees the condition may be termed Indeterminate Deviation or more often Extreme Right Axis Deviation.

factor for sudden cardiac death, Since medications can promote or exacerbate the condition, detection of QT interval prolongation is important for clinical decision support.

intraventricular conduction abnormalities secondary to myocardial degeneration.

cardiac arrhythmia or irregular heart beat. The ventricles contract irregularly, leading to a rapid and irregular heartbeat.

Electrocardiogram Test (ECG) – May 6, 2012 Nursing Implications: Explain the purpose of the test and explain that there will be no pain

from the test.

Explain the procedure of the test. The test may be performed when the patient is fully awake, drowsy, undergoing stimuli, asleep, during sleep deprivation, under sedation, or other situations.

Prepare the patient: Restrict only sedatives and/or stimulants such as caffeine, alcohol, etc. prior to the test.

Patient Teaching: Be sure to include family in the teaching process. The machine may look frightening to the patient. Reassure the patient that he will not get a shock from the machine, especially if this is the first time this patient will have this test. Patients have other misconceptions and fears about the test.

Report to the physician if the patient is taking any medications. Some drugs (legal or otherwise) may affect the results of the test. Report if the patient is unusually anxious or upset before the test.

The patient will be carefully observed during the test. Ask the patient to relax and lay still during the test.

Usually, normal activity may resume after the test.

Liver Enzymes – May 7, 2012 11:06pmComponent S.I. Result Normal

Value Interpretation

AST (SGOT)

ALT (SGPT)

41u/L

37u/L

15-37 u/L

30-65 u/L

Increased

Normal

AST is normally found in red blood cells, liver,

heart muscle tissue, pancreas, and kidneys.

↑AST may involve prolonged intake of several medication,

alcoholism, or due to hyperthyroidism

Arterial Blood Gases (ABG) – May 8, 2012Arterial Blood Gas 05-08-12 3:40PM

Component Result Normal Value Interpretation

PH :

pCO2:

pO2

HCO3:

B.E

Sat O2

Total CO2:

7.455

30.2 mm/Hg

97.5 mm/Hg

22.9 mmol/L

1.9 mmol/L

97.8 %

21.7 mmol/L

7.350-7.450

35.00-45.00

80.00-100.00

Normal

Decreased

Normal

Normal

Normal

Course in the Ward

May 7, 20126am-2pm Shift

Time Data Action Response6:00 am -received pt. in high fowler’s position,

conscious and coherent

- with O2 support via nasal cannula at 4LPM

- With IV contraption on R metacarpal infusing PNSS 1L x 40cc/min

-with CTT to thoraco bottle on L lower lateral chest wall at 300 water peak level. Initial H2O in CTT: 200

-maintain pt. in high fowler’s position.

-maintain o2 support via nasal cannula at 4lpm

-monitored IV rate

-monitored placement and patency of CTT

6:30 am “Paputol-putol yung tulog ko dito kasi maingay at maya-maya ginigising ako.”>Dark circles around the eyes> Weakness and restlessness.>Naps whenever possible>Yawning

>Assessed sleep pattern disturbances associated with the environment.>Observed and obtain feedbacks regarding on the usual sleeping pattern, bedtime routine and the usual number of hours of sleep and rest.>Did as much care as possible without waking up the client and do as much care as possible while the client is still awake.>Explained necessity of disturbances for monitoring Vital Signs and care when hospitalized.

7:00 am -v/s taken and recorded

-chest tube tubing’s, dressing and patency was checked

-medication given:

methimazole 20mg

1tab PO after breakfast

-Temp : 36.8°c

RR: 27 cpm

PR: 105 bpm

BP: 130/80 mmHg

-chest tube are patent, tubing’s are hang in straight line from mattress to the drainage bottle

7:14am -clinical chemistry done

-chest tube tubing’s, dressing and patency was checked

-Chest tube is patent, tubing’s are hanged in a straight line from mattress to the drainage bottle

7: 30am “Nahihirapan akong huminga””Parang hinihingal ako.”RR – 27cpm>(+) facial grimace>(+) difficulty of breathing>(+) dry cough>(+)chest wall retraction>(+) use of accessory muscles>(+) shallow breathing>Diminished breath sounds.

>Auscultated breath sounds>evaluated respiratory function. >Maintained the client’s position (High Fowler’s)>Encouraged client to do deep breathing exercises and effective coughing.>Monitored bottle for fluctuation>Maintained O2 therapy @ 4lpm>Administered Salbutamol + Ipratropium through nebulization

8:00 am Monitored BP before and after meds.

-meds given:

Furosemide 20mg

1tab PO/ODx 3 days

Enalapril 5mg 1tab PO/OD

-Daily O2 Saturation and CBG taken

BP within normal ranges.

-O2 sat. 96%

-CBG: 109 mg/ dL

8:30 am “Mas nakakahinga na ko ng maayos.”

RR- 20cpm

-Client has established an effective respiratory pattern

-Client has shown improved ventilation

9:00 am “Masakit yung sa gilid ng dibdib ko, parang tinutusok tusok.”

(+) facial grimace

(+) guarding at the affected area

- Pain on the Left lateral chest

P – Exacerbates when coughing and moving.

Q- Stabbing pain

S- 6/10

R – Radiates to the left shoulder

T – 5-10 sec

“nanghihina ako, hinahapo pa ako tuwing bumabangon ako.”

>(+) fatigue

--assessed pt.-v/s taken & recorded-medication given:Tramadol 50mg TIV>Evaluated medications the client is taking to see if they could be causing activity intolerance.>Assessed nutritional needs associated with activity intolerance.>Monitored vitals before and after any activity, noting any abnormal changes.> Assessed for pain before activity.> Instructed client in energy-conserving techniques (e.g. carrying out activities at a slower pace).

9:30am “mga 3 nalang ang score kumpara kanina.”

-client verbalized a decrease in the level of pain from 6/10 to 3/10

10:00am -bed side care done

-health teaching on chest tube drainage system provided

-pt. verbalized understanding on chest tube system precaution

12:00 nn - v/s taken and recorded

-input & output measured

-meds given:

Ceftriaxone 2g TIV (loading dose)

-encouraged ambulation

- Temp: 36.9°c RR = 20

breaths per minute

RR: 23 cpm

PR: 103 bpm

BP: 130/70 mmHg

- Input Oral: 500 cc

IV: 80cc

Total: 580 cc

- urine output: 430 cc

-Chest tube drainage output: 40cc

Total: 470cc

-BM: 02:00 pm -Endorsed patient to the next

shift

May 8, 20126am-2pm Shift

Time Data Action Response6:00 am -received pt. sitting on bed, conscious

and responsive

-continuous with O2 support via nasal cannula at 4LPM

- With IV contraption on R metacarpal infusing PNSS 1L x KVO

-with CTT to thoraco bottle on L lower lateral chest wall at 300water peak level. Initial H2O in CTT: 200

-maintained pt. on sitting position

-maintained o2 therapy

-monitored IV rate

-maintained patency of CTT

-pt. verbalized increased comfort

6:30am “mas okay tulog ko kumapara kahapon.”

>Patient displayed improvements in sleeping pattern.

7:00 am -v/s taken and recorded

- medication given: methimazole 20mg 1tab PO afterbreakfast

-Temp : 36.9 °c

RR: 23 cpm

PR: 100bpm

BP: 130/80 mmHg

8:00 am -Monitored BP before and after meds- meds given:Furosemide 20mg 1tab PO/ODx 3days Enalapril 5mg 1tab PO/OD-meds given: Ceftriaxone 500mg q 8 hours

BP: 110/70mmHg

9:00 am“From time to time may inaabot ako sa mesa.”“Makukulit mga kamag-anak ko dito sa pwesto ko.”>CTT bottle not secured under the bed.

-Daily O2 Saturation and CBG taken>Instructed to refrain from lying or pulling on tubing.>Monitored changes and situations like change in sound of bubbling, sudden “air hunger” and chest pain, and disconnection of equipment.

-O2 sat. 97%

-CBG: 116 mg/ dL

10:00am “Madalas wala dito ang asawa pag natutulog ako.”>With left side rails down while client is in semi-fowler’s position.>Caregiver is absent.>Limited ROM >(+) Body weakness

>Ensured patient’s safety by raising the side rails

>Advised client not to rise abruptly from a supine position

>Provided emotional support to client

10:30am “May dugong nalabas sa tubo.”

“Madalas akong naihi.”

>Noted signs and symptoms of dehydration such as dry mucous membranes, and thirst.>Measured intake and output accurately.

12:00 nn - v/s taken and recorded-input & output measured-meds given: Ceftriaxone 500mg q 8 hours

- Temp: 36.9°c RR = 20

breaths per minute RR: 23 cpm PR: 99 bpm BP: 120/80 mmHg- Input Oral: 300 cc IV: 320cc Total: 620 cc- urine output: 480 cc CTT output: 30ccTotal: 510cc-BM: 0

2:00 pm -Endorsed patient to the next shift

-The client was free from injury and falls throughout the 8 hour nursing shift.

Anatomy and Physiology

ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

Respiration is essential to all living things because all of the living cells in the body need adequate oxygenation and produces carbon dioxide. Respiratory System, in anatomy and physiology, comprises of organs that deliver oxygen to the circulatory system for transport to all body cells. Oxygen is essential for cells, which use this vital substance to liberate the energy needed for cellular activities. The respiratory system brings oxygen through the airways of lungs into the alveoli, where it diffuses into the blood for transport to the tissue; this process is so vital that difficult inbreathing is expected as a threat to life in self. The respiratory system allows oxygen from the air to enter the blood and carbon dioxide to leave the blood and enter the air. The cardiovascular system transport oxygen from the lungs to the cells of the body and carbon dioxide. Without healthy respiratory and cardiovascular system, the capacity to carry out normal activity is reduced, and without adequate respiratory and cardiovascular system friction, life itself is possible.

A. Nasal PassagesThe nose, the uppermost portion of the human respiratory system, is a hollow air passage

that functions in breathing and in the sense of smell. While transporting air to the pharynx, the nasal passage is vital because it plays two critical roles: they filter the air to remove potentially disease-causing particles; and they moisten and warm the air to protect the structures in the respiratory system.

B. PharynxAir leaves the nasal passages and flows to the pharynx, a short, funnel-shaped tube about 13

cm (5 in) long that transports air to the larynx. Like the nasal passages, the pharynx is lined with a protective mucous membrane and ciliated cells that remove impurities from the air. When the adenoids are swollen, they block the flow of air from the nasal passages to the pharynx, and a person must breathe through the mouth.

C. LarynxAir moves from the pharynx to the larynx, a structure about 5 cm (2 in) long located

approximately in the middle of the neck. Several layers of cartilage, a tough and flexible tissue, comprise most of the larynx. While the primary role of the larynx is to transport air to the trachea, it also serves other functions. It plays a primary role in producing sound; it prevents food and fluid from entering the air passage to cause choking; and its mucous membranes and cilia- bearing cells help filter air.

D. Trachea, Bronchi, and BronchiolesAir passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6in)

long located just below the larynx. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy cartilage rings hold the trachea open, enabling air to pass freely at all times. The open part of the C-shaped cartilage lies at the back of the trachea, and the ends of the “C” are connected by muscle tissue. The base of the trachea is located a little below where the neck meets the trunk of the body. Here the trachea branches into two tubes, the left and right bronchi, which deliver air to the left and right lungs, respectively. Within the lungs, the bronchi branch into smaller tubes called bronchioles. The trachea, bronchi, and the first few bronchioles contribute to the cleansing function of the respiratory system, for they, too, are lined with mucous membranes and ciliated cells that move mucus upward to the pharynx.

E. AlveoliThe bronchioles divide many more times in the lungs to create an impressive tree with

smaller and smaller branches, some no larger than 0.5 mm (0.02 in) in diameter. These branches dead-end into tiny air sacs called alveoli. The alveoli deliver oxygen to the circulatory system and remove carbon dioxide. Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli and remove foreign substances that have not been filtered out earlier. The macrophages are the last line of defense of the respiratory system; their presence helps ensure that the alveoli are protected from infection so that they can carry out their vital role.

Differential Diagnosis

SIGNS AND SYMPTOMS PNEUMOTHORAX PLEURAL EFFUSION PULMONARY EDEMA

Productive cough Absent Present Present

Absent or diminished breath sounds on the affected side

Evident Evident Not evident

Tachypnea Present Present PresentDyspnea Present Present PresentDifficulty of breathing Present Present Present

Absent or diminished tactile fremitus on the affected side

Evident Evident Not evident

Dullness on the affected side when percussed

Absent Present Absent

Asymmetrical chest expansion Evident Evident Not evident

Sharp chest pain exacerbated when coughing

Present Present Absent

Orthopnea Present Present PresentLateral CXR: Opaque densities on the lower lobe, blunting of the costophrenic angle

Absent Present Absent

Posteroanterior CXR: Air in the pneumo region shown is much darker than the air within the

actual lung in the affected part

There is an area of whiteness in the affected area

Kerley lines: thin linear pulmonary opacities:

Pathophysiology

Nursing Care Plan

Assessment Diagnosis Inference Planning Nursing Intervention Rationale EvaluationS: “Nahihirapan akong huminga”O:> conscious and coherent> V/S: RR – 27cpm>(+) facial grimace>(+) difficulty of breathing>(+) dry cough>(+)chest wall retraction>(+) use of accessory muscles>Diminished breath sounds.>With under water seal Chest tube on the Left lung, 5th ICS, LMA line.

Ineffective breathing pattern related to decreased lung expansion.

Air accumulation in the pleural space

Increase pressure around the lungs

Decreased lung expansion

Inspiration/expiration doesn’t provide adequate

ventilation

Ineffective breathing pattern

After 1 hour of nursing intervention, the Client will establish an effective respiratory pattern with a normal respiratory rate of 16-20cpm.

Independent:1. Auscultated breath sounds

and evaluate respiratory function, noting rapid/shallow respirations, dyspnea,reports of “air hunger,” development of cyanosis, changes in v/s

2. Maintained the client’s position (High Fowler’s)

3. Monitored bottle for fluctuation

4. Monitored Chest tube drainage output.

5. Positioned chest tube drainage below the bed.

Dependent:6. Maintained O2 therapy @

4lpm7. Administered Salbutamol +

Ipratropium .Collaborative:8. Monitored Chest x-rays

Independent:1. Regularly scheduled

evaluation provides a baseline to evaluate resolution of pneumothorax .Respiratory distress and changes in v/s occur as a result of physiologic distress and pain, or may indicate development of shock due to hypoxia/ hemorrhage.

2. Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion.

3. To check for chest tube patency.

4. To determine if patient is bleeding from a vessel that was not cauterized during closure of chest or a ruptured graft.

5. To avoid kinking, damaging and any instances that will affect the drainage system.

Dependent:6. Oxygenation provides more

o2 supply.7. This medication dilates the

bronchi and creates a better airway.

Collaborative: 8. To monitor the progress of

resolving pneumothorax and re-expansion of lungs.

After 1 hour of nursing intervention, the Client has established an effective respiratory pattern as evidenced by respiratory rate of 20cpm.

Assessment Diagnosis Inference Planning Nursing Intervention Rationale EvaluationS:

”Parang hinihingal ako.”

O:

conscious and coherent

> V/S:

RR – 27cpm

PR – 105bpm

>(+) difficulty of breathing

>(+) dry cough

>(+)chest wall retraction

>(+) use of accessory muscles

>Diminished breath sounds.

>With under water seal Chest tube on the Left lung, 5th ICS, LMA line.

Impaired Gas exchange related to decreased lung expansion secondary to air accumulation in the pleural space.

Air accumulation in the pleural space

Increase pressure around the lungs

Decreased lung expansion

Decreased surface area for oxygen and

carbon dioxide to exchange

Impaired Gas Exchange

After 1 hour of nursing intervention, the Client will have improved ventilation and adequate oxygenation as evidenced by respiratory rate of 16-20.

Independent:1. Maintained airway

clearances clean and patent.

2. Monitored ABG results

3. Maintained client’s High Fowler’s position.

4. Have patient practice pursed lip breathing.

5. Encouraged client to stop smoking

Dependent:1. Administered O2 at 4

LpmCollaborative:6. Monitored ABG and

Chest X-ray results.

Independent:1. Clearing airways of

secretions improves ventilation–perfusion relationship.

2. ABG results provide integral information to determine deficits in capacity and effect of oxygen delivery.

3. To facilitate chest expansion

4. Promotes alveolar open

5. To decrease risk and prevent further decline in lung function

Dependent:6. To provide O2 to the

client’s body and balance ABG.

Collaborative:7. To monitor the

progress of the client’s condition

After 1 hour of nursing intervention, the Client has improved ventilation and adequate oxygenation as evidenced by 20cpm.

Assessment Diagnosis Inference Planning Nursing Intervention RationaleS:“Masakit ang dibdib ko, parang tinutusok tusok.”O:> conscious and coherent> V/S: RR – 27cpm>(+) facial grimace>Guarding at the affected area>Pain at the Left thoracic region. P – Exacerbates when coughing and moving.Q- Stabbing painS- 6/10R – Radiates to the left shoulderT – 5-10 sec

Acute Pain related to

impaired pleural integrity

Tissue damage

Peripheral neurotransmitters

released

Free nerve endings (nociceptors) triggered

Signals travel to spinal cord

Signals rerouted to appropriate area of brain

Brain interprets quality and intensity of pain

present

After 30 minutes of nursing intervention, the client will verbalize a decrease of level of pain from a score of 6/10 to a 3/10

Independent:1. Monitored pain. Let the

client describe the pain he feels.

2. Assisted client on splinting the painful area when coughing and deep breathing.

3. Provided a calm, quiet environment.

4. Monitored vital signs.5. Monitored the sleep–rest

pattern.6. Stabilized chest tube.7. Explained and demonstrated

the proper breathing exercise to the pt

8. explained and demonstrated cutaneous stimulation to the pt

9. Explained the ways and benefits of diversional activities to alleviate the pain of the pt

Dependent:10. Administer Tramadol 50mg

TIV

Independent:1. Pain is subjective in nature,

and only the patient can fully describe it.

2. Splinting the affected area may lessen the pain that the client feels.

3. Promotes action and effect of medication by providing decreased stimuli.

4. To detect changes that might indicate pain or a complication of pain.

5. Fatigue may contribute to an increased pain response, or pain can contribute to interrupted sleep.

6. To reduce pull or drag on latex connector tubing which could add up to the pain.

7. Enhances sense of control and may improve coping abilities.

8. Reduces muscle tension and anxiety associated with pain.

9. Enhances sense of well-being and helps forget the thought of pain.

Dependent:10. Analgesics given TIV reach

the pain centers immediately, providing more effective relief with small doses of medication.

Assessment: Nursing diagnosis: Inference: Planning: Intervention: Rationale: Evaluation:Subjective:“Paputol-putol yung tulog ko dito kasi maingay at maya-maya ginigising ako.”

Objective:

>Dark circles around the eyes

> Weakness and restlessness.

>Taking nap when there is a chance or if there is a free time.

>Yawning

Disturbed Sleep Pattern related to interruptions for therapeutics, monitoring and other generated awakening and excessive stimulation (noise and lighting).

External noises and interruptions

Excessive environmental

stimulation

Disruption of relaxation

Reduced initiation of the body to induce sleep

Patient is unable to obtain

adequate sleep

Disturbed sleep pattern

After 1 day of nursing intervention the patient will display improvements in sleeping pattern.

Independent:1. Assess sleep pattern

disturbances that are associated with the environment.

2. Observe and obtain feedbacks regarding on the usual sleeping pattern, bedtime routine and the usual number of hours of sleep and rest.

3. Do as much care as possible without waking up the client and do as much care as possible while the client is still awake.

4. Explain necessity of disturbances for monitoring Vital Signs and care when hospitalized.

5. Provide information about relaxation techniques (such as instrumental music and meditation).

Dependent:1. Administer sedatives

as indicated

Independent:1. High percentage of sleep

disturbances can affect the recovery of the patient.

2. To determine usual sleeping pattern and to compare if there are any improvements on the sleeping pattern of the patient.

3. To avoid disturbances during sleep, and also to maximize the sleep and rest of the client.

4. For the patient to have an understanding of the importance of care being done to her and to minimize the complaints.

5. For the client to condition his body for sleeping.

Dependent:1. Timely medication can

enhance rest or sleep.

After 1 day of nursing intervention the patient was able to display improvements in sleeping pattern.

Assessment Nursing diagnosis Inference Planning Intervention Rationale EvaluationSubjective:

“nanghihina ako, hinahapo pa ako tuwing bumabangon ako.”

Objective:

>RR- 27cpm

>Weak in appearance

>(+) fatigue

>thin in appearance

>(+) DOB

Activity intolerance r/t generalized weakness and fatigue

Generalized weakness

Insufficient physical or psychological

energy to endure or perform desired

activities

Activity intolerance

After 4 hours of nursing intervention, the patient will be able to identify techniques in enhancing activity tolerance.

Independent: 1. Evaluated medications the

client is taking to see if they could be causing activity intolerance.

2. Assessed nutritional needs associated with activity intolerance.

3. Monitored vitals before and after any activity, noting any abnormal changes.

4. Assessed for pain before activity.5. Instructed client in energy-conserving techniques (e.g. carrying out activities at a slower pace).Collaborative:1. Administer analgesics as indicated

Independent:1. Medications such as

beta-blockers, lipid- lowering agents, which can damage muscle tissue, and some antihypertensive can result in decreased functioning.

2. The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers.

3. This can be caused by a temporary insufficiency of blood supply

4. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.

5. Energy-saving technique reduces the energy expenditure, thereby assisting in equalization of oxygen supply and demand.

Collaborative:1. Relief of pain can help

increase tolerance to activities

After 4 hours of nursing intervention, the patient was be able to identify techniques in enhancing activity tolerance


“From time to time may inaabot ako sa mesa.”

“Makukulit mga kamag-anak ko dito sa pwesto ko.”

O:

> With under water seal Chest tube on the Left lung, 5th ICS, LMA line.

>CTT bottle is not secured under the bed

>Patient is restless

Risk for Trauma related to dependence on Chest tube Drainage system

Chest tube insertion

Chest tube Drainage system dependence

CTT bottle is not secured under the

bed

Visitors constantly moving around the

bed

Risk for Trauma

Client will be free from trauma throughout the 8 hour nursing shift

Independent:

1. Instruct client to refrain from lying or pulling on tubing.

2. Monitor changes and situations like change in sound of bubbling, sudden “air hunger” and chest pain, and disconnection of equipment.

3. Provide safe transportation when client is sent off unit for diagnostic purposes.

4. Anchor thoracic catheter to chest wall and provide extra length of tubing before turning or moving client.

5. Monitor thoracic insertion site, noting condition of skin and presence and characteristics of drainage from around the catheter. Change and reapply sterile occlusive dressing as needed.

6. Observe for signs of respiratory distress if thoracic catheter is disconnected/ dislodged.

Independent:

1. Reduces risk of obstructing drainage or inadvertently disconnecting the tubing.

2. Timely intervention may prevent serious complications.

3. Promotes continuation of optimal evacuation of fluid or air during transport.

4. Prevents thoracic catheter dislodgment or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing.

5. Provides for early recognition and treatment of developing skin or tissue erosion or infection.

6. Pneumothorax may recur/ worsen, compromising respiratory function and requiring emergency intervention

Client was free from trauma throughout the 8 hour nursing shift

ASSESSMENT NURSING DIAGNOSIS

INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:“Madalas wala dito ang asawa pag natutulog ako.”Objective:>With left side rails down while client is in semi-fowler’s position.

>Caregiver is absent.

>Limited ROM

>(+) Body weakness

Risk for falls related to generalized weakness

Body weakness

Decreased muscle strength

Lowered side rails

Patient is left unattended by the significant

other

Risk for falls

Within the 8 hour nursing shift, the client will be free from falls

Independent:

1. Assessed patient’s general condition

2. Ensured patient’s safety by raising the side rails

3. Monitored vital signs

4. Advised client not to rise abruptly from a supine position

5. Provided emotional support to client

6. Created an individualized exercise program for the client

Collaborative:

1. Consult with dietician for proper diet and nutrition

Independent:

1. To determine the patient’s status

2. To keep the patient from falling of f the bed when moving

3. To obtain baseline data4. Abrupt change of

position can lead to orthostatic hypotension

5. To decrease anxiety.

6. Engaging in regular exercise and activity will strengthen muscles, improve balance, and increase bone density.

Collaborative:

1. Proper nutrition and diet promotes body strength and bone density.

Within the 8 hour nursing shift, the client was free from falls


“May dugong nalabas sa tubo.”

“Madalas akong naihi.”

O:

>Conscious and coherent

> With under water seal Chest tube on the Left lung, 5th ICS, LMA line.

> With ongoing IVF, PNSS 1L x 40cc/ min attached to patients right metacarpal vein.

> Client is also under medication of Furosemide 20mg, 1 tab OD x 3 days

Risk for deficient fluid volume related to treatment regimen

Treatment regimen(chest tube drainage

system and Furosemide medication)

Collection of blood and air from the

chest tube. Furosemide

creates diuresis

Decreased fluid in the body

Risk for deficient fluid volume

Throughout the 8 hour nursing intervention, the client will be able to maintain a near balance between intake and output.

Independent:

1. Measure I&O accurately. Weight daily. Calculate insensible fluid losses.

2. Encourage fluid intake. Provide allowed fluids throughout 24 hour period.

3. Monitor BP, noting postural changes and heart rate

4. Note signs and symptoms of dehydration such as dry mucous membranes, thirst, dulled sensorium and peripheral vasoconstriction

5. Control environmental temperature, limit bed linens as indicated.

Collaborative:

1. monitor labs studies such as sodium

Independent:

1. Helps estimate fluid replacement needs.

2. To replace lost fluids.

3. orthostatic hypotension and tachycardia suggest hypovolemia

4. For immediate prevention of severe dehydration.

5. may reduce diaphoresis which contributes to overall fluid losses.

Collaborative:

1. To gain a more accurate assessment of the patient’s condition

Throughout the 8 hour nursing intervention, the client was able to maintain a near balance between intake and output

ASSESSMENT NURSING DIAGNOSIS

INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:“Di ako masyado nakakagalaw-galaw.”Objective:>Client is conscious and coherent

>Limited ROM

>(+) Body malaise

Risk for constipation related to changes in level of activity

Body weakness and lack of

privacy

Decrease in level of activity

Decreased stimulation of

the smooth muscles of the

G.I tract.

Decrease in peristalsis

Risk for constipation

After 1 hour of nursing intervention, the Client will verbalize understanding of ways in improving bowel elimination patterns an effective respiratory pattern.

Independent:1. Ascertained usual

bowel pattern and aids used. Compare with current routine.

2. Provided diet high in fiber bulk in the form of whole-grain cereals, breads, and fresh fruits.

3. Encouraged increased fluid intake.

4. Institute an individualized program of exercise, rest, and diet.

5. Provided emotional support to client

Dependent:1. Administered

medications as indicated (e.g. bulk providers and stool softeners)

Independent:1. Determines extent of

problem and indicates types of interventions appropriate.

2. Improves stool consistency, promotes evacuation

3. Promotes normal stool consistency.

4. Increase in activities and movement increases peristalsis.

5. Decreases feelings of embarrassment and frustration.

Dependent:1. Promotes regularity by

increasing bulk or improving consistency.

After 1 hour of nursing intervention, the Client has verbalized understanding of ways in improving bowel elimination patterns an effective respiratory pattern

ASSESSMENT NURSING DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIONSUBJECTIVE:“Mahirap tumigil sa pagyoyosi eh.”OBJECTIVE:>Request forInformation about the disease process.>Inaccurate follow through of instructions.> Demonstrates nonacceptance of health status change.

Risk forProne healthbehaviorrelated tolack ofknowledgeabout thedisease

Lack of knowledge about the disease

process

Reduced motivation to modify lifestyle

Reduced interest in self-care

Risk for prone health behavior

After 4 hoursof nursinginterventions,the patient will demonstrate increase in interest and participation in self-care

INDEPENDENT:1. Established rapport2. Assessed patient’s general condition.3. Assisted the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol, smoking, and drinking.4. Reinforced the importance of adhering to treatment regimen and keeping follow up appointments.5. Identify with the client past and present significant support systems (family, church, groups and organizations).6. Identify possible cultural beliefs / values influencing client’s response to change.7. Acknowledge client’s efforts to adjust: “You have done your best.”Collaborative:1. Refer to spiritual adviser in necessary

INDEPENDENT:1. To prevent patient anxiety and establish cooperation2. To determine patient’s status.3. These risk factors have been shown to contribute to the development of several types of diseases.4. Provides basis for understanding of the condition. Lack of cooperation may lead to failure of therapy.5. Identifies helpful resources that may be needed in current situation.6. Different cultures deal with change of health issues.7. Avoids feelings of blame / guilt and defensive response.Collaborative:1. For the client to be given spiritual counseling.

After 4 hoursof nursinginterventions,the patient will demonstrate increase in interest and participation in self-care

Drug Study

DRUG NAME CLASSIFICATION MECHANISM OF ACTION

INDICATION DOSAGE/ROUTE/FREQUENCY NURSING CONSIDERATIONS

EVALUATION

BRAND NAME:ReglanGENERIC:Metoclopramide

Antiemetic, Dopaminergic blocker, GI stimulant

Stimulates motility of upper GI tract

without stimulating gastric,

biliary or pancreatic secretions.

Sensitizes tissues to action of

acetylcholine

Relaxes pyloric sphincter, which when combined with effects of

motility

Accelerates gastric emptying and

intestinal transit; little effect on gallbladder or colon motility

Increases esophageal

sphincter pressure, has sedative properties

Induces release of prolactin.

-Relief of symptoms of acute and recurrent gastroparesis.-Stimulation of gastric emptying and intestinal transit of barium.

10 mg/ TIV/ now then PRN for nausea & vomiting.

-Assess for allergy to metoclopramide, GI hemorrhage, mechanical obstruction or perforation, epilepsy.-Assess the patient’s orientation, reflexes, VS, bowel sounds, normal output, EEG.-Monitor BP carefully during IV administration.-Monitor for extrapyramidal reactions, and notify physician if they occur.-Report involuntary movement of the face, eyes, limbs, severe depression & severe diarrhea.

-The patient’s VS were monitored, in normal ranges during IV administration.-Nausea and vomiting was prevented.



EVALUATION

BRAND NAME:Propyl-ThyracilGENERIC:Propylthiouracil

Antithyroid drug Inhibits the synthesis of

thyroid hormones

Partially inhibits the peripheral

conversion of T4 to T3 the more potent form of

thyroid hormone.

Hyperthyroidism 50 mg / 1 tab per orem/ q6 -Asses for allergy to antithyroid drugs.-Assess the patient’s skin color, lesions, pigmentations, orientation, reflexes.-Administer drug in three equally divided doses at 8 hour intervals, schedule to maintain patient’s sleep pattern.-Arrange for regular, periodic blood tests to monitor bone marrow depression and bleeding tendencies.-Report fever, sore throat, unusual bleeding or bruising. Headache & general malaise.

-The client’s thyroid hormones are within normal levels.



EVALUATION

BRAND NAME:VasotecGENERIC:Enalapril

ACE inhibitor, Antihypertensive

Renin released into circulation

Acts on a plasma precursor to

produce angiotensin I

Converted by ACE to angiotensin II

Increases BP.

Blocks the conversion of

angiotensin I to angiotensin II

Decreases BP and aldosterone

secretion, slightly increases serum K+ levels and causing Na+ and fluid loss.

Treatment of hypertension

5 mg/ 1 tab Per Orem/ OD -Assess for allergy to enalapril, impaired renal function, salt or volume depletion.-Assess patient’s skin color, lesions, turgor, orientation, reflexes, peripheral sensations, VS, mucous membranes, bowel sounds and liver evaluation.-Monitor patient on diuretic therapy for excessive hypotension after the first few doses of enalapril.-Monitor patient closely in any situation that may lead to a drop in BP secondary to reduced fluid volume (excessive perspiration, and dehydration, vomiting and diarrhea).

-Patient was monitored closely for any situation that might lead to a drop in BP.-Patient’s blood pressure is within normal ranges.


INDICATION DOSAGE/ROUTE/FREQUENCY

NURSING CONSIDERATIONS

EVALUATION

BRAND NAME:Apo-FurosemideGENERIC:Furosemide

Loop diuretic Action at the proximal and distal

tubules and ascending limb of the loop of Henle

Inhibition of

reabsorption of sodium and

chloride

Leads to a sodium-rich diuresis.

For mild to moderate hypertension

20 mg/ 1 tab Per Orem/ OD x 3 days

-Assess allergy to medication.-Assess the patient’s skin color, lesions.-Reduce dosage if given with antihypertensive drugs , readjust dosage gradually as BP responds.-Give early in the day so that increased urination will not disturb sleep.-Avoid IV use if oral use is at all possible.-Measure and record weight to monitor fluid changes.-Arrange to monitor serum electrolytes, hydration, liver and renal function.-Arrange for potassium – rich diet or supplemental potassium as needed.

-Patient’s sleep pattern was not disturbed.-Patient’s blood pressure is within normal ranges.




EVALUATION

BRAND NAME:InnoPran XLGENERIC:Propranolol

Antianginal, antiarrhythmic. Antihypertensive, Beta-adrenergic blocker (non selective)

Completely blocks beta-adrenergic

receptors in the heart and

juxtoglomerular apparatus

Decreases the influence of sympathetic

nervous system on these tissues, the excitability of the heart,

cardiac workload and O2

consumption, and the release

of renin and lowering BP.

For adult hypertension

20 mg/ 1 tab Per Orem/ q8

-Assess allergy to beta-blocking agents, sinus bradycardia, second or third degree heart block, cardiogenic shock, peripheral vascular diseases.-Assess the patient’s weight, skin color, lesions, edema, reflexes.-Provide continuous cardiac and regular BP monitoring with IV form.-Give oral drug with food to facilitate absorption.-Report difficulty of breathing, night cough, swelling of extremities, slow pulse, confusion, depression, rash fever, sore throat.

Patient’s cardiac status and BP were maintained within the normal range.




EVALUATION

BRAND NAME:TapazoleGENERIC:Methimazole

Antithyroid drug Inhibits the synthesis of thyroid hormone.

Treatment of hyperthyroidism.

Methimazole 20mg 1 tab Per Orem after breakfast Methimazole 5mg/ tab 2 Per Orem tab after dinner

-Assess allergy to antithyroid products.-Assess for skin color, lesions, pigmentation, orientation. Reflexes.-Give drug in three equally divided doses at 8-hr interval.-Establish a schedule that fits the patient’s routine.-Advise the patient that taking this drug could increase the risk of bleeding problems.-Report fever, sore throat, unusual bleeding or bruising, headache and general malaise.-Obtain regular, periodic blood tests to monitor bone marrow depression and bleeding tendencies.

-Thyroid storm was prevented.-Patient did not develop any allergies to the medication




EVALUATION

BRAND NAME:RocephinGENERIC:Ceftriaxone

Antibiotic, Cephalosporin (third generation)

Binds to receptors of bacterial cells

Inhibits synthesis of bacterial cell

wall

Causes cell death

Lower respirations infections

2g/ TIV/ OD (loading dose)500mg for consecutive doses TIV q8

-Assess for hepatic and renal impairment.-Assess the skin status, renal function tests, culture of affected area, sensitivity tests.-Advice the patient that he may experience stomach upset and diarrhea.-Report severe diarrhea, difficulty breathing, unusual tiredness or fatigue, pain at the injection site.-Discontinue if hypersensitivity occurs.

Patient was monitored closely for stomach upset and diarrhea.




EVALUATION

BRAND NAME:TitradoseGENERIC:Isosorbide Dinitrate

Vasodilator Relaxes vascular smooth muscle with a resultant

decrease in venous return

Decrease in arterial BP

Reduces left ventricular workload

Decreases myocardial

oxygen consumption

Treatment and prevention of angina pectoris/ chest pain

5mg/tab/ 1 tab OD for chest pain

-Assess for any allergy to nitrates, severe anemia, GI hypermobility.-Assess for skin color, lesions, orientation, reflexes.-Monitor effectiveness of drug in relieving angina.-Headaches tend to decrease in intensity and frequency with continued therapy but may require administration of analgesic and reduction in dosage.-Make position changes slowly, particularly from recumbent to upright posture, and dangle feet and ankles before walking.-Keep a record of angina attacks and the number of sublingual tablets required to provide relief.

Patient was monitored closely and chest pain was relieved.



NURSING CONSIDERATIONS EVALUATION

BRAND NAME:DuoNebGENERIC:Salbutamol + Ipatropium

Antiasthmatic & COPD preparations

IPATROPIUM:Anticholinergic agent inhibits

vagally-mediated reflexes by

antagonizing the action of

acetylcholine.

Prevents the increase in

intracellular concentration of cyclic guanosine monophosphate w/c are brought

about by interaction of

acetylcholine with the muscarinic receptors on

bronchial smooth muscle.

SALBUTAMOL:Direct acting

Beta2-adrenergic agent.

Acts on the airway

smooth muscle resulting in

bronchodilation.

Provides inhalation for DOB.

1 nebule Q6 PRN for DOB

-Monitor respiratory status; Auscultate lungs before and after inhalation.-Report treatment failure (exacerbation of respiratory symptoms) to physician.-Do not allow the solution to enter the eyes.-Allow 30-60 seconds between puffs for optimum results.-Advice patient to wait for 5 mins between this and other inhaled medications.-Let the patient rinse mouth after medication puffs to reduce bitter taste.

Patient’s DOB was managed and relieved.

DRUG NAME CLASSIFICATION ACTION INDICATION DOSAGE/ROUTE/FREQUENCY


EVALUATION

BRAND NAME:

Tramadine

GENERIC NAME:

Tramadol

Analgesics (opioid)

Inhibits reuptake of

norepinephrine, serotonin and enhances

serotonin release.

Inhibits reuptake of

norepinephrine, serotonin and enhances

serotonin release.

Decreased pain

Indicated for the management of moderate to moderately severe pain.

50mg TIV p.r.n. q6 -Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration.

-Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression

-Discontinue drug and notify physician if S&S of hypersensitivity occur.

-Assess bowel and bladder function; report urinary frequency or retention.

-Monitor ambulation and take appropriate safety precautions.

-Client has verbalized that pain was either reduced or relieved.

Discharge Plan

Discharge Plan

Medications:• Inform the client the importance of compliance with taking the medications as prescribed by the physician.• Continue medications prescribed such as:• Methimazole 20mg 1 tab Per Orem after breakfast • Methimazole 5mg/ tab 2 Per Orem tab after dinner• Pain medication should be given on discharge.

Exercise:•Instruct on Deep Breathing Exercise and effective coughing•Instruct patient to avoid extremes exercises, which will lead him to stress; and as to avoid shortness of breath.•Instruct client to perform exercise as tolerated •Treatment:•Instructed client to continue steam inhalation and gentle chest physiotherapy.•

Health Education:Self care:

•Encourage patient to avoid doing strenuous activities•Chest tube wound site should be monitored for infection and to ensure proper healing.•Encourage patient to stop smoking and avoid excessive alcohol intake•Provide information about Pneumothorax and its signs and symptoms to avoid another occurrence in the future.•Home Care: •Encourage to have a regular BP check-up at the nearest barangay health station•Keep an environment free of air and noise pollution.

Discharge PlanOPD follow – up:

•Instruct patient to return if there is chest pain or shortness of breath•Teach patient when to notify the physician of complication (e.g. infections and an unhealed wound)•Review all follow- up appointments with the patient, involving chest x-rays, arterial blood gas analysis, and a physical exam.

Diet:

•Instructed client on regular fluid intake and regular diet•Eat foods high in protein and high in calories. Foods such as whole dairy products, nuts and peanut butter, and fatty cuts of meat can help to add needed nutrients.•Eat foods with enough calcium contents such as dairy products.•Avoid excessive intake of caffeine

Spirituality:•Support client’s religious practices.•Refer client for spiritual counseling.

Thank you! :D

CasePres Pneumothorax

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