Hard Bound

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I. INTRODUCTION

“Time and health are two precious assets that we don’t recognize and appreciate until

they have been depleted.”

- Denis Waitley

Health is the most precious and the most valuable piece of man, if a man

recognizes that he is free from sickness and any diseases, and then by all means he is

aware of his surroundings. If a man does not take care of his/her health then that person

is vulnerable to acquiring such diseases; which may jeopardize his/her health in the

future. Time and health is a blessing in this world that a man must cherish. Maintaining

your health in full conditions is not always easy. It has problems, too and challenges lies

in maintaining and keeping it in full condition, a man needs courage and patience on

keeping his health wealthy. Difficulties in keeping you in condition will test your

courage, patience and perseverance and true character of a human being. Until you find

out that your health is depleted that is when hardship comes in and would make you a

strong person and ready to change for the better.

A good example would be a condition affecting the lungs. The lungs are very

important in the body because whenever you inhale and exhale, oxygen gets supplied into

and out of your lungs for oxygenation. When the lungs are not functioning well, it not

only hinders you from breathing normally but it will affect your normal daily living until

then you realize that the simplest and the utmost undemanding labors in life is hindered

by the condition you are suffering from, such as Tuberculosis that can lead to

Bronchiectasis.

Tuberculosis (TB) is an infectious disease that primarily affects the lung

parenchyma. It also may be transmitted to other parts of the body, including the

meninges, kidneys, bones, and lymph nodes. The primary infectious agent,

Mycobacterium tuberculosis, is an acid-fast aerobic rod that grows slowly and is sensitive

to heat and ultraviolet light. TB spreads from person to person by airborne transmission.

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An infected person releases droplet nuclei through talking, coughing, sneezing, laughing,

or singing. Larger droplets settle; smaller droplets remain suspended in the air and are

inhaled by a susceptible person. Symptoms are cough of more than two weeks, loss of

weight, fever, chest pain or spiting with blood. A TB patient may infect 10- 15 persons

per year. It is usually an illness of adults but it can also affect children. TB is curable and

preventable (Bare et.al, 2010).

The initial damage to the bronchi may result from a number of different causes;

one of these is Tuberculosis, leading to Bronchiectasis. Bronchiectasis is a disease state

defined by localized, irreversible dilation of part of the bronchial tree caused by

destruction of the muscle and elastic tissue. It is classified as an obstructive lung disease,

involved bronchi are dilated, inflamed, and easily collapsible, resulting in airway

obstruction and impaired clearance of secretions (National Heart, Lungs and Blood

Institute, 2011). According to World Health Organization (WHO), Bronchiectasis is an

abnormal widening of one or more airways. Normally, tiny glands in the lining of the

airways make a small amount of mucus. Mucus keeps the airways moist and traps any

dust and dirt in the inhaled air, but because bronchiectasis creates an abnormal widening

of the airways, extra mucus tends to form and pool in parts of the widened airways. This

condition is more common in adults, although it may originate in childhood. The

common, defining symptom is the frequent coughing up of foul, smelly secretions that

are thick and green or yellow in color and may be blood-flecked. The person suffers from

frequent respiratory infections and is often breathless and unwell. In addition, the person

may be abnormally tired and anemic. The main treatment is the practice of postural

drainage to eliminate the accumulated secretions. Also, surgery to remove a part of the

lung (lobectomy) may be needed and antibiotics to fight infections (Elicano, 2013).

a. Current Trends about the disease condition

A compound from the South African toothbrush tree inactivates a drug target for

tuberculosis in a previously unseen way. Tuberculosis causes more deaths worldwide

than any other bacterial disease. At the same time as rates are increasing, resistance

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strains are emerging due, in part, to non-compliance with the treatment required. Many

current drugs are nearly 50 years old and alternatives are needed to the long, demanding

treatment schedules.

The compound under research, diospyrin, binds to a novel site on a well-known

enzyme, called DNA gyrase, and inactivates the enzyme. DNA gyrase is essential for

bacteria and plants but is not present in animals or humans. It is established as an

effective and safe drug target for antibiotics. "The way that diospyrin works helps to

explain why it is effective against drug-sensitive and drug-resistant strains of

tuberculosis," said Professor Tony Maxwell from the John Innes Centre. In traditional

medicine the antibacterial properties of the tree are used for oral health and to treat

medical complaints such bronchitis, pleurisy and venereal disease. Twigs from the tree

are traditionally used as toothbrushes.

Most antibiotics originate from naturals sources, such as the soil bacteria

Streptomyces. Antibiotics derived from plants are less common, but they are potentially

rich sources of new medicines. "Extracts from plants used in traditional medicine provide

a source for novel compounds that may have antibacterial properties, which may then be

developed as antibiotics," said Professor Maxwell. "This highlights the value of

ethnobotany and the value of maintaining biodiversity to help us address global

problems."

Professor Maxwell is continuing the work on diospyrin and related

naphthoquinone compounds as part of the efforts of a consortium of European

researchers, More Medicines For Tuberculosis (MM4TB). The collaboration between 25

labs across Europe is dedicated to the development of new drugs for TB (Norwich

BioScience Institutes, 2013).

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b. Statistics

Tuberculosis is a worldwide public health problem that is closely associated with

poverty, malnutrition, overcrowding, sub-standard housing, and inadequate health care.

Mortality and morbidity rates continue to rise; Mycobacterium tuberculosis infects an

estimated one third of the world‘s population and remains the leading cause of death from

infectious disease in the world. According to the WHO, an estimated 1.6 million deaths

resulted from Tuberculosis in 2005 (WHO, 2007). In the Philippines, TB is a major

health problem. It is the sixth leading cause of death and illness. In 2011, WHO estimates

there are 260,000 incident cases in the country, and 28,000 die in a year. Tuberculosis

prevalence is high among the high-risk groups such as the elderly, urban poor, smokers

and those with compromised immune systems such as people living with HIV,

malnutrition and diabetes. It is estimated that 10,600 patients have multi-drug resistant

TB (MDR-TB) in 2011. This situation leads to substantial socio-economic losses to the

country (World Health Organization in Western Pacific, 2013).

c. Reasons For Choosing Case Presentation

“To heed about what is less likely to be unknown is to bring a change on the way

we experience and think about things---it would be a quantum shift, not only on a

professional manner but also to gain a higher level of intellectual grounds… To seek is to

see and to see, it may be.”

- Anonymous

Hence, a case with Pulmonary Tuberculosis as a history, leading to Bronchiectasis

and Fungus Ball, this condition is seldom studied as evidenced by the difficulty of

finding statistical data to directly measure its pertinence, frequency and incidence.

Neither a specific book nor internet site has enough information which is completely

focused, updated and is sufficient to fully quantify its pertinence especially on the local

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setting. Almost all the references just include it as an inclusion or more so, an estimated

statistical basis is only done.

With all this in mind and because of the understanding of the possibilities, risks,

and other complications that the condition may bring, the need to study it profoundly had

deemed it relevant for the group to take this condition as their case study. Research in this

area can help shed light into the workings of the disease, the predisposing factors, impact

on the morbidity and mortality rates and the measures taken by the health care team in the

treatment be it in nursing, medical and surgical management and control of the condition.

Furthermore, the analysis and synthesis of both the patient-centered

pathophysiology and that of available literature, as well as the medical management and

nursing management that transpired during the confinement of the patient and the

corresponding progress evaluation of the patient‘s condition are ultimately significant not

only in the field of research but also in the clinical area in that therapeutic management

that is both effective and significant may be identified which can lead to the ruling out of

the less effective measures undertaken and prioritizing on the effectiveness of the other

interventions. Such results can be significant for future management and clinical handling

of the disease.

But personally, the group would want to expand their horizons with this case.

They thought of this as a great deal to challenge their intellectual grounds. More so, it is

really a good subject for their case and a lot of learning may possibly be extracted to it

because appropriate managements were performed to the patient during the entire

hospitalization; with these the group decided to choose this as their case because of the

many learnings; skills and proper approach that they will be gaining during the entire

student nurse and patient interaction.

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d. Objectives

General Objectives

After the completion of the study, the student nurse-researchers will be able to:

Acquire knowledge and have a deeper understanding of the development of

disease condition in relation to the modifiable and non-modifiable factors that have

predisposed the client to the occurrence of the disease condition hence, be able to discuss

management and treatment and provide better nursing care and preventive health

teachings through the utilization of the nursing process.

OBJECTIVES

A. Student Nurse – Centered Objectives

Short- Term Objectives

After 5 days of nurse-patient interaction, the student nurses shall have:

1. Familiarized the attitude of the patient‘s family health and obtained the

personal and pertinent family health-illness history of the client and relate it

to the present disease condition;

2. Identified the statistics and prevalence of the disease condition as well as the

latest trends in the management of the disease condition.

3. Gathered pertinent information about the patient regarding his personal and

socio-economic histories, cultural beliefs and environmental factors that

may have contributed in the development of the disease condition.

4. Analyzed the diagnostics and laboratory procedures performed to diagnose

the condition of the patient.

5. Identified and prioritized appropriate nursing care plans to aid in the

management of the patient‘s condition.

6. Provided various therapeutic nursing interventions that are suitable with the

presenting problems experienced by the patient.

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Long- Term Objectives

After completion of this case study, the student nurses shall have:

1. Discussed Tuberculosis, Bronchiectasis and Fungus Ball, Diabetes Mellitus

Type II and Hypertension, its definition, risk factors, sign and symptoms that

had contributed to the occurrence of the disease condition. As well as

identified the apparent sign and symptoms manifested by the patient in

relation to the mentioned disease condition.

2. Performed a comprehensive assessment; physical, neurological and

neurovascular assessment as to general condition of the patient; as well as its

effects to the significant other may be it physically, socially, mentally and

spiritually to confirm the diagnosis of Pulmonary Tuberculosis,

Bronchiectasis, and Fungus ball, Diabetes Mellitus Type 2, Hypertension; or

to identify other possible causes of patient‘s symptoms;

3. Comprehensively analyzed and interpreted the different laboratory and

diagnostic procedures in relation to the clinical manifestations of the disease

condition; and the different nursing interventions that must be done before,

during and after each procedure.

4. Identified nursing problems and appropriate nursing care plan that involves

the patient and the significant others.

5. Specified the various treatments modalities such as medical management and

surgical management as well as current trends in managing Tuberculosis,

Bronchiectasis and Fungus Ball, Diabetes Mellitus Type II and Hypertension.

6. Identified the appropriate nursing diagnosis and make corresponding

interventions and carry them out as the situation permits as to promote patient

wellness.

7. Made daily progress chart to evaluate patient‘s response to medical

management

8. Formulated discharge planning and care of patient at home.

9. Formulated conclusions based on findings and enumerate recommendations

concerning the management of Tuberculosis, Bronchiectasis and Fungus Ball,

Diabetes Mellitus Type II and Hypertension.

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10. Evaluated effectiveness of nursing care and medical interventions rendered

B. Client-Centered Objectives

Short-Term Objectives

After 5 days of nurse-patient interaction, the patient/SO shall have:

1. Established rapport with student nurses and will trust and cooperate with

them;

2. Determined their level of understanding about the disease condition;

3. Understood the purpose of the student nurse purpose for acquiring related

information about the patient with regards to the condition;

4. Cooperated during the interview process and gathering of data thereby sharing

of information that is significant to the present condition of the patient.

5. Willingly answered the questions of the student nurses and shared relevant

information about their health belief and practices. Shared their perceptions

regarding the history of illness their family are experiencing.

6. Demonstrated awareness on the activities necessary to accomplish the case

study

7. Imparted their views in what the possible effects of these health problems are

and what interventions can be done to solve them.

Long-Term objectives

After the completion of the case study the patient and his family shall have:

1. Enumerated the underlying cause of the disease and its occurrence;

2. Participated in the modality of the treatment given to the patient;

3. Obtained pharmacological and non-pharmacological treatment to alleviate

disease condition;

4. Acquired palliative care and management of pain as well as reducing the

occurrence of complication from disease condition;

5. Participated in formulating various nursing care plans with the student nurses

to improve patient‘s condition.

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II. NURSING PROCESS

A. ASSESSMENT

1. Personal History

a. Demographic Data

Mr. Baga, who is a 58 years old male, a natural born Filipino, currently residing at

Tarlac, Pampanga. He was born on April 13, 1955 in his hometown in Pampanga. He

was admitted to one of the tertiary hospitals in Angeles City on November 3, 2013,

9:52 am, with an admitting diagnosis of Recurrent Massive Hemoptysis to consider

Tuberculosis Bronchiectasis versus Fungus Ball, Left Upper Lobe.

During the interview the student nurses‘ informant was his second eldest daughter

Alveoli, who was very informative and patient in answering all the student nurse‘s

queries.

The patient was discharged last November 15, 2013 with the Final diagnosis of

Recurrent Massive Hemoptysis Secondary to Tuberculosis Bronchiectasis, Fungus

Ball, Left upper lobe.

b. Socio-Economic and Cultural Factors

b.1. Income and Expenses

Mr. Baga was a farmer, since he was 13 years old up until he was 45 years old.

According to Alveoli, his father earns every four months when they harvest rice. He

also owns the rice field in his hometown. He planted corn crops other than rice and

has mango trees on his farm. He also owns an ―itikan‖ . According to Alveoli his

father uses chemical pesticides on his farm without proper protective equipment like

mask because according to the patient they are not used of wearing mask, one

example of pesticide they use is the urea 14X14X14. He is also a tricycle driver

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during the time that he is not in his farm.

The family‘s primary source of income is from the monthly remittances of Mr.

Baga‘s children, which is Php 30,000 pesos/month. According to Alveoli their profit

from farming depends on their harvest every 4 months, the average net profit is Php

40,000 plus the remittances of Php 30,000 the total income is Php 70,000/month

when it is harvest season, but when it is not harvest season the family will have Php

30,000 as their monthly income. Mrs. Baga budgets the income as follows:

Expenses Amount

Food (rice/ fish/ pork/ vegetables)

(Php 250.00 x 30 days)

Php 7,500.00

Electricity (lights, appliances & Jetmatic) Php 1000.00

Water bill Php 1000.00

Miscellaneous

Groceries- (Php 500 x 2 a month)

Maintenance Drugs (Estimated amount: 1000)

Php 1,000.00

Php 1,000.00

Total Expenditures Ph 11,500.00

Php 30,000- Php 11,500 = 18,500/ month (during non-harvest season)

Php 70,000 – Php 11,500 = Php 58,500 total savings every 4 months

According to NEDA, each member of the family should have at least 2,768.60

pesos to use per month. This is computed by dividing the family‘s total monthly income

by the number of family members. Computing the adequacy of the family‘s income, Mr.

Baga‘s family is categorized to be not poor since the division of the Php 70,000 pesos

monthly income of the family into 5 as the total number of the members of the family

yields an estimation of Php 14,000 pesos.

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b.2. Educational Attainment

Mr. Baga‘s highest educational attainment is elementary level. According to

Alveoli he wanted to continue his studies but due to financial constraints he stopped

schooling to help with his family and support all his other 8 siblings.

b.3. Religious Affiliation

According to Alveoli her father is the only Iglesia ni Cristo (INC) in their family

since 2007 while the rest of the members of family are Roman Catholic, he is an active

member, he usually attends their church service every Thursdays and Sundays at the

nearby INC church. Alveoli said that when it comes to health beliefs, his father as an INC

member does not have any restrictions on health beliefs.

b.4. Cultural factors affecting health of the family

Alveoli verbalized that the family believed in ―hilot‖ or herbolarios except for

Mr. Baga who is always consulting his private doctor when his health is compromised.

She also said that her father has a monthly check up on his diabetologist.

Mr. Baga used to be a smoker, he can consume 40 sticks a day, he started

smoking when he was a teenager, 15 years old, he stopped smoking last 2008 when he

was diagnosed of Tuberculosis, 53 years old.Pack years: 40 sticks /day multiply by 38

years of smoking = 76 pack years.

He drinks hard liquor occasionally, such as Emperador approximately 500ml.

According to Alveoli, Mr. Baga‘s diet prior to diagnosis of Diabetes Mellitus compose of

eating rice every meal, during breakfast, lunch and dinner even his snacks he eats rice

with 1 viand it could be fish, chicken, pork and beef. He became conscious of the food he

eats, avoiding sweet and fatty food when he was diagnosed of DM in 1994.

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c. Environmental Factors

Mr. Baga‘s family is made up of six members namely Mr. Baga who stands as the

head of the family, with regards to family‘s health Mr. Baga and his wife shares on

decision making; his wife Mrs. Baga takes care of the household; Bronchi, the eldest

daughter; Alveoli, second oldest daughter; Pleural, his only son and Surfactant his

youngest daughter. Currently all of Mr. Baga‘s children are overseas Filipino workers.

The family‘s internal relationship is said to be harmonious, although there are moments,

which seldom occur, that distort this harmony between the members of the family, but

they are able to manage it. Alveoli verbalized that her parents Mr. Baga and Mrs. Baga

lives on a house near their rice fields with their three grandchildren which makes his

family a Skipped type of family. Mr. Baga‘s house is made up of concrete/wood with 3

bedrooms and 1 bathroom; they have a total of 9 windows as verbalized by Alveoli.

Alveoli stated that their house is well ventilated and lighted although their house is under

renovation. The family‘s sleeping arrangement composed of bedroom 1 which is being

shared by Mr. and Mrs. Baga, bedroom 2 is for their 3 grandchildren, they also have an

extra bedroom wherein their son and daughters stay when they visit them.

According to Alveoli, Mrs. Baga cooks food for her family everyday where she

goes to the nearest market, being mindful of Mr. Baga‘s diet, which is suitable for

diabetic, Alveoli said that Mr. Baga usually eats ampalaya and one cup of rice per meal,

he refrains from eating sweets and usually jogs in the morning. As for their left-over

food, they keep it covered with a plate and store it inside their refrigerator. The family‘s

primary source of water is through the use of Jet matic. They get their drinking water by

buying purified water from nearby water station. Their garbage is stored in a sack, being

disposed at the back of their house where they have a garbage pit and as verbalized by

Alveoli, they have a closed drainage system

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2. Family Health Illness History

Mr. Baga is the 6th

oldest in their family with a total of 9 siblings. Four out of the

nine siblings has Diabetes Mellitus, and one of them had a history of kidney failure. Two

of Mr. Baga‘s oldest siblings are deceased, the cause of the death are kidney failure and

complications of Diabetes, respectively. Mr. Baga‘s both parents were deceased, the

father died from heart attack and the mother from Alzheimer‘s disease and old age.

As stated by Alveoli, there is no known familial history of Tuberculosis in the

family. According to Alveoli, when Mr. Baga has cough and colds he will immediately

seek for medical care on his private doctor.

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GENOGRAM

Mr. Baga

Kidney

Failure

Complication

of DM

With

Diabetes

With

Diabetes

With

Diabetes

LEGEND:

Deceased Deceased MALE

Female Male

With Dse With Dse FEMALE

Female Male

Father

Heart Attack Mother

Old Age with

Alzheimer‘s

PATERNAL MATERNAL

Grandfather

Unknown

Grandmother

Unknown

Grandfather

Unknown

Grandmother

Unknown

PTB; BRONCHIECTASIS; DM;

HPN

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3. History of Past Illness

According to Alveoli, in the year 1991, her father Mr. Baga had an accident, which is

being electrocuted through faulty wire on his farm‘ fences while he was trying to fix it. Leaving

lesions on his right hand due to burns.

In the year 2001, Mr. Baga had a self-accident; he was riding a motorcycle when he lost

control and swerved on the road with minor injuries.

As stated by Alveoli, Mr. Baga started to have high blood pressure on April 2013 and

was diagnosed as Secondary Hypertension he takes Amlodipine (calcium channel blocker) 10

mg once a day as his maintenance drug.

4. History of Present Illness

On 1994, Mr. Baga was diagnosed of Diabetes Mellitus Type II; he has a monthly check

up with his diabetologist and has been managing his DM with Diamicron (oral hypoglycemic

agent) twice a day one in morning and at night which he religiously take every day.

According to Alveoli, in the year 2008, Mr. Baga was farming and afterwards complains

of fatigue from work, She stated that while her father is farming he also coughed out blood and

the family rushed him to one of the hospitals in Pampanga. The family did not see any earlier

symptoms prior to vomiting of blood as verbalized by Alveoli. Mr. Baga was diagnosed of

Primary Tuberculosis and they gave him 4 kinds of medication; Rifampicin, Isoniazid,

Pyrazinamide, and Ethambutol (RIPE). Wherein, he completed treatment for more than 6

months. Alveoli verbalized that Mr. Baga was relieved of the signs and symptoms after the

treatment. From 2008-2010 he continued with farming and no other signs for PTB were noted.

In the year 2010, two years after, Mr. Baga‘s Tuberculosis recurred as verbalized by

Alveoli, she said that her father was farming and experienced the same event, coughing off

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blood; Thus they rushed him to the hospital and recommended to undergo another 2 months of

treatment with the same combination of anti tuberculosis drugs, and after completing the

treatment he was relieved and no signs of TB was experienced up until June of 2013.

The episodes of hemoptysis started again on July 2013 as verbalized by Alveoli,

amounting to almost one glass of blood. He undergone computed tomography scan and x-ray

after that his doctor suggested undergoing surgery, which is lobectomy but Mr. Baga refused to

have one. He was then given another option, which is to have chemical embolization, in which

he agreed upon, it was performed on August 28, 2013 in one of the tertiary hospitals in Tarlac.

Three weeks after the procedure, his episodes of hemoptysis recurred.

On September 29, 2013 Mr. Baga was admitted in one of the tertiary hospitals in Tarlac

due to massive hemoptysis amounting to 2 liters as verbalized by Alveoli and he was then re-

admitted to same hospital in Tarlac. X-ray result shows Pneumonia, Left Upper Lobe, and Left

ventricular cardiomegaly. He was given a combination drug of RIPE (Fixcom) where he had an

allergic reaction (blisters on upper extremities accompanied by urticaria) after a day of

administration. The drug was immediately stopped and treatment was halted, after which Alveoli

said that his father‘s hemoptysis got worse that he fainted and he was confined in the hospital for

6 days. On October 2, 2013 he was diagnosed of Chronic Kidney Disease stage 3 secondary to

Diabetic Nephropathy and he was discharged on October 4, 2013 at 2 pm.

On the same day, October 4, 2013, 9pm, when they went home Mr. Baga had another

episode of hemoptysis, he was rushed again to the same hospital but according to Alveoli no

medical management was given not until they find an allgergologist to check which of the

components of Fixcom he was allergic to. An allergologist was found in one of the tertiary

hospitals in Angeles City, which made them transfer Mr. Baga from Tarlac to Angeles City. On

October 7, 2013 Fiber Optic Bronschoscopy and bronchial washing was done to him with result

shows that there is no microorganism, acid fast Bacilli and fungal elements seen. Rifampicin

challenge was done on October 8, 2013 and was been stopped on October 9, 2013 because of

allergic reaction which then Ethambutol challenge was done and show no allergic reaction to the

Ethambutol. Desensitization was done on October 15, 2013 and was given Dipenhydramine

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(anti-histamine) for his allergies. He was been diagnosed of Pulmonary Tuberculosis,

Hypetension SII, Diabetes Mellitus Type II, Adverse reaction to Rifampicin.

He was then given medical management for Tubercolosis after having an allergologist

performed desensitization, and was admitted on October 20, 2013. Mr. Baga does not want to

have the surgery and was discharged on October 24, 2013 with a final diagnosis of Bleeding

Bronchiectasis secondary to PTB hemoptysis, Hypertension II, DM II and was given home

medications: Unasyn 750mg/tab BID x 7days; Tranexamic Acid 500mg/tab TID for bloody

phlegm, Pantoprazole 40mg/tab OD x 5 days; Levocetirizine 500mg/tab OD for itchiness;

Levopront syrup 1 teaspoon BID X 5days; Losartan 100 mg/tab OD; Amlodipine 10mg/tab OD;

Carvediol 25 mg/tab ½ tab BID; Sinecod Forte 1tab/TID x 5 days; Rifampicin 60 mg/tab 1 tab

after breakfast, Isoniazid 400mg/tab OD; Ethambutol 400mg/tab TID; Mixtard 44 units at 6am,

22 units at 6pm; which Mr. Baga complied religiously taking his home medications.

On November 3, 2013, Mr. Baga had another episode of massive hemoptysis and they

went to a doctor in Angeles City because his father‘s condition got worse. He was admitted again

to the same tertiary hospital with the admitting diagnosis of recurrent massive hemoptysis to

consider TB Bronchiectasis versus Fungus Ball on the left upper lobe. The doctor suggested

having a surgery, which is lobectomy on the left upper lobe of the lung, that made Mr. Baga to

agree with his doctor and was scheduled to have it done on November 5, 2013.

5. PHYSICAL ASSESSMENT

November 3, 2013 (Lifted from the chart)

Upon admission : The patient is afebrile, does not have dyspnea, positive recurrent

hemoptysis for 5 days, with body weakness, with Difficulty Of Breathing on exertion, with

Diabetes Mellitus, Hypertension and positive Pulmonary Tuberculosis.

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11:20 pm done by NOD

BP: 120/70 PR: 64bpm RR: 21cpm Temp : 36C

GENERAL APPEARANCE: patient is awake, conscious and coherent, with intravenous

fluid of #1 PNSS1L x 80cc/hr

November 4, 2013 done by nurse on duty

8am- BP: 120/70 PR: 60bpmRR: 20cpm Temp: 36

4pm- BP: 140/70 PR: 60bpm RR: 20cpm Temp: 36

11pm- BP: 120/70 PR: 64 RR: 21 Temp: 36

GENERAL APPEARANCE: patient is awake, afebrile, appears weak, conscious and

coherent, intravenous out

3:05 pm done by NOD (lifted from the chart)

GENERAL APPEARANCE: patient is awake, conscious and coherent, with an ongoing

intravenous fluid of #2 PNSS 1L x 80cc/hr, no signs of infiltration, no signs of

respiratory distress, no complains of pain

November 5, 2013

12 midnight

GENERAL APPEARANCE: patient is on bed, asleep but arousable, with an ongoing

intravenous fluid of #2PNSS 1L x 80cc/hr, without infiltration, no difficulty of breathing,

no chest pain, no nausea and vomiting, afebrile

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6-2pm done by the Nurse on duty (lifted from the chart)

9am- BP: 160/80 PR: 60bpm RR: 21cpmTemp:36

GENERAL APPEARANCE: patient is on moderate high back rest, awake, oriented to

time, place and person, with an ongoing intravenous fluid of #3 PNSS 1L x 80cc/hr

infusing well over left hand, no signs of phlebitis and infiltration, no difficulty of

breathing, no chest pain, no signs of respiratory distress, afebrile, for thoracotomy left

upper lobectomy under General Endotracheal Anesthesia using double lumen

Endotracheal tube.

@9AM endorsed to OR nurses ----------------OPERATING ROOM------------------

10 am done by the NOD (lifted from the chart)

GENERAL SURVEY: received patient from floor via wheelchair, conscious and

coherent, with ongoing intravenous fluid of #4 D5LRS 1L x 80cc/hr

GENERAL APPEARANCE: Patient @ OR table, conscious and coherent, hooked to

O2 inhalation via nasal cannula @3-4Lpm, hooked to cardiac monitor, general anesthesia

started, Foley catheter inserted, patient on side lying position, body and arm straps are

applied, draped aseptically

Operation started at 11:10 am, specimen out at 2:20 pm.

November 6, 2013

GENERAL APPEARANCE: Patient was seen on a high fowler‘s position, conscious,

coherent and oriented to person, place and time, with intravenous fluid of #7 PNSS 1L x

100cc/hr, dopamine drip at 3mcg/kg/min. with anterior and posterior closed thoracotomy

tube with output level of 70/300cc on anterior and 400/400cc serosanguinous on

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posterior at 1:30pm, with indwelling Foley catheter connected to urine bag, with intake

of 868cc/80cc, with oxygen therapy via nasal cannula at 3-4Lpm.

9am done by Student Nurse (1ST

NURSE-PATIENT INTERACTION)

SKIN

The patient has dark complexion noted. Presence of pitting edema on both upper

extremities

HEAD/SCALP

Hair is black and is equally distributed upon inspection. The patient has no

pediculosis, dandruff, scratches or depressions. No abnormal mass and no tenderness

upon palpation of scalp.

EYES

The patient has pink palpebral conjunctiva and anicteric sclera. The eyes are able

to move in cardinal directions no deviation or nystagmus and with normal blinking reflex.

Eyes are symmetrical, no abnormal protrusion noted and with parallel eye movement.

EARS

The patient‘s ears are symmetrical in size and shape upon inspection and no

abnormal discharge was noted. No excess cerumen was observed in the auditory canal

upon inspection. Pain is not felt upon palpation of ears. Patient is able to hear clearly the

voice of the nurse without difficult and able to hear the tickling sound on the watch tick

test.

NOSE

The patient has no nasal deviation. No nasal discharges and deformities noted. No

obstruction and nasal flaring upon inspection. Air moves freely as the patient breathes

through the nares with Oxygen via nasal cannula.

21

FACE

No facial asymmetry or facial deviation, no edema or bruises noted. There is no

tenderness upon palpation. Patient has no difficulty in swallowing.

NECK

No lateral deviation of the neck and has normal range of motion actively done pain

free. No tenderness and no abnormal mass are noted upon palpation.

CHEST AND LUNGS

Patient has asymmetrical chest expansion and no complains of dyspnea. No pain or

tenderness felt upon palpation and normal tactile fremitus. Crackles heard upon

auscultation. Patient uses accessory muscles when breathing, no chest pain noted.

Presence of Anterior (upper left) and posterior (lower left) closed thoracotomy tube.

HEART

The patient‘s heart rate is of normal rate and regular rhythm.

ABDOMEN

The patient has no distension of abdomen.

6am: with fever T: 38.0

8am: BP: 120/80 mmHg; PR: 84 bpm; RR: 24 bpm; Temp: 37.1 °C

9:25am: BP: 140/70 PR:72bpm RR: 24cpm Temp: 37.3

10:20: asleep

11:20: BP: 130/70 PR:64bpm RR:21cpm Temp:37.3

12:20: BP: 130/70 PR: 68 RR: 22 Temp: 37.3

4:10: BP: 110/70 PR: 64 RR: 24 Temp: 36

5:15: BP: 140/70 PR: 66 RR: 24 Temp: 36.2

6:10: BP: 130/70 PR: 60 RR: 22 Temp: 36.2

8:10: BP: 130/70 PR: 62 RR: 22 Temp: 36.6

11:31: BP: 120/80 PR: 64 RR: 22 Temp:36.6

22

1:05: BP: 120/80 PR: 62 RR: 23 Temp: 36

2 am: BP: 140/70 PR: 65 RR: 24 Temp: 36.7

3:35 BP: 120/70 PR: 68 RR: 24 Temp: 36.7

4:35: BP: 130/70 PR: 67 RR: 22 Temp: 36.4

6:20: BP: 140/70 PR: 76 RR: 24 Temp:_36.5

CRANIAL NERVES

Cranial Nerve Assessment Technique Normal Response Actual Response

1. Olfactory

Type: Sensory

Fxn: Sense of smell

Patient was asked to

close eyes and was

asked to determine the

scent of the material

used which is coffee

grounds.

Patient must be able to

identify the scent of

coffee grounds when

allowed to smell it.

Patient was able to

identify the scent

of coffee grounds

when allowed to

smell it.

2. Optic

Type: Sensory

Fxn: Sense of vision

and visual fields


read news paper.

Patient must see the pen

or penlight clearly from

a certain distance; must

be able to read

newspaper with writings

14 inches away.

Patient was able to

see the pen or

penlight from a

certain distance,

and had difficulty

of reading the

newspaper.

3. Oculomotor

Type: Motor

Fxn: Pupil

constriction and

raising of eyelid


follow the direction of

the penlight and ask to

look straight while light

was shone through his

eyes.

Eyes must follow the

direction of the

movement of the

penlight;

In lightly dimmed

environment, the pupils

of the eyes will dilate

but upon the

introduction of light,

pupils will constrict.

The Patient was

able to follow the

movement of the

penlight through

his eyes and his

pupils were

equally rounded

and reactive to

light

accommodation.

23

4. Trochlear

Type: Motor

Fxn: Downward

inward eye

movement

The patient was asked

to follow the tip of the

penlight downward and

inward movement.

The eye must follow the

movement of the tip of

penlight in different

directions with

coordination.

The Patient was

able to follow the

penlight with his

eyes without

moving his head.

5. Trigeminal

Type: Sensory and

Motor

Fxn: Jaw

movements, chewing

and mastication

Corneal Sensitivity test

through the use of

cotton wisp.

The Patient must elicit

blinking reflex upon

touching the cornea

with the use of cotton.

(Corneal Sensitivity

Test)

The Patient

elicited blinking

reflex upon

touching the

cornea.

6. Abducens

Type: Motor

Fxn: Lateral

movements of the

eyes

Use of penlight to

follow lateral directions.

Patient must follow the

tip of the penlight and

its movements.

The Patient was

able to follow the

tip of the penlight

and its lateral

direction.

7. Facial

Type: Motor and

Sensory

Fxn: Movement of

muscles of the face

and sense of taste on

the anterior two-

thirds of the tongue

Use of hard candy to

assess anterior 2/3 of

taste buds.

Asked the patient to do

facial expressions


raise eyebrows, show

teeth, frown, smile, pout

and puff out cheeks.

Also, the Patient must

also be able to taste the

sweetness of hard

candy.

The Patient was

able to raise

eyebrows, show

teeth frown, smile,

pout and puff out

cheeks. Also, the

Patient was able to

taste the sweetness

of hard candy.

8. Acoustic

(Vestibulocochlear)

Type: Sensory

Fxn: Sense of

hearing

Used watch tick test,

watch was place on the

auditory canal and

asked the patient is he

can hear it.


hear the tick of the

watch.

The Patient was

able to hear tick of

the watch.

24

9. Glossopharyngeal

Type: Motor and

Sensory

Fxn: Pharyngeal

movements and

swallowing

Sense of taste on the

posterior one-third

of the tongue

Use of tongue depressor

to elicit gag reflex

The patient must be able

to swallow foods that

were chewed. Also, the

gag reflex should be

stimulated.

The Patient was

able to swallow

food and elicit gag

reflex.

10. Vagus

Type: Motor

Fxn: Swallowing and

speaking


to take sips of water


to tolerate sips of water.

The Patient was

able to tolerate

sips of water

without difficulty.

11. Accessory

Type: Motor

Fxn: Movement of

shoulder muscles


raise his shoulders

The patient must able to

elevate his shoulders

against resistance.

(Sternocleidomastoid

and Trapezius muscles

function test)

The Patient was

able to elevate his

shoulders against

resistance.

12. Hypoglossal

Type: Motor

Fxn: Movement of

tongue and strength

of the tongue


to stick his tongue and

move it from side to

side


move his tongue side to

side and protrude his

tongue.

The patient was

able to move his

tongue side to side

and protrude his

tongue.

25

November 7, 2013 (2nd

nurse-patient interaction)

8am- BP: 140/70 PR: 64 RR:22 Temp: 36.4

9am: asleep

10am: BP: 140/80 PR: 76 RR: 20 Temp: 36.4

11am: asleep

12nn: BP: 140/70 PR: 62 RR: 21 Temp: 36.2

GENERAL APPEARANCE: patient on bed, with ongoing intravenous fluid on left

hand of #8 PNSS 1L x 100cc/hr, no phlebitis and infiltration, with dopamine drip

3mcg/kg/min, side drip of insulin drip 5‖u‖ humulin R in 100cc PNSS, with anterior

posterior Closed Tube, with fluctuation,negative bubbling, both closed tubes maintained

on Emerson pump, with indwelling foley catheter connected to urine bag, with intake

and output of 3200L/880cc with O2via nasal cannula at 2-3Lpm.

SKIN, HAIR, NAILS: the patient has dark complexion, warm to touch skin, no signs of

pallor,(-)rashes, skin is relatively dry, with good skin turgor, with black and equally

distributed hair, no pediculosis and dandruff upon inspection, with short and clean

fingernails.

EYES AND EARS: eyes are symmetrical, eyelids covers the quarter top of the iris, with

equally distributed eyelashes. With anicteric sclera, with complains of blurred vision,

patient has difficulty in reading newspaper. Ears are symmetrical in size and shape,

presence of dry cerumen was noted, and no mass and tenderness was noted upon

palpation. Patient reports normal hearing ability.

NOSE, MOUTH, THROAT AND NECK: patient‘s nose is at the center, no swelling

and deformity is noted, no nasal discharge, with minimal nasal flaring, patient‘s lips

was slightly pale and dry, with pinkish tongue, incomplete set of teeth, no swollen lymph

nodes, with pulsations, no neck masses upon palpation.

26

LUNGS: no difficulty of breathing, not using accessory muscles when breathing. Patient

has asymmetrical chest expansion. No pain or tenderness felt upon palpation and normal

tactile fremitus. Crackles heard upon auscultation.

CARDIOVASCULAR: no jugular vein distention, with localized pulsation, with normal

heart rhythm, no chest pain at the moment, no murmurs

ABDOMEN: flat, non-tender to palpation no complains of pain upon palpation, had no

bowel movement for 5 days according to the patient.

EXTREMITIES: no pallor, with regular pulses

NEUROLOGIC EXAM: GCS=15 (E4V5M6)

LEVEL OF CONCIOUSNESS: conscious

MOTOR: 5/5

CRANIAL NERVES


1. Olfactory

Type: Sensory

Fxn: Sense of smell


close eyes and was




grounds.



coffee grounds when


Patient was able to

identify the scent

of coffee grounds

when allowed to

smell it.

2. Optic

Type: Sensory


and visual fields


read newspaper.




be able to read


14 inches away.

Patient

complains of

blurred vision

and has difficulty

in reading

newspaper

27

writings in 14

inches focal

length.

3. Oculomotor

Type: Motor

Fxn: Pupil

constriction and

raising of eyelid






eyes.


direction of the

movement of the

penlight;

In lightly dimmed



but upon the



The Patient was

able to follow the

movement of the

penlight through

his eyes and his

pupils were

equally rounded

and reactive to

light

accommodation.

4. Trochlear

Type: Motor

Fxn: Downward

inward eye

movement



penlight downward

inward movement.




directions with

coordination.

The Patient was

able to follow the

penlight with his

eyes without

moving his head.

5. Trigeminal

Type: Sensory and

Motor

Fxn: Jaw

movements, chewing

and mastication


through the use of

cotton wisp.



touching the cornea



Test)

The Patient

elicited blinking

reflex upon

touching the

cornea.

6. Abducens

Type: Motor

Fxn: Lateral

movements of the

eyes

Use of penlight to




its movements.

The Patient was

able to follow the

tip of the penlight

and its lateral

direction.

7. Facial

Type: Motor and





The Patient was

able to raise

28

Sensory

Fxn: Movement of

muscles of the face


the anterior two-


taste buds.


facial expressions





sweetness of hard

candy.

eyebrows, show

teeth frown, smile,

pout and puff out

cheeks. Also, the

Patient was able to

taste the sweetness

of hard candy.

8. Acoustic

(Vestibulocochlear)

Type: Sensory

Fxn: Sense of

hearing



auditory canal and


can hear it.



watch.

The Patient was


the watch.

9. Glossopharyngeal

Type: Motor and

Sensory

Fxn: Pharyngeal

movements and

swallowing


posterior one-third

of the tongue







stimulated.

The Patient was

able to swallow

food and elicit gag

reflex.

10. Vagus

Type: Motor

Fxn: Swallowing and

speaking





The Patient was

able to tolerate

sips of water

without difficulty.

11. Accessory

Type: Motor

Fxn: Movement of

shoulder muscles


raise his shoulders



against resistance.



function test)

The Patient was

able to elevate his

shoulders against

resistance.

29

12. Hypoglossal

Type: Motor

Fxn: Movement of

tongue and strength

of the tongue




side




tongue.

The patient was

able to move his

tongue side to side

and protrude his

tongue.


4:10: BP: 120/70 PR: 70 RR: 23 Temp: 38

6:10: BP:130/60 PR: 68 RR: 23 Temp: 36.4

8:10: BP: 140/70 PR: 68 RR: 21 Temp: 37

Patient on bed, with intravenous fluid, with side drip of Nephrosteril 500cc x 12 hrs., side

drip of insulin drip, 100 humulin R in 100cc PNSS at 12 ―u‖/hr via soluset, with anterior

posterior closed thoracostomy connected to bottle with fluctuation, negative bubbling,

with anterior level of 80cc/350cc and posterior level of 400cc/600cc, both with

serosanguinuous fluid at 8:45pm, with indwelling foley catheter, with O2 via nasal

cannula at 2-3Lpm, no respiratory distress.


12mn: BP: 120/70 PR: 72 RR: 22 Temp: 36.2

1am: 120/70 PR: 62 RR: 25 Temp: 36.6

Patient on bed, with intravenous fluid of PNSS 1L,#2Dopamine drip at 8mcg/kg/min

16cc/hr, with side drip of insulin drip 100 ―u‖ humulin R in 100cc PNSS at 10‖u‖/hr,

with closed thoracostomy tube connected to emerson pump for 20cc/hr, with indwelling

foley catheter, no difficulty of breathing and no chest pain, with dry cough, no

complains of pain, afebrile, with stable vital signs.

.

30

November 8, 2013 (6-2 done by NOD)

8am: BP: 140/70 PR: 64 RR: 18Temp: 36.2

9am: BP: 130/70 PR: 56 RR: 20 Temp: 36.1

10am: BP: 130/70 PR: 54 RR: 18 Temp: 36.2

11am: BP: 140/70 PR: 56 RR: 18 Temp: 36.3

12nn: BP: 140/70 PR: 64 RR: 70 Temp: 36.4

GENERAL APPEARANCE: patient on bed, with ongoing intravenous fluid on left

hand of #9 PNSS 1L x 100cc/hr, no phlebitis and infiltration, with dopamine drip

3mcg/kg/min, side drip of insulin drip 100‖u‖ Humulin R in 100cc PNSS at 8‖u‖/hr.,

with anterior posterior closed Tube connected to bottle, with anterior chest tube level of

40cc, posterior chest tube level of 30cc serosanguinous consistency with fluctuation,

negative bubbling, with indwelling foley catheter connected to urine bag, on bladder

training, with intake of 33cc and output of 22cc at 9:50AM, with O2via nasal cannula at

3Lpm. Afebrile.

10:50 am (3rd

nurse-patient interaction)

BP: 140/70 PR: 64bpm RR: 18cpm Temp: 36.2C

GENERAL APPEARANCE: received on high fowler‘s position, oriented to time, place

and person; with ongoing IVF of #9 PNSS 1L x 100cc/hr on right hand, with side drip of

Dopamine drip at 3mcg/kg/min, Side Drip of Insulin drip at 8u/hr, with anterior posterior

closed tube bottle with fluctuations, negative bubbling, with anterior closed tube level of

40cc with moderate bloody consistency, with posterior closed tube level of 30cc with

serosanguinous consistency; with indwelling foley catheter connected to urine bag

draining well to a yellow colored urine received at 400cc level; with O2 inhalation via

nasal cannula at 3Lpm; with complains of pain on closed tube site; with deep regular

rhythm of respirations, with use of accessory muscles, with stabbing pain upon

movement, localized on surgical site, 7/10 severity; pain relieved by rest.

31


pallor, no rashes, skin is relatively dry, with good skin turgor, with black and equally


fingernails.



patient has difficulty in reading. Ears are symmetrical in size and shape, presence of

dry cerumen was noted, and no mass and tenderness was noted upon palpation. Patient

reports normal hearing ability.


and deformity is noted, no nasal discharge, no nasal flaring, patient‘s lips was slightly

pale and dry, with pinkish tongue, incomplete set of teeth, no swollen lymph nodes, with

pulsations, no neck masses upon palpation.

LUNGS: no difficulty of breathing, do not use accessory muscles when breathing.

Patient has asymmetrical chest expansion. No pain or tenderness felt upon palpation and

normal tactile fremitus. Crackles heard upon auscultation.

CARDIOVASCULAR: no jugular vein distention, no decreased cardiac output, with

localized pulsation, with normal heart rhythm, no chest pain at the moment, no murmurs

ABDOMEN: flat, with normal bowel sounds, non-tender to palpation no complains of

pain upon palpation.

EXTREMITIES: with regular pulses



MOTOR: 5/5

32

CRANIAL NERVES


1. Olfactory

Type: Sensory

Fxn: Sense of smell


close eyes and was




grounds.



coffee grounds when


Patient was able to

identify the scent

of coffee grounds

when allowed to

smell it.

2. Optic

Type: Sensory


and visual fields


read newpaper.




be able to read


14 inches away.

Patient

complains of

blurred vision

and has difficulty

in reading

newspaper

writings in 14

inches focal

length.

3. Oculomotor

Type: Motor

Fxn: Pupil

constriction and

raising of eyelid






eyes.


direction of the

movement of the

penlight;

In lightly dimmed



but upon the



The Patient was

able to follow the

movement of the

penlight through

his eyes and his

pupils were

equally rounded

and reactive to

light

accommodation.

4. Trochlear

Type: Motor

Fxn: Downward

inward eye



penlight downward

inward movement.




directions with

The Patient was

able to follow the

penlight with his

eyes without

33

movement coordination. moving his head.

5. Trigeminal

Type: Sensory and

Motor

Fxn: Jaw

movements, chewing

and mastication


through the use of

cotton wisp.



touching the cornea



Test)

The Patient

elicited blinking

reflex upon

touching the

cornea.

6. Abducens

Type: Motor

Fxn: Lateral

movements of the

eyes

Use of penlight to




its movements.

The Patient was

able to follow the

tip of the penlight

and its lateral

direction.

7. Facial

Type: Motor and

Sensory

Fxn: Movement of

muscles of the face


the anterior two-




taste buds.


facial expressions







sweetness of hard

candy.

The Patient was

able to raise

eyebrows, show

teeth frown, smile,

pout and puff out

cheeks. Also, the

Patient was able to

taste the sweetness

of hard candy.

8. Acoustic

(Vestibulocochlear)

Type: Sensory

Fxn: Sense of

hearing



auditory canal and


can hear it.



watch.

The Patient was


the watch.

9. Glossopharyngeal

Type: Motor and

Sensory

Fxn: Pharyngeal

movements and







stimulated.

The Patient was

able to swallow

food and elicit gag

reflex.

34

swallowing


posterior one-third

of the tongue

10. Vagus

Type: Motor

Fxn: Swallowing and

speaking





The Patient was

able to tolerate

sips of water

without difficulty.

11. Accessory

Type: Motor

Fxn: Movement of

shoulder muscles


raise his shoulders



against resistance.



function test)

The Patient was

able to elevate his

shoulders against

resistance.

12. Hypoglossal

Type: Motor

Fxn: Movement of

tongue and strength

of the tongue




side




tongue.

The patient was

able to move his

tongue side to side

and protrude his

tongue.


BP: 140/70mmHg

GENERAL APPEARANCE: patient on bed, oriented to time and place; with ongoing

Intravenous fluid of #10 PNSS 1L x 100cc/hr, with side drip of Dopamine at

3mcg/kg/min at approximately 170cc; with closed thoracostomy tube posterior connected

to Emerson pump at 20cc/hr., anterior 300cc clear; posterior @430cc level; IV site

bulged and painful as verbalized by the patient.

35

November 9, 2013 done by NOD (lifted from the chart)

3:00 am

GENERAL APPEARANCE: received patient on bed, with ongoing intravenous fluid of

#10 PNSS 1L x 100cc/hr, side drip of nephrosteril 500cc x 12hrs; no signs of infiltration,

with closed thoracostomy tube dry and intact, anterior containing 350cc level, clear;

posterior at 500cc level with light red fluid, afebrile, no difficulty of breathing, with

complains of pain on incision site.

6:35 am

GENERAL APPEARANCE: received patient on bed, awake and coherent, oriented to

time, place and person, with intravenous fluid of #10 PNSS 1L x 100cc/hr; no infiltration

was noted; with closed thoracostomy tube connected to bottle, anterior bottle at 300cc

level, with moderate bloody fluid, posterior bottle at 350 cc level; with

serosanguinuous fluid, with fluctuations, no bubbling, no difficulty of breathing, no chest

pain; with non-productive cough, afebrile, with pain scale of 7/10, with stable vital

signs.

3:50 pm

GENERAL APPEARANCE patient on high back rest, awake, oriented to time and

place, with ongoing Intravenous fluid of #10 PNSS 1L x 100cc/hr, with side drip of

Nephrosteril 500cc x 12hrs, without signs of infiltrations and phlebitis, with closed

thoracostomy tube output of 400cc at posterior area and 300cc on anterior area,

with fluctuations, negative bubbling, with dry and intact closed thoracostomy tube

dressing, no difficulty of breathing, no chest pain, no respiratory distress, with non-

productive cough, able to expectorate, has the ability to perform deep breathing exercise

yet with slight pain upon inhalation, with stable vital signs.

36


2 am

GENERAL APPEARANCE: patient on bed, awake, with ongoing intravenous fluid of

#10 PNSS 1L x 100cc/hr, afebrile, with stable vital signs; with closed tube anterior @

300cc level, posterior @ 500cc level; no difficulty of breathing and chest pain, no

nausea and vomiting; with intake of 2640cc and output of 2620cc at 4:30am.

7:24 am

GENERAL APPEARANCE: patient on high back rest, awake and oriented to time,

place and person, with an ongoing intravenous fluid of #11 PNSS 1L x 100cc/hr, no signs

of phlebitis and infiltration; with anterior closed tube, with fluctuation, no bubbling,

dressing dry and intact, no difficulty of breathing, no chestpain, not in respiratory

distress.


8 am

GENERAL APPEARANCE: patient on high back rest, awake and oriented to time,

place and person, with an ongoing Intravenous fluid of #12 PNSS 1L x 100cc/hr, no signs

of phlebitis and infiltration; with posterior closed tube output of 150cc, with serous

fluid, closed tube maintained in place, with fluctuation, no bubbling, dressing dry and

intact, no difficulty of breathing, no chest pain, not in respiratory distress.

November 12, 2013 (4th

nurse patient interaction)

8:30am

BP: 140/70 PR: 64 RR: 23 Temp: 36.4

GENERAL APPEARANCE: patient on sitting position, with ongoing intravenous fluid

of #14 PLRS 1L x100cc/hr on right hand, no phlebitis and infiltration, with posterior

Closed Tube connected to drainage bottle, draining to a yellow fluid @ 320cc level,

37

with fluctuation, no bubbling, afebrile, needs assistance when changing of position and

activity,




fingernails.



patient has difficulty reading newspaper. Ears are symmetrical in size and shape, and

no mass and tenderness was noted upon palpation. Patient reports normal hearing ability.


and deformity is noted, no nasal discharge, with minimal nasal flaring after activity,

patient’s lips was slightly pale and dry, with pinkish tongue, no swollen lymph nodes,

with pulsations, no neck masses upon palpation.

LUNGS: no difficulty of breathing at rest, not using accessory muscles when breathing.

Patient has asymmetrical chest expansion. No pain or tenderness felt upon palpation,

crackles heard upon auscultation on both lung fields.


heart rhythm, no chest pain, no murmurs



EXTREMITIES: no pallor, with good muscle strength, with regular pulses



MOTOR: 5/5

38

CRANIAL NERVES


1. Olfactory

Type: Sensory

Fxn: Sense of smell


close eyes and was




grounds.



coffee grounds when


Patient was able to

identify the scent

of coffee grounds

when allowed to

smell it.

2. Optic

Type: Sensory


and visual fields


read newspaper.




be able to read


14 inches away.

Patient

complains of

blurred vision

and has difficulty

in reading

newspaper

writings in 14

inches focal

length.

3. Oculomotor

Type: Motor

Fxn: Pupil

constriction and

raising of eyelid






eyes.


direction of the

movement of the

penlight;

In lightly dimmed



but upon the



The Patient was

able to follow the

movement of the

penlight through

his eyes and his

pupils were

equally rounded

and reactive to

light

accommodation.

4. Trochlear

Type: Motor

Fxn: Downward

inward eye



penlight downward

inward movement.




directions with

The Patient was

able to follow the

penlight with his

eyes without

39


5. Trigeminal

Type: Sensory and

Motor

Fxn: Jaw

movements, chewing

and mastication


through the use of

cotton wisp.



touching the cornea



Test)

The Patient

elicited blinking

reflex upon

touching the

cornea.

6. Abducens

Type: Motor

Fxn: Lateral

movements of the

eyes

Use of penlight to




its movements.

The Patient was

able to follow the

tip of the penlight

and its lateral

direction.

7. Facial

Type: Motor and

Sensory

Fxn: Movement of

muscles of the face


the anterior two-




taste buds.


facial expressions







sweetness of hard

candy.

The Patient was

able to raise

eyebrows, show

teeth frown, smile,

pout and puff out

cheeks. Also, the

Patient was able to

taste the sweetness

of hard candy.

8. Acoustic

(Vestibulocochlear)

Type: Sensory

Fxn: Sense of

hearing



auditory canal and


can hear it.



watch.

The Patient was


the watch.

9. Glossopharyngeal

Type: Motor and

Sensory

Fxn: Pharyngeal

movements and







stimulated.

The Patient was

able to swallow

food and elicit gag

reflex.

40

swallowing


posterior one-third

of the tongue

10. Vagus

Type: Motor

Fxn: Swallowing and

speaking





The Patient was

able to tolerate

sips of water

without difficulty.

11. Accessory

Type: Motor

Fxn: Movement of

shoulder muscles


raise his shoulders



against resistance.



function test)

The Patient was

able to elevate his

shoulders against

resistance.

12. Hypoglossal

Type: Motor

Fxn: Movement of

tongue and strength

of the tongue




side




tongue.

The patient was

able to move his

tongue side to side

and protrude his

tongue.

10:50pm done by NOD (lifted from the chart)

With closed tube output of 90cc for 24hrs, with fluctuations negative bubbling, patient

complains of epigastric pain.

November 13, 2013 (5th

nurse patient interaction)

8am

BP: 140/70 PR: 64 RR: 23 Temp: 36.4

GENERAL APPEARANCE: patient on sitting position, with ongoing intravenous fluid

of #15 PLRS 1 L x 100cc/hr infusing well on right hand, no phlebitis and infiltration,

41

with posterior closed Tube connected to drainage bottle at 320cc level, with

fluctuation, negative bubbling, afebrile.




fingernails.



patient has difficulty reading newspaper. Ears are symmetrical in size and shape, and

no mass and tenderness was noted upon palpation. Patient reports normal hearing ability.


and deformity is noted, no nasal discharge, no nasal flaring, patient’s lips was slightly

pale and dry, with pinkish tongue, no swollen lymph nodes, with pulsations, no neck

masses upon palpation.

LUNGS: no difficulty of breathing at rest, not using accessory muscles. Patient has

asymmetrical chest expansion. No pain or tenderness felt upon palpation, crackles heard

upon auscultation on both lung fields.


heart rhythm, no chest pain, no murmurs



EXTREMITIES: no pallor, with good muscle strength, with regular pulses



MOTOR: 5/5

42

CRANIAL NERVES


1. Olfactory

Type: Sensory

Fxn: Sense of smell


close eyes and was



used, which are coffee

grounds.



coffee grounds when


Patient was able to

identify the scent

of coffee grounds

when allowed to

smell it.

2. Optic

Type: Sensory


and visual fields


read newspaper.




be able to read


14 inches away.

Patient

complains of

blurred vision

and has difficulty

in reading

newspaper

writings in 14

inches focal

length.

3. Oculomotor

Type: Motor

Fxn: Pupil

constriction and

raising of eyelid






eyes.


direction of the

movement of the

penlight;

In lightly dimmed



but upon the



The Patient was

able to follow the

movement of the

penlight through

his eyes and his

pupils were

equally rounded

and reactive to

light

accommodation.

4. Trochlear

Type: Motor

Fxn: Downward

inward eye



penlight downward

inward movement.




directions with

The Patient was

able to follow the

penlight with his

eyes without

43


5. Trigeminal

Type: Sensory and

Motor

Fxn: Jaw

movements, chewing

and mastication


through the use of

cotton wisp.



touching the cornea



Test)

The Patient

elicited blinking

reflex upon

touching the

cornea.

6. Abducens

Type: Motor

Fxn: Lateral

movements of the

eyes

Use of penlight to




its movements.

The Patient was

able to follow the

tip of the penlight

and its lateral

direction.

7. Facial

Type: Motor and

Sensory

Fxn: Movement of

muscles of the face


the anterior two-




taste buds.


facial expressions







sweetness of hard

candy.

The Patient was

able to raise

eyebrows, show

teeth frown, smile,

pout and puff out

cheeks. Also, the

Patient was able to

taste the sweetness

of hard candy.

8. Acoustic

(Vestibulocochlear)

Type: Sensory

Fxn: Sense of

hearing



auditory canal and


can hear it.



watch.

The Patient was


the watch.

9. Glossopharyngeal

Type: Motor and

Sensory

Fxn: Pharyngeal







The Patient was

able to swallow

food and elicit gag

reflex.

44

movements and

swallowing


posterior one-third

of the tongue

stimulated.

10. Vagus

Type: Motor

Fxn: Swallowing and

speaking





The Patient was

able to tolerate

sips of water

without difficulty.

11. Accessory

Type: Motor

Fxn: Movement of

shoulder muscles


raise his shoulders



against resistance.



function test)

The Patient was

able to elevate his

shoulders against

resistance.

12. Hypoglossal

Type: Motor

Fxn: Movement of

tongue and strength

of the tongue




side




tongue.

The patient was

able to move his

tongue side to side

and protrude his

tongue.

3:50pm done by NOD (lifted from the chart)

GENERAL APPEARANCE: patient lying on bed, awake, with an ongoing intravenous

fluid of nephrosteril 500cc x 12 hrs on right hand, mainline off, with closed tube

posterior at 350cc, serosanguinuous, with fluctuation, no bubbling, no difficulty of

breathing and no chest pain, no nausea and vomiting, no headache.

11:30pm

GENERAL APPEARANCE: patient on bed, intravenous out, no difficulty of brathing,

no chest pain, afebrile, with stable initial Vital Signs, with closed thoracostomy

45

tube(posterior) connected to CT bottle at 400cc level connected to bedside, with

fluctuation, negative bubbling, with serous fluid.

Rehooked Intravenous, infusing well, no signs and symptoms of phlebitis and

infiltration, no difficulty of breathing and chest pain..


3 pm

GENERAL APPEARANCE: patient on bed, awake and coherent, with ongoing

intravenous fluid, no infiltration noted, with posterior closed tube connected to closed

thoracostomy tube bottle at 390cc level, with serous fluid, no difficulty of breathing

and no chest pain no complains of pain on operative site, with dry and intact dressing,

afebrile, with stable Vital Signs.

November 15, 2013

12:30 am

GENERAL APPEARANCE: patient on bed, asleep but arousable, intravenous out,

afebrile, no complains of pain, with dry and intact closed thoracostomy tube dressing on

left anterior posterior thorax.

7:00 am

GENERAL SURVEY: patient on bed, awake, conscious and coherent, intravenous out,

no difficulty of breathing

no chest pain, with stable Vital Signs,

3:05 pm

GENERAL SURVEY: patient on bed, awake and coherent, no contraptions noted, with dry and

intact dressing, no difficulty of breathing and chest pain, no complains of pain, afebrile, with

stable Vital Signs.

46

DIAGNOSTIC AND LABORATORY FINDINGS

Diagnostic/

Laboratory

Procedures

Date ordered

and date

result(s) in

Indication(s) or purpose Results Normal value Analysis and interpretation

of results

COMPLETE

BLOOD

COUNT

Date ordered:

11-03-2013

11-06-2013

Date results

in:

11-03-2013

11-07-2013

A complete blood count (CBC) is

a series of tests used to evaluate

the composition and

concentration of the cellular

components of blood. It consists

of the following tests: red blood

cell (RBC) count, white blood

cell (WBC) count, and platelet

count; measurement of

hemoglobin and mean red cell

volume; classification of white

blood cell (WBC differential);

and calculation of hematocrit and

red blood cell indices,

(Chernecky and Berger, 2011).

http://www.surgeryencyclopedia.com/Fi-La/Hematocrit.html

47

CBC is inexpensively, easily and

rapidly performed as a screening

test. This is indicated to

determine any alteration in Mr.

Baga‘s blood component since

the patient is coughing up blood,

testing on November 3, 2013. It

focuses on determining the rate of

bleeding and any risk to

breathing; moreover, it was used

as a preoperative test and cardio

clearance for surgery to ensure

both adequate oxygen carrying

capacity and hemostasis; also to

aid in diagnosing anemia and

other blood diseases, to monitor

blood loss and infection; thus to

identify acute and chronic illness

and/or bleeding tendencies.

48

Hence, on November 5 and 6,

2013 the patient was subjected for

another Complete Blood Count to

check the effect of surgery and

medical management, monitor

response of the patient‘s body to

blood loss since his hgb and hct

count since November 3, 2011,

prior to surgery until November

5, 2013 are at low levels thus to

evaluate if he needed a blood

transfusion.

Hemoglobin

Date ordered:

11-03-2013

11-05-2013

11-06-2013

Date results

in:

11-03-2013

The hemoglobin concentration is

a measure of the total amount of

Hgb in the peripheral blood,

which then reflects the number of

RBCs in the blood. Hgb serves as

a vehicle for the patient to check

his oxygen and carbon dioxide

128

140.00 –

175.00 g/L

Result retrieved on

November 3, 2013 shows

that Hemoglobin count is

below the normal range

which means that during this

time, there might be a

problem in oxygen supply

and patient may suffer

49

transport (Muchnick, 2010).

Since there is affectation in the

patient‘s respiratory system it is

indicated to the patient to assess

adequacy of his tissue

oxygenation primarily in the heart

and lungs and other parts of the

body. Also, to determine if

patient has anemia related to

reported massive hemoptysis

and/or poor nutrition. It is done

also to check if the patient is fit to

undergo surgery which is

lobectomy of left lung.

anemia due to episode of

massive hemoptysis reported

prior to admission. However,

the doctor has cleared the

patient for surgery and has

ordered preparation of 4

units of fresh whole blood

type ‗O‘, 2 units of which to

be crossmatched and reserve

the other 2 units if blood

transfusion will be necessary

during the surgery. Hitt

(2012) and Liumbruno et al

(2009) explains that Blood

transfusion (BT) is indicated

if hemoglobin level has

reached below 60-70 mg/dL

where in the client had was

128 mg/dL that did not

necessitate the order to be

50

11-05-2013

11-07-2013

107

112

executed.

On November 5, 2013, post-

operative Hgb count is below

the normal range indicating a

decreased in hemoglobin

which may be caused by

further blood loss due to

surgery, hence, at this point

the patient may have

problems in oxygenation and

is more prone to suffer

anemia.

Further, on November 6,

2013 the patient was then

again subjected to hgb and

hct count to monitor patient‘s

response and compensation

due to blood loss, thus result

51

retrieved on November 7,

2013 reveals that patient‘s

hgb count has increased from

107 to 112 however it is still

below the normal range but

then no signs and symptoms

of possible anemia was noted

during periods of decreased

hemoglobin levels. There

was no blood transfusion

ordered and done to Mr.

Baga.

Hematocrit

Date ordered:

11-03-2013

11-05-2013

11-06-2013

This procedure is used to measure

RBC number and volume. It is

routinely performed as a part of

complete blood count.

The Hct is a measure of the

percentage of total blood volume

As said, hct is directly

related with hgb. With the

below normal results of hgb,

hct count also reveal below

normal results. It also

indicates that the patient‘s

body did not effectively

52

Date results

in:

11-03-2013

11-05-2013

that is made up by the red blood

cells. The Hct closely reflects the

hgb and RBCs values. Therefore,

it is also made to check for any

alteration with oxygen transport.

It is indicated to the patient to

determine if there is problem with

vascular volume depletion with

hemoconcentration, prior to

surgery so that appropriate

management can be done prior or

during the surgery, more so to

rule out presence of anemia and

dehydration related to reported

massive hemoptysis and/or poor

nutrition.

Test is done after the surgery to

check effects of the blood loss.

0.35 %

0.31 %

0.41 – 0.50 %

compensate well with the

problem.

Result retrieved on

November 3, 20103 shows

that Hct count is below the

normal range which means

that during this time, there

might be a problem in

oxygen supply and the

patient may suffer anemia

due to episode of massive

hemoptysis reported prior to

admission. Hence, during the

surgery the patient was given

haesteril which is a plasma

volume expander.

On November 5, 2013, post-

operative Hct count is below

53

11-07-2013

It was repeated after increase

PNSS regulation to 100 cc/hr.

This is to check vascular volume

after increase IVF rate.

0.31%

the normal range indicating a

decreased in hemoglobin

which may be caused by

further blood loss due to

surgery, hence, at this point

the patient may have

problems in oxygenation and

is more prone to suffer

anemia.

Moreover, on November 6,

2013 the patient was then

again subjected to hgb and

hct count to monitor patient‘s

response and compensation

due to blood loss, thus result

retrieved on November 7,

2013 reveals that patient‘s

hct‘s count remain the same

which is 0. 31%. The

54

increase in IVF regulation

from 80 cc to 100 cc of

PNSS maintained vascular

volume thus can prevent

shock.

White Blood Cell

Date ordered:

11-03-2013

11-06-2013

Date results

in:

It determines the number of white

blood cells microliter a cubic

millimeter of whole blood.

Due to strenuous exercise, stress

or digestion, the WBC count may

increase or decrease significantly

with certain diseases but it is

diagnostically useful only when

patient‘s white cell differential

and clinical status are considered.

It is done to determine infection

of inflammation.

It is done to rule out infectious

55

11-03-2013

and inflammatory diseases of the

respiratory and other systems of

the patient‘s body. The body is

also in stress due to his condition

the WBC may have an increased

result brought about by the

surgery.

Test is done to determine

presence of infection and prior to

surgery in order to give

appropriate management prior the

said surgery like administration of

prophylaxis.

6.48 x 10

9/L

4.50 – 11.00

9/L

WBC count is within the

normal range which indicates

that the patient‘s body has

adequate protection from

disease-fighting cells, viruses

and bacteria hence, making

him less susceptible to

outside infections or

disallowing multiplication of

organisms within the body

which would normally kept

in check by a healthy

56

11-07-2013

12.36 x

10 9/L

immune system. However,

since the patient was ordered

to undergo surgery he was

given (Cefepime 1g IV q

12hrs).

On November 7, 2013 WBC

count relayed an above

normal result which may be

due to the patient‘s body‘s

response to an infection,

inflammation and stress after

the surgery.

Neutrophils

Date ordered:

11-03-2013

11-06-2013

Date results

in:

Neutrophils are the most common

Polymorphonuclear leukocytes

(PMN) which is a division of

WBC in granulocytes, comprising

about 50%-70% of all white

blood cells. They are phagocytic,

0.70

0.18 – 0.70

Neutrophils count is within

the normal range however it

is slightly increased and falls

on the peak normal level

which may indicate that the

patient‘s body is responding

57

11-03-2013

11-07-2013

meaning that they can ingest

microorganisms. Neutrophils are

the first immune cells to arrive at

a site of infection. Neutrophil

count is indicated to the patient to

determine acute bacterial

infection.

0.88

to infection or inflammation

at this time

Latter neutrophils count is

increased due to effect of

inflammation after surgery

but this was manage by

giving (Cefepime 1g IV q 12

hrs).

Lymphocytes

Date ordered:

11-03-2013

11-06-2013

Date results

in:

11-03-2013

Lymphocytes are WBCs under

the division of agranulocytes that

is primarily involve is cellular-

type immune reactions and

hormonal immunity or antibody

production.

0.13

0.10-0.48

Lymphocytes count is within

the normal range, indicating

that the patient has adequate

defenses against bacterial

and viral infections.

However, the lymphocytes

are commonly and more

certain for viral infections.

58

11-07-2013

It is indicated to Mr. Baga to

determine the ability of his body

to fight bacterial infection

.

0.10

Relayed lymphocytes count

on November 7, 2013 is

within the normal range

however it is slightly

decreased or at its borderline

level. The infection is

possibly caused by bacteria.

Monocytes

Date ordered:

11-03-2013

11-06-2013

Date results

in:

11-03-2013

11-07-2013

Monocytes are phagocytic cells

capable of fighting bacterial

infection.

It was ordered on November 3

and 6, 2013 to determine if there

is any bacterial microorganism

invading his body.

0.04

0.02

0.00 – 0.04

Monocytes count results are

within normal range thus

there may still be no

systemic infection at this

point.

59

Eosinophils

Date ordered:

11-03-2013

11-06-2013

Date results

in:

11-03-2013

11-07-2013

Eosinophil is performed to find

out if patient has allergic reaction

or parasitic infections.

It was performed to the patient as

part of the institution‘s routine

analysis and to abet if there is an

allergic reaction and or parasitic

infections.

0.02

0.01

0.00 – 0.03

Eosinophil count results are

within normal range thus

indicating absence of allergic

reaction or parasitic

infection.

Platelet

Date ordered:

11-03-2013

11-06-2013

Indicates the amount of platelets

in a given amount of blood, the

platelets are the ones responsible

for blood clotting and stop

bleeding.

60

Date results

in:

11-03-2013

11-07-2013

It was indicated to the patient to

check platelet count level which

can be a reason for massive

hemoptysis which was

experienced by the patient. More

so, the patient was subjected to

this test to determine risk for

bleeding during and after surgery.

It was done to the patient to check

risk for possible bleeding after the

surgery.

172 x10

9/L

122 x10

9/L

150-400

x10 9/L

On November 3, 2013

platelet count is within the

normal range signifying that

that thromboregulatory

process of the patient is

maintained.

On November 7, 2013, Post-

operative abnormally low

platelet level

(thrombocytopenia) may

indicate that the patient has

increased destruction of

platelets once they are

produced and released into

the circulating blood.

61

Nursing Responsibilities:

Prior:

Verify doctor‘s order.

Identify the patient.

Explain the procedure to the patient, its purpose and how it is done.

Instruct patient about the schedule of the test.

Tell the patient that no fasting is required.

Assure patient that collecting blood sample take less than 3 min.

Inform patient that the patient will be experiencing pain on the site where the needle was pricked.

Refer to the member of the health care team.


Explain the procedure and purpose to the patient.

Tell the patient that fasting not required.

Instruct patient there are no special measures needed.

During:

Select a vein for venipuncture.

Clean venipuncture site with alcohol; allow area to dry. Use antiseptic technique when obtaining the sample.

Perform venipuncture by entering the skin with needle at approximately a 15 degree angle to the skin, needle bevel up.

After blood is drawn, place cotton ball over site; withdaraw the needle and exert pressure. Apply bandage if needed.

62

After:

Record the date and time of blood collection. Attach a label to each blood tube.

Properly dispose of contaminated materials.

Fill-up the laboratory form properly and send to the laboratory technician.

Check the venipuncture site for bleeding.

Obtain results and secure it to the patient‘s chart.

Refer the result to the physician.

63

BLOOD

CHEMISTRY

Indication(s) or purpose Results Normal value Analysis and interpretation

of results

Creatinine Date ordered:

11-06-2013

11-07-2013

11-08-2013

11-10-2013

Date results

in:

11-06-2013

11-07-2013

This test measures the amount of

creatinine in the blood. Creatinine

is produced by the breakdown of

creatinine phosphates in the

muscles by catabolism and is

excreted by the kidney. It is an

end product of muscle energy

metabolism.

It is indicated to the patient to

assess renal function that can be

affected due to a disease

condition.

Hence, further creatinine tests

were ordered on November 6, 7, 8

and 10, 3013 because there is a

\

3.29

mg/dl

3.61

mg/dl

0.79 – 1.56

mg/dl

Results relayed on November

6, 7, and 9, 2013 shows high

creatinine levels. Elevated

creatinine level signifies

impaired kidney function due

to persistent high level of hgt

and DM thus the patient was

diagnosed of having CKD

stage 3 secondary to Diabetic

64

11-09-2013

documented decreased patient‘s

output compared to his input

(320/60 ml) on November 6,

2013, (3,200/880 ml) on

November, 7, 2013 and

(3,300/2000 and 2,200/500 ml)

on November 8, 2013, this is

indicative of a problem with the

patient‘s renal function,

moreover, the patient has Chronic

Kidney disease (CKD) Stage 3

secondary to Diabetic

Nephropathy.

2.23

mg/dl

Nephropathy. As the

kidneys become impaired for

any reason, the creatinine

level in the blood will rise

due to poor clearance of

creatinine by the kidneys.

Abnormally high levels of

creatinine thus warn of

possible malfunction or

failure of the kidneys.

Furthermore, The patient was

given Furosemide to help in

proper elimination of fluids

thru urination because

Creatinine is not eliminated

well in the body as evidence

by imbalance in Input and

Output.

http://www.medicinenet.com/kidney_failure/article.htm

65

11-11-2013

This test is done to evaluate also

results of massive hemoptysis,

bleeding during the surgery,

increased HGT result and

possible affectation of the kidneys

due to DM.

1.54

mg/dl

Management done includes

orders for the administartion

of Furosemide 20 mg IV stat

on November 6, 2013 due to

imbalance in patient‘s intake

and output; followed by an

increased in the dosage and

frequency of Furosemide to

40mg IV now then q 8hrs on

November 7 and 8, 2013.


2013 result retrieved shows a

normal level of creatinine of

Mr.Baga, signifying that

convertion of oliguric to

non‐oliguric renal

impairment with the use of

Furosemide helped with fluid

and electrolyte management.

66

Blood Urea

Nitrogen

Date ordered:

11-07-2013

11-08-2013

11-10-2013

Date results

in:

11-07-2013

11-09-2013

11-11-2013

A blood urea nitrogen (BUN) test

measures the amount of nitrogen

in blood that comes from the

waste product urea. Urea is made

when protein is broken down in

the body. Urea is made in

the liver and passed out off the

body in the urine.

A BUN test is done to the patient

to see how well the kidneys and

liver are working.

A BUN test may be done with a

blood creatinine test. The level of

creatinine in the blood also tells

how well the patient‘s kidneys are

working-a high creatinine level

may mean his kidneys are not

working properly. Blood urea

46.27

mg/dl

47.39

mg/dl

39.38

mg/dl

7.84 – 20. 17

mg/dl

BUN result on November 7,

9, and 11 2013 reveals high

BUN level. This may

indicate that the kidneys are

not able to remove urea from

the blood normally, thus the

patient‘s kidneys or liver

may not be working properly

http://www.webmd.com/hw-popup/urea

http://www.webmd.com/hepatitis/liver

http://www.webmd.com/kidney-stones/kidneys

http://www.webmd.com/hw-popup/creatinine

http://www.webmd.com/urinary-incontinence-oab/picture-of-the-kidneys

http://www.webmd.com/heart/anatomy-picture-of-blood

67

nitrogen (BUN) and creatinine

tests can be used together to find

the BUN-to-creatinine ratio

(BUN:creatinine). A BUN-to-

creatinine ratio can help doctors

check for problems, such as

dehydration, that may cause

abnormal BUN and creatinine

levels.

Same with creatinine tests, BUN

tests ordered on November 6, 7, 8

and 10, 3013 because there is a

documented decreased patient‘s

output compared to his input

(320/60 ml) on November 6,

2013, (3,200/880 ml) on

November, 7, 2013 and (33/2 and

22/50 ml) on November 8, 2013,

this is indicative of a problem

with the patient‘s renal function,

was diagnosed of having

CKD stage 3 secondary to

Diabetic Nephropathy. .

http://www.webmd.com/a-to-z-guides/dehydration-adults

68

moreover, the patient has CKD

but urine with pus and increasing

creatinine was evaluated. This

test is also done to evaluate also

results of massive hemoptysis,

bleeding during the surgery,

increased HGT result and

possible affectation of the kidneys

due to DM.

Serum Sodium

Date ordered:

11-04-2013

11-11-2013

Date results

in:

11-04-2013

Sodium is the principal

electrolyte of the extracellular

fluid of the blood maintaining

osmotic pressure, and is involved

in acid-base balance and the

transmission of nerve impulses.

The test is ordered to monitor

electrolyte balance, water balance

and base balance. The patient had

massive hemoptysis on

138

meq/L

135-150

meq/L

Serum sodium is within

normal range so as with

potassium. It indicates that

there is normal sodium-water

balance which inhibits

sodium excretion and

promotes its absorption (with

water) by the renal tubules to

maintain balance. Also

shows that extracellular fluid

69

11-11-2013

November 3, 2013 and he was

scheduled for surgery on

November 5, 2013. This test was

done to Mr. Baga to determine

extracellular osmolality and

monitor fluid and electrolyte

balance especially before and

after surgery.

139.4

mEq/L

osmotic pressure is

maintained and it helps

promote neuromuscular

function.

Latter testing was done on

November 11, 2013

revealing normal sodium

level. It again indicates that

there is normal sodium-water

balance which inhibits

sodium excretion and

promotes its absorption by

the renal tubules to maintain

balance. Also shows that

extracellular fluid osmotic

pressure is maintained and it

helps promote

neuromuscular function.

70

Serum

Potassium

Date ordered:

11-04-2013

11-05-2013

11-06-2013

11-07-2013

11-11-2013

Date results

in:

11-04-2013

(7:38AM)

11-05-2013

(9:55AM)

Potassium is the principal

electrolyte of the intracellular

fluid, with only low

concentrations circulating in the

extracellular fluid.

The test determines Mr. Baga‘s

level of potassium in the body,

because again as said, on

November 3, 2013 he had

massive hemoptysis, and he was

scheduled for surgery on

November 5, 2013. This test was

done to Mr. Baga to determine

intracellular osmolality and

monitor fluid and electrolyte

balance especially before and

after surgery.

Potassium is necessary to

5.13

mEq/L

5.43

mEq/L

3.50-5.50

mEq/L

Results relayed on November

4 and 5, 2013 for serum

potassium are within normal

ranges so as with sodium. It

indicates that the cellular

osmotic equilibrium and

regulation of muscle activity,

acid-base balance is

maintained.

71

11-06-2013

(2:00PM)

(5:12PM)

maintain nerve conduction and

plays a major role in control of

cardiac output. It is important to

maintain serum potassium within

normal ranges, so as not to further

promote serious arrhythmias.

5.96

mEq/L

5.41

mEq/L

However, on November 6 at

2:00PM the result relayed

reveals increased potassium

level may indicate a kidney

problem since potassium is

excreted by the kidneys.,

thus D5050 + insulin was

ordered and was given at

5:00PM to manage

hyperkalemia. Insulin is

known to move the

potassium present in the

blood inside the cells. This

however is only a temporary

measure because in few

hours the potassium will

move back to the blood.

However, this technique

helps to procure time until

72

11-07-2013

(8:30am)

(5:00PM)

6.03

mEq/L

5.16

mEq/L

the excess potassium is

excreted through kidneys.

Dextrose is also given to

prevent insulin from causing

hypoglycemia (low glucose

levels). Hence, the patient

was again subjected to this

test and result shown normal

potassium level at 5:12PM,

thus the patient was

continously given D5050 +

insulin until 6pm.


2013 result shown is

increased potassium level.

To manage episode of

hyperkalemia the patient was

then again given D5050 +

insulin and Calcium

73

11-11-2013

(6:00AM)

4.41

mEq/L

Gluconate at 10:20am, thus

the patient was also

submitted to 12-lead ECG

monitoring to rule out

serious dysrrhythmias

present. Moreover, result at

5:00PM revealed normal

level of potassium of 5.16

mEq/L.

Latter testing was done on

November 11, 2013

revealing normal potassium

level so as with sodium. It

indicates that the cellular

osmotic equilibrium and

regulation of muscle activity,

acid-base balance is restored.

Thus, the kidneys are

functioning well that they

74

can able to excrete and

reabsorb potassium well.


Prior:


Identify the patient.

Explain the procedure to the patient, its purpose and how it is done.


Tell the patient that no fasting is required.

Assure patient that collecting blood sample take less than 3 min.

Inform patient that the patient will be experiencing pain on the site where the needle was pricked.

Refer to the member of the health care team.


Explain the procedure and purpose to the patient.

Tell the patient that fasting not required.

Instruct patient there are no special measures needed.

75

During:

Select a vein for venipuncture.

Clean venipuncture site with alcohol; allow area to dry. Use antiseptic technique when obtaining the sample.

Perform venipuncture by entering the skin with needle at approximately a 15 degree angle to the skin, needle bevel up.

After blood is drawn, place cotton ball over site; withdaraw the needle and exert pressure. Apply bandage if needed.

After:

Record the date and time of blood collection. Attach a label to each blood tube.

Properly dispose of contaminated materials.

Fill-up the laboratory form properly and send to the laboratory technician.

Check the venipuncture site for bleeding.

Obtain results and secure it to the patient‘s chart.

Refer the result to the physician.

76

Diagnostic/

Laboratory

Procedures

Date ordered

and date

result(s) in

Indication(s) or purpose Results

Normal Value

Analysis and

interpretation

of results

Electrocardiography

Date ordered:

11-04-2013

Date results in:

11-04-2013

ECG is a graphical

representation of the electrical

impulses that the heart generates

during the cardiac cycle.

Indicated by the physician for

cardiopulmonary (CP) clearance

since the patient is for operation.

11-04-2013

Sinus

Bradycardia

First Degree

AV Block

Normal sinus

rhythm; with

normal P -wave,

QRS complex

and T- wave.

Patient‘s

bradycardia and

AV block may

due to the use of

beta-blocker

(Carvedilol) as

maintenance

drug for

hypertension.

Carvedilol

works by

relaxing blood

vessels and

slowing heart

rate to improve

77

blood flow and

decrease blood

pressure.

Date ordered:

11-05-2013

Date results in:

11-05-2013

12 lead ECG was ordered to

check the activity of the Heart,

in related to the proper pumping

of blood to supply the vital

organs of the body (e.g. kidneys)

after surgery. Also to check

GETA and ET tube insertion

effects post-op.

11-05-2013

Sinus

Bradycardia

Normal sinus

rhythm; with

normal P -wave,

QRS complex

and T- wave.

The patient‘s

bradycardia is

may due to the

use of GETA

which can

decrease heart

rate. Also

Dopamine drip

may contribute

in lowering the

heart rate

because of its

side effect.

Date ordered:

11-05-2013


check the activity of the Heart,

11-05-2013

Sinus

Normal sinus

rhythm; with

The patient‘s

bradycardia is

78

Date results in:

11-05-2013

in related to the proper pumping

of blood to supply the vital

organs of the body (e.g. kidneys)

after surgery. Also to check the

effect of hyperkalemic episode

of the patient that may lead to

sinus bradycardia. Also to check

GETA effects post-op.

Bradycardia

normal P -wave,

QRS complex

and T- wave.

May due to the

use of GETA

which can

decrease heart

rate. Also

Dopamine drip

may contribute

in lowering the

heart rate

because of its

side effect.

Date ordered:

11-05-2013

Date results in:

11-06-2013


check if the activity of the Heart

was restored.

11-06-2013

Sinus

Bradycardia

Normal sinus

rhythm; with

normal P -wave,

QRS complex

and T- wave.

The patient‘s

bradycardia is

may due to the

use of

Dopamine drip

because of its

side effect of

decrease heart

rate.

79


Patient preparation:


Explain the procedure to the patient.

Tell the patient that no food or fluid restriction is necessary.

Assure the patient that the flow of electric current is from the patient. The patient will feel nothing during the procedure.

Expose only the patient‘s chest and arms. Keep the abdomen and thighs adequately covered.

After:

Remove the electrodes from the patient‘s skin and wipe off the electrode gel.

Indicate on the ECG strip or request slip if the patient has experiencing chest pain during the study. The pain may be correlated

with an arrhythmia on the ECG.

80

Diagnostic/

Laboratory

Procedures

Date ordered

and date

result(s) in


Normal

Value

Analysis and

interpretation of

results

Random Blood

Sugar (RBS)

DO: 11-03-13

DR: 11-03-13

TR: 6PM

A blood sample will be taken at

a random time. Blood sugar

values are expressed in

milligrams per deciliter (mg/dL)

or millimoles per liter (mmol/L).

The patient is a candidate for

operation; the physician has

ordered a 12hour monitoring of

CBG/HGT to give immediate

measures in controlling an

elevated or decreased level of

glucose in blood. This is done to

check if the patient is fit for

surgery because patient has DM.

345 mg/dL

The result is

higher thus the

patient was given

insulin of Mixtard

30 HM 22 units

(PM dose) to

manage glucose

level in the blood

prior to surgery

and the glucose

level was checked

again at 6 AM

November 4

result was 137

mg/dL.

81

DO: 11-04-13

DR: 11-04-13

TR: 6AM

Continuous monitoring for the

serum glucose of the patient as

ordered by the physician.

137 mg/dL The result was

slightly increased

thus patient was

given Mixtard 30

HM 40 units (AM

dose) to maintain

glucose level

within normal

range.

DO: 11-04-13

DR: 11-04-13

TR: 8AM





increased thus the

patient was given

Mixtard 30 HM

40 units (PM

dose)

DO: 11-05-13

DR: 11-05-13

TR: 9:20AM



ordered by the physician. The

test was ordered to check CBG

level because patient has to be in


low thus the

physician ordered

to withhold the

Mixtard

82

NPO prior to surgery. administration

while patient is on

NPO status (for

OR)

Shifted PNSS to

D5LRS 1L x 80

cc/hr – done to

increase the

serum glucose

with the use of a

D5 containing

IVF

DO: 11-05-13

DR: 11-05-13

TR: 6PM

This is done to check

effectiveness of holding Mixtard

and shifting IVF to D5LRS.


increased thus the

patient was given

HR 8 units SC

because Mixtard

was hold. But the

CBG result of the

83

patient at 8PM

was increased

(335 mg/dL)

DO: 11-05-13

DR: 11-05-13

TR: 8PM

This is to check effectiveness of

giving HR 8 units SC.

335 mg/dL Patient was given

HR 10 units IV to

control increasing

levels of CBG but

still the result at

11 PM was

increased (237

mg/dL)

DO: 11-05-13

DR: 11-05-13

TR: 11PM

To check effectiveness after

giving HR 10 units IV STAT

237 mg/dL Still the result

was above normal

level but no

management

done or insulin

given.

DO: 11-06-13

DR: 11-06-13

TR: 6AM



ordered by the physician

287 mg/dL The result is sill

high so the doctor

ordered D5LRS

84

to consume and

change to PNSS

1L x 80 cc/hr.

D5LRS was

changed to PNSS

because D5

containing fluids

are high in

dextrose or

glucose.

Physician ordered

to give Mixtard

20 units SC, now

Mixtard 20 units

SC (AM dose)

Mixtard 20 units

SC (PM dose)

DO: 11-06-13

DR: 11-06-13

TR: 12PM



ordered by the physician for


high so the doctor

ordered to give to

85

appropriate management for

CBG.

the patient HR 12

units SC and 12

units IV at 5 PM.

It was checked

again after and

the result was 199

mg/dL

DO: 11-06-13

DR: 11-06-13

TR: 5PM

The test was ordered to check

effectiveness of HR 12 units SC

and 12 units IV which was given

to the patient at 12 PM. It is done

also to monitor CBG levels for

appropriate management.


D50/50 1 vial + 10

units HR FOR 3

DOSES (1). This

is to lower down

the patient’s

potassium level of

5.96 meq/L.

Physician ordered

to halt

administration of

Mixtard (PM

86

dose) temporarily

and continue

tomorrow’s AM

dose

DO: 11-06-13

DR: 11-06-13

TR: 6PM

This was done to check

effectiveness of the

administration of D50/50 1 vial

+ 10 units HR and holding of

Mixtard.

331 mg/dL The patient’s

CBG result was

above normal.

The patient was

given D5050 was

given to decrease

the potassium

level, but due to

this procedure the

pt HGT level

increased to 344

mg/dL

DO: 11-06-13

DR: 11-06-13

TR: 7PM


effectiveness of administering

d5050 1 vial + 10 units of HR


D50/50 1 vial + 10

units HR (3)

87

The result was

above normal

level because the

patient has eaten

consisting of rice

porridge and also

given D5050 +

insulin to lower

down the K+

level.

DO: 11-06-13

DR: 11-06-13

TR: 8PM


effectiveness of administering

d5050 1 vial + 10 units of HR


above normal

level because the

patient has eaten

food such as plain

soup, an apple

and a fruit drink.

DO: 11-06-13

DR: 11-06-13

TR: 9PM




369 mg/dL Still the result

was abnormally

high so the doctor

then ordere to

88

continue CBG

monitoring q 1°.

Insulin drip 100

units HR in 100cc

PNSS A 10 units/

hr.

Continuous

management for

high level of

CBG.

DO: 11-06-13

DR: 11-06-13

TR: 10PM



ordered by the physician. To

check also effectiveness of

insulin drip.


abnormally high

so the doctor

ordered for the

patient to have an

insulin drip 100

units HR in 100

cc of PNSS at 10

units/hr

89

DO: 11-06-13

DR: 11-06-13

TR: 11PM





insulin drip.

312 mg/dL The result is still

abnormally high

so the doctor

ordered

continuous

insulin drip 100

units HR in 100

cc of PNSS at 10

units/hr

DO: 11-07-13

DR: 11-07-13

TR: 12MN




254 mg/dL Patient has an

insulin drip 100

units HR in 100

cc of PNSS at 15

units/hr. The

doctor also

ordered to repeat

CBG after 1 hour.

DO: 11-07-13

DR: 11-07-13

TR: 1AM





insulin drip 100

units HR in 100

90


increasing the rate of the insulin

drip after 1 hour.

cc of PNSS at 15

units/hr

DO: 11-07-13

DR: 11-07-13

TR: 2AM






drip after 2 hours.


insulin drip 100

units HR in 100

cc of PNSS at 15

units/hr

DO: 11-07-13

DR: 11-07-13

TR: 3AM






drip after 3 hours.

114 mg/dL Insulin drip was

hold because the

results are almost

in normal levels.

DO: 11-07-13

DR: 11-07-13

TR: 4AM

To test the result of holding the

insulin drip.


hold because the

results are almost

in normal levels

91

DO: 11-07-13

DR: 11-07-13

TR: 5AM





hold because the

results are almost

in normal levels.

DO: 11-07-13

DR: 11-07-13

TR: 6AM




226 mg/dL The CBG went up

again so the

doctor ordered to

resume insulin

drip of 100 units

HR in 100 cc of

PNSS at 5

units/hr

DO: 11-07-13

DR: 11-07-13

TR: 7AM

To check the effectiveness of

resuming insulin drip of 100

units HR in 100 cc of PNSS at 5

units/hr.


insulin drip 100

units HR in 100

cc of PNSS at 5

units/hr

DO: 11-07-13

DR: 11-07-13

TR: 8AM

To check the CBG level while on

insulin drip of 100 units HR in

100 cc of PNSS at 5 units/hr.

199 mg/dL The result is still

high so the doctor

ordered to

92

increase rate of

insulin drip 100

units HR in 100

cc of PNSS from 5

units/hr to 12

units/hr

DO: 11-07-13

DR: 11-07-13

TR: 9AM


increasing the rate of insulin drip

of 100 units HR in 100 cc of

PNSS from 5 units/hr to 12

units/hr.

165 mg/dL Management for

above normal

level of CBG was

continuous.

DO: 11-07-13

DR: 11-07-13

TR: 10AM


increasing the rate of insulin drip

of 100 units HR in 100 cc of

PNSS from 5 units/hr to 12

units/hr.


insulin drip 100

units HR in 100

cc of PNSS at 12

units/hr and the

doctor ordered

d5050 1 vial + HR

10 units x 3 days

1 hour interval to

93

lower down the

levels of

potassium with

6.03 meq/L

DO: 11-07-13

DR: 11-07-13

TR: 11AM

Test was done to check

effectiveness of insulin drip and

d50/50 1 vial + HR 10 units x 3

days 1 hour interval.


checked again to

check CBG level.

The CBG is

slightly high. The

doctor ordered

continuous

insulin drip of

100 units HR in

100 cc of PNSS at

5 units/hr

DO: 11-07-13

DR: 11-07-13

TR: 12NN

Test was done to check

effectiveness of insulin drip of

100 units HR in 100 cc of PNSS

at 5 units/hr


still high so the

doctor ordered

continuous

insulin drip of

94

100 units HR in

100 cc of PNSS at

5 units/hr

DO: 11-07-13

DR: 11-07-13

TR: 1PM



ordered by the physician and to

check effectiveness of insulin

drip.


still high so the

doctor ordered

continuous

insulin drip of

100 units HR in

100 cc of PNSS at

5 units/hr

DO: 11-07-13

DR: 11-07-13

TR: 2PM





drip.


still high so the

doctor ordered

continuous

insulin drip of

100 units HR in

100 cc of PNSS at

5 units/hr

95

DO: 11-07-13

DR: 11-07-13

TR: 3PM





drip.


above normal so

the doctor

ordered to

increase the rate

of the insulin drip

of 100 units HR in

100 cc of PNSS

from 5 units/hr to

13 units/hr

Patient is on

Nephrosteril

DO: 11-07-13

DR: 11-07-13

TR: 4PM




check the effectiveness of


drip from 5 units/hr to 13

units/hr

146 mg/dL The result of the

CBG was still

high so the doctor

ordered to

continue insulin

drip 100 units HR

in 100 cc of PNSS

at 13 units/hr

96

DO: 11-07-13

DR: 11-07-13

TR: 5PM




Patient refused There were no

results because

patient refused to

have CBG taking.

Patient has an

insulin drip 100

units HR in 100

cc of PNSS at 13

units/hr

DO: 11-07-13

DR: 11-07-13

TR: 6PM

Test was done to determine the

current CBG level after refusal

of the patient to the previous

CBG taking.

85 mg/dL The result

decreased to 85

mg/dL so the

doctor ordered to

decrease insulin

to 10 units/hr.

DO: 11-07-13

DR: 11-07-13

TR: 7PM

To test the effectiveness of

decreasing the rate of the insulin

drip after having a CBG reading

of 85 mg/dL.

185 mg/dL Result elevated

rapidly but there

was no extra

management

given except for

97

the insulin drip

100 units HR in

100 cc of PNSS at

10 units/hr

DO: 11-07-13

DR: 11-07-13

TR: 9PM




86 mg/dL The result went

down again so the

doctor ordered to

decrease the rate

of the insulin drip

of 100 units HR in

100 cc of PNSS

from 10 units/hr

to 8 units/hr

DO: 11-07-13

DR: 11-07-13

TR: 11PM

To test effectiveness of

decreasing the rate of the insulin

drip from 10 units per hour to 8

units per hour.


high rapidly but

no extra

management

rendered except

for the continuous

infusion of the

98

insulin drip of

100 units HR in

100 cc of PNSS at

8 units/hr

DO: 11-08-13

DR: 11-08-13

TR: 1AM





slightly elevated

but there was no

extra

management

ordered but the

doctor ordered

for the continuous

infusion of insulin

drip of 100 units

HR in 100 cc of

PNSS at 8

units/hr

DO: 11-08-13

DR: 11-08-13

TR: 3AM



ordered by the physician

145 mg/dL The result came

down and the

doctor ordered

99

for the continuous

infusion of insulin

drip of 100 units

HR in 100 cc of

PNSS at 8

units/hr

DO: 11-08-13

DR: 11-08-13

TR: 5AM




147 mg/dL The result did not

change thus the

doctor ordered

the continuous

infusion of insulin

drip 100 units HR

in 100 cc of PNSS

at 8 units/hr

DO: 11-08-13

DR: 11-08-13

TR: 7AM





CBG suddenly

dropped but no

extra

management

100

except for the

continuous

infusion of the

insulin drip of

100 units HR in

100 cc of PNSS at

8 units/hr

DO: 11-08-13

DR: 11-08-13

TR: 9AM




71 mg/dL The result

decreased to 78

mg/dL so the

doctor ordered to

hold insulin drip

temporarily and

to feed patient

then repeat CBG

after 30 minutes.

DO: 11-08-13

DR: 11-08-13

TR: 11AM


holding insulin drip temporarily

because of the decreased CBG

level of 71 mg/dL as of 9AM

145 mg/dL The result of

CBG increased

rapidly but still

insulin drip was

101

result on November 08 2013. hold temporarily

as ordered by the

doctor.

DO: 11-08-13

DR: 11-08-13

TR: 1PM





CBG is increased

yet the doctor did

not order to

resume insulin

drip.

DO: 11-08-13

DR: 11-08-13

TR: 3PM





CBG is increased

so the doctor

ordered HR 3

units SC STAT to

decrease the CBG

levels. After 15

mins, the doctor

ordered another 3

units of HR to be

given SQ.

102

DO: 11-08-13

DR: 11-08-13

TR: 5PM


giving HR 3 units SC STAT and

another HR 3 units SC to

manage Hgt result of 200 mg/dL


CBG is still

increased so the

doctor ordered

HR 8 units SC

now to decrease

the CBG levels.

DO: 11-08-13

DR: 11-08-13

TR: 7PM


giving HR 8 units SC now to

manage Hgt result of 213 mg/dL


CBG was

decreased so the

doctor did not

order any insulin

injection to lessen

the CBG level of

the patient.

DO: 11-08-13

DR: 11-08-13

TR: 8PM





CBG increased so

the doctor

ordered to give

Mixtard 22 units

103

SC at 8PM then

Mixtard 44 units

SC at 8AM

DO: 11-09-13

DR: 11-09-13

TR: 12MN

To see the effectiveness of

giving Mixtard 22 units SC at

8PM


CBG was

decreased so the

doctor did not

order any insulin

injection to lessen

the CBG level of

the patient.

DO: 11-09-13

DR: 11-09-13

TR: 4AM





CBG was

decreased to 92

mg/dL thus the

doctor did not

order any insulin

injection to lessen

the CBG level of

the patient.

104

DO: 11-09-13

DR: 11-09-13

TR: 8AM





CBG was

increased slightly

to 114 mg/dL and

the doctor

ordered on

11/08/13 at 8PM

to give Mixtard

44 units SC at

8AM.

DO: 11-09-13

DR: 11-09-13

TR: 12PM


giving Mixtard 44 units at 8AM

in attempting to lower down

CBG level of 114 mg/dL


CBG was

increased to 207

mg/dL so the

doctor ordered to

give HR 5 units

SC now

DO: 11-09-13

DR: 11-09-13

TR: 4PM


giving HR 5 units SC now in

attempting to lower down CBG


CBG was

increased to 216

105

level of 207 mg/dL mg/dL so the

doctor ordered to

increase HR to 6

units SC now

DO: 11-09-13

DR: 11-09-13

TR: 8PM



attempting to lower down CBG

level of 216 mg/dL


CBG was still

high so the doctor

ordered to give

Mixtard 22 units

SC now

DO: 11-10-13

DR: 11-10-13

TR: 12MN


giving Mixtard 22 units SC now

in attempting to lower down

CBG level of 187 mg/dL


CBG was elevated

but the doctor did

not made any

orders in

decreasing the

elevated levels of

CBG of 208

mg.dL

106

DO: 11-10-13

DR: 11-10-13

TR: 4AM





CBG lowered

from 208mg/dL to

114 mg/dL thus

the doctor did not

made any orders

of lessening it

further.

The doctor made

an order to

decrease Hgt

Monitoring to q

6°

DO: 11-10-13

DR: 11-10-13

TR: 12NN





CBG was elevated

so the doctor

ordered to give

HR 6 units IV

now and HR 6

107

units SC now

DO: 11-10-13

DR: 11-10-13

TR: 6PM

To monitor the effectiveness of

giving HR 6 units IV now and

HR 6 units SC now in attempting

to lower down a CBG of 223

mg/dL


CBG was almost

the same so the

doctor ordered to

give HR 5 units

SC now

DO: 11-11-13

DR: 11-11-13

TR: 12MN



attempting to lower down a CBG

of 221 mg/dL


CBG was elevated

so the doctor

ordered to give

HR 3 units SC

now

DO: 11-11-13

DR: 11-11-13

TR: 6AM




of 230 mg/Dl


CBG was still

elevated but the

doctor did not

order any insulin

or management to

decrease the CBG

108

level of 189

mg/dL as of 6AM

results.

DO: 11-11-13

DR: 11-11-13

TR: 12PM





CBG was

abnormally

elevated so the

doctor ordered to

give HR 6 units

IV now and 6

units SC now

DO: 11-11-13

DR: 11-11-13

TR: 6PM


giving HR 6 units IV now and 6

units SC now in attempting to

lower down a CBG of 290 mg/dl


CBG was still

elevated so the

doctor ordered to

give HR 6 units

IV now.

DO: 11-12-13

DR: 11-12-13

TR: 12MN


giving HR 6 units IV now in



CBG was in

normal level

109

of 272 mg/dl which the doctor

did not order any

management.

DO: 11-12-13

DR: 11-12-13

TR: 6AM





CBG was

decreased slightly

but still elevated

yet the doctor did

not order insulin

for increased

CBG, but the pt is

taking oral anti-

hyperglycemia

(Linagliptin).

DO: 11-12-13

DR: 11-12-13

TR: 12NN





CBG was elevated

so the doctor

ordered 6 units of

Mixtard as STAT

dose

110

DO: 11-12-13

DR: 11-12-13

TR: 6PM


giving 6 units of Mixtard as

STAT dose in attempting to

lower down a CBG of 267

mg/dL


CBG was

decreased. The

doctor has

ordered at 9AM

of 11/12/13 to give

Mixtard 24 units

SC (PM dose)

DO: 11-13-13

DR: 11-13-13

TR: 12MN


giving Mixtard 24 units SC (PM

dose) as ordered as of 9AM of

11/12/13.


CBG was

decreased. The

doctor did not

order further

management for

lowering down

CBG level.

DO: 11-13-13

DR: 11-13-13

TR: 6AM





CBG was

increased. The

doctor has

111

ordered at 9AM

of 11/12/13 to give

Mixtard 48 units

SC (AM dose)


BEFORE

Identify the patient by asking the patient to state his/her name. Also check the client‘s identification band. ( confirm patient‘s

identity using two patient identifiers, based on the hospital protocol)

Explain the procedure to the patient or parents (if patient is a child) to gain cooperation

Choose the puncture site. For adults and children fingertips and earlobe can be use.

Wash hands and don clean gloves

If glucometer is used, load the strip into the device beforehand.

DURING

Swab alcohol pad to the chosen puncture site. Use sterile/clean gauze to dry it thoroughly. Piecing the skin with a wet skin

(alcohol) allows the chemical to pass through the outer layer of the skin thus, causing the procedure more painful and

uncomfortable

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To collect a blood sample, position the lancet (pricking needle) at the side of the site. To minimize pain and patient‘s anxiety

pierce the skin sharply and briefly. This technique also increases blood flow. For better results, some agencies are using a

lancing device (mechanical blood-letting device) wherein the lancets are simply loaded in the spring of the equipment. (It‘s

like using a spring-loaded pen, once you click the button the spring releases the lancet and immediately retracts it after piercing

the skin). However, be sure to load an unused lancet before using to prevent spread of blood-transmitted diseases.

Don‘t squeeze the puncture site to prevent diluting the sample with fluids from tissues.

Place gauze over the punctured area and briefly apply pressure until the bleeding stops.

AFTER

Apply an adhesive bandage once the bleeding on the puncture site has stopped.

Remove gloves and record the resulting glucose level from the digital display for glucometer or from the color of reagent strip

to the standardized chart

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Diagnostic/

Laboratory

Procedures

Date ordered

and date

result(s) in


Normal Value

Analysis and

interpretation

of results

URINALYSIS Date ordered:

11-07-2013

Date results in:

11-07-2013

Urinalysis is a test that evaluates

a sample of your urine.

Urinalysis is used to detect and

assess a wide range of disorders,

including urinary tract infection,

kidney disease and diabetes.

Urinalysis involves examining

the appearance, concentration

and content of urine. Abnormal

urinalysis results may point to a

disease or illness.

Color

Light yellow

Transparency

Slightly turbid

Specific gravity

1.010

Volume

600 to 2500 mL

in 24 hours

Color

Pale yellow to

amber

Transparency

Clear to slightly

hazy

Specific gravity

1.005 to 1.030

with a normal

fluid intake

The patient

have

components

that should not

be present on

the urine

(Albumin, Pus

cells,

Amorphous

Urates, and

Bacteria).

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Reaction

acidic

Sugar

Trace

Albumin

Trace

Pus cells

3-5/HPF

Reaction

slightly acidic

Sugar

negative

Albumin

Negative

Pus cells

negative

The patient has

traced sugar

since the

patient is

diabetic.

Increased levels

of protein in

urine may be a

sign of kidney

disease.

Pus cells are

white blood

cells that

115

RBC

0-2/HPF

Epithelial Cells

Rare

RBC

0-5/HPF

Epithelial Cells

Few; hyaline

casts: 0-1/lpf

signify infection

in the body,

especially if the

urine also

contains

bacteria.

Presence of pus

cells in the

urine may also

be a sign of

infection or

inflammation in

the kidneys and

bladder.

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A. Urates

Few

A. Urates

negative

Amorphous

urates (Na, K,

Mg, or Ca salts)

tend to form in

acidic urine

and may have a

yellow or

yellow-brown

color.

Generally, no

specific clinical

interpretation

can be made

based on the

finding of

amorphous

crystals.

(Cornell

University).

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Bacteria

Few

Bacteria

Negative

The presence of

bacteria may

indicate an

infection or

contamination

of the sample.


BEFORE

Ensure that you have the correct equipment - urine dipsticks, disposable gloves and apron, sterile receiver and disposable

towel.

Obtain informed consent for procedure;

Provide any necessary patient education with regard to specimen collection;

Check manufacturer‘s recommendations;

Check product expiry date;

Wash hands. Don gloves and apron;

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DURING

Collect a midstream urine sample or catheter specimen from the patient using a sterile receiver and in accordance with

organizational policy

Remove reagent dipstick and immediately replace cap

Immerse the dipstick into urine, and then remove

Wait for appropriate length of time

Wipe the edge of the strip against the rim of the vessel in order to remove any excess urine. Dab the long edge and then the

back of the test strip on an absorbent surface such as a paper towel;

Hold dipstick at a slight angle. This prevents pad-to-pad contamination;

Read the reagent pads against the reference guide

AFTER

Dispose of urine and dipstick as with organizational policy;

Remove gloves and apron. Wash hands;

Document results

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7. ANATOMY AND PHYSIOLOGY

RESPIRATORY SYSTEM

Respiration is necessary because all living cells of the body require oxygen and

produce carbon dioxide. The respiratory system assists in gas exchange and performs

other functions as well.

1. Gas Exchange. The respiratory system allows oxygen from the air to enter 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 from

cells of the body to the lungs. Thus the respiratory and cardiovascular systems

work together to supply oxygen to all cells and remove carbon dioxide from the

cells and remove carbon dioxide. Without healthy respiratory and cardiovascular

systems, the capacity to carry out normal activity is reduced, and without

adequate respiratory and cardiovascular system function, life itself is impossible.

2. Regulation of blood pH. The respiratory system can alter blood pH by changing

blood carbon dioxide levels.

3. Voice production. Air movement past the vocal cords makes sound and speech

possible.

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4. Olfaction. The sensation of smell occurs when airborne molecules are drawn into

the nasal cavity.

5. Innate immunity. The respiratory system provides protection against some

microorganisms by preventing their entry into the body and by removing them

from the respiratory surfaces.

Anatomy of the Respiratory System

The respiratory system consists of the external nose, the nasal cavity, the pharynx,

the larynx, the trachea, the bronchi, and the lungs. Although air frequently passes through

the oral cavity, it is considered to be part of the digestive system instead of the respiratory

system. The upper respiratory tract refers to the external nose, nasal cavity, pharynx, and

associated structures; and the lower respiratory tract includes larynx. Trachea, bronchi,

and lungs. These terms are not official anatomical terms, however, and there are several

alternative definitions.

Nose

The nose consists of the external nose and the nasal cavity. The external nose is

the visible structure that forms a prominent feature of the face. Most of the external nose

is composed of hyaline cartilage, although the bridge of the external nose consists of

bone. The bone and cartilage are covered by connective tissue and skin.

The nasal cavity extends from nares to the choane. The nares or nostrils are the

external openings of the nose and the choane are openings into the pharynx. The nasal

septum is a partition dividing the nasal cavity into the right and left parts. A deviated

nasal septum occurs when the septum bulges to one side or the other. The hard palate

forms the floor of the nasal cavity, separating the nasal cavity from the oral cavity. Air

can flow through the nasal cavity when the mouth is closed or when the oral cavity is full

of food.

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Three prominent bony ridges called conchae are present on the lateral walls on

each of each side of the nasal cavity. The conchae increase the surface area of the nasal

cavity.

Paranasal sinuses are air- filled spaces within bone. The maxillary, frontal,

ethmoid, and sphenoidal sinuses are named after the bones in which they are located the

paranasal sinuses open into the nasal cavity and are lined with a mucous membrane. They

reduce weight of the skull, produce mucus, and influence the quality of the voice by

acting as resonating chambers.

The nasolacrimal ducts which carry tears from the eyes also open into the nasal

cavity. Sensory receptors for the sense of smell are found in the superior part of the nasal

cavity.

Air enters the nasal cavity through the nares. Just inside the nares the epithelial

lining is composed of stratified squamous containing coarse hairs. The hairs trap some of

the large particles of dust suspended in the air. The rest of the nasal cavity is lined with

pseudostratified columnar epithelial cells containing cilia and many mucus- producing

goblet cells also traps debris in the air. The cilia sweep the mucus posteriorly to the

pharynx, where it is swallowed. As air flows through the nasal cavities, it is humidified

by moisture from the mucous epithelium and is warmed by blood flowing through the

superficial capillary networks underlying the mucous epithelium.

Pharynx

The pharynx is the common passageway of both the respiratory and digestive

systems. It receives air from the nasal cavity and air, food, and water from the mouth.

Interferiorly, the pharynx leads to the rest of the respiratory system through the opening

into the larynx and to the digestive system through the esophagus. The pharynx can be

divided into three regions: the nasopharynx, the oropharynx, and the laryngopharynx.

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The nasopharynx is the superior part of the pharynx. It is located posterior to the choanae

and superior to the soft palate, which is an incomplete muscle and connective tissue

partition separating the nasopharynx from the oropharynx. The uvula is the posterior

extension of the soft palate. The soft palate forms the floor of the nasopharynx. The

nasopharynx is lined with pseudostratified ciliated columnar epithelium that is continuous

with the nasal cavity. The auditory tubes extend from the middle ears and open into the

nasopharynx. The posterior part of the nasopharynx contains pharyngeal tonsil, which

aids in defending the body against infection. The soft palate elevated during swallowing;

this movement results in the closure of the nasopharynx, which prevents food from

passing from the oral cavity into the nasopharynx.

The oropharynx extends from the uvula to the epiglottis, and the oral cavity opens

into the oropharynx. Thus food, drink and air pass through the oropharynx. The

oropharynx is lined with stratified squamous epithelium, which protects against abrasion.

Two sets on tonsils, the palatine tonsil and the lingual tonsils, are located near the

opening between the mouth and the oropharynx. The palatine tonsils are located in the

lateral walls near the border of the oral cavity and the oropharynx. The lingual tonsil is

located o the surface of the posterior part of the tongue.

The laryngopharynx passes posterior to the larynx and extends from the tip of the

epiglottis to the esophagus. Food and drink pass through the laryngopharynx to the

esophagus. A small amount of air is usually swallowed with the food and drink

swallowing too much air can cause excess gas in the stomach and may result in belching.

The laryngopharynx is lined with squamous epithelium and ciliated columnar epithelium.

Larynx

The larynx is located in the anterior throat, and it is continuous superiorly with the

pharynx and inferiorly with the trachea. The larynx consists of an outer casting of nine

cartilages that are connected to one another by muscles and ligaments. Three of nine

cartilages are unpaired, and six of them form three pairs. The largest cartilage is the

unpaired thyroid cartilage, or Adam‘s apple. The thyroid cartilage is attached superiorly

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to the hyoid bone. The most inferior cartilage of the larynx is the unpaired cricoid

cartilage, which forms the base of the larynx on which the other cartilages rest. The

thyroid and cricoids cartilages maintain an open passageway for air movement.

The third unpaired cartilage is the epiglottis. It differs from the other cartilages in

that it consists of elastic cartilage rather than hyaline cartilage. Its inferior margin is

attached to the thyroid cartilage anteriorly, and the superior part of the epiglottis projects

as a free flap toward the tongue. The epiglottis helps prevent swallowed materials from

entering the larynx. As the larynx elevates during swallowing, the epiglottis tips

posteriorly to cover the opening of the larynx.

The six paired cartilages consist of three cartilages on either side of the posterior

part of the larynx. The top cartilage on each side is the cuneiform cartilage, the middle

cartilage is the corniculate cartilage, and the bottom cartilage is the arytenoids cartilage.

The arytenoids cartilages articulate with the cricoids cartilage inferiorly. The paired

cartilages form an attachment site for the vocal folds.

Two pairs of ligament extend from the posterior surface of the thyroid cartilage to

the paired cartilages. The superior pair forms the vestibular folds, or false vocal cords,

and the inferior pair composes the vocal cords or true vocal cords. The vestibular folds

comes together, they prevent air from leaving the lungs such as when a person holds his

breath. Along with the epiglottis, the vestibular folds also prevent food and liquids from

entering the larynx.

The vocal folds are the primary source of voice production. Air moving past the

vocal folds causes them to vibrate, producing sound. Muscles control the length and

tension of the vocal folds. The force of air moving past the vocal folds controls the

loudness, and the tension of the vocal folds controls the pitch of the voice. And

inflammation of the mucous epithelium of the vocal folds is called laryngitis. Swelling of

the vocal folds during laryngitis inhibits voice production.

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Trachea

The trachea, or windpipe, is a membranous tube that consists of connective tissue

and smooth muscle, reinforced with 16- 20 C- shaped pieces of cartilage. The adult

trachea is about 1.4- 1.6 centimeter in diameter and about 10- 11 cm long. It begins

immediately inferior to the cricoid cartilage, which is the most inferior cartilage of the

larynx. The trachea projects through the mediastinum, and divides into the right and left

primary bronchi at the level of the fifth thoracic vertebra. The esophagus lies immediately

posterior to the trachea.

C- shaped cartilage form the anterior and lateral sides of the trachea. The

cartilages protect the trachea. The cartilages protect the trachea and maintain an open

passageway for air. The posterior walls of the trachea has no cartilage and consists of

ligamentous membrane and smooth muscle can alter diameter of the trachea.

The trachea is lined with pseudostratified columnar epithelium which contains

numerous cilia and goblet cells. The cilia propel mucus produced by the goblet cells, as

well as foreign particles embedded in the mucus, out of the trachea, through the larynx,

and into the pharynx, from which they are swallowed.

Constant irritation of the trachea by cigarette smoke can cause the tracheal

epithelium to change to stratified squamous epithelium. The stratified sqamous

epithelium has no cilia and therefore lacks the ability to clear the airway of mucus and

debris. The accumulations of mucus provide a place for microorganisms to grow,

resulting in respiratory infections. Constant irritation and inflammation of the respiratory

passages stimulate the cough reflex, resulting in ―smoker‘s cough‖

Bronchi

The trachea divides into the left and right main bronchi, each of which connects to

a lung. The left main bronchus is more horizontal than the right main bronchus because it

is displaced by the heart. Foreign objects that enter the trachea usually lodge in the right

main bronchus, because it is more vertical than the left main bronchus and therefore more

in direct line with the trachea. The main bronchi extend from the trachea to the lungs.

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Like the trachea, the main bronchi are lined with pseudostratified ciliated columnar

epithelium and supported by the C- shaped pieces of cartilage.

Lungs

The lungs are the principal organs of respiration. Each lung is cone-shaped, with

its base resting on the diaphragm and its apex extending superiorly to a point about 2.5

cm above the clavicle. The right lung has three lobes called the superior, middle, and

inferior lobes. The left lung has two lobes called the superior and inferior lobes. The

lobes of the lungs are separated by deep, prominent fissures on the surface of the lung.

Each lobe is divided into bronchopulmonary segments separated from one another by

connective tissue septa, but these separations are not visible as surface fissures.

Individual diseased bronchopulmonary segments can be surgically removed, leaving the

rest of the lung relatively intact, because major blood vessels and bronchi do not cross the

septa. There are 9 bronchopulmonary segments in the left lung and 10 in the right lung.

The main bronchi branch many times to form the tracheobronchial tree. Each

main bronchus divides into lobar bronchi as they enter their respective lungs. The lobar

(secondary) bronchi, two in the left lung and three in the right lung, conduct air to each

lobe. The lobar bronchi in turn give rise to segmental (tertiary) bronchi, which extend to

the bronchopulmonary segments of the lungs. The bronchi continue to branch many

times, finally giving rise to bronchioles. The bronchioles also subdivide numerous times

to give rise to terminal bronchioles, which then subdivide into respiratory bronchioles.

Each respiratory bronchiole subdivides to form alveolar ducts, which are like long,

branching hallways with many doorways. The doorways open into alveoli, which are

small air sacs. The alveoli become so numerous that the alveolar duct wall is little more

than a succession of alveoli. The alveolar ducts end as two or three alveolar sacs, which

are chambers connected to two or more alveoli. There are about 300 million alveoli in the

lungs.

As the air passageways of the lungs become smaller, the structure of their walls

changes. The amount of cartilage decreases and the amount of smooth muscles increases,

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until at the terminal bronchioles, the walls have a prominent smooth muscle layer, but no

cartilage. Relaxation and contraction of the smooth muscle within the bronchi and

bronchioles can change the diameter of the air passageways. For example, during

exercise the diameter can increase, thus increasing the volume of air moved. During an

asthma attack, however, contraction of the smooth muscle in the terminal bronchioles can

result in greatly reduced air flow. In sever cases, air movement can be so restricted that

death results.

As the air passageways of the lungs become smaller, the lining of their walls also

changes. The trachea and bronchi have pseudostratified ciliated columnar epithelium, the

bronchioles have ciliated simple columnar epithelium, and the terminal bronchioles have

ciliated simple cuboidal epithelium. The ciliated epithelium of the air passageways

functions as a mucus-cilia escalator, which traps debris in the air and removes it from the

respiratory system.

As the air passageways beyond the terminal bronchioles become smaller, their

walls become thinner. The walls of the respiratory bronchioles are cuboidal epithelium

and those of the alveolar ducts and the alveoli are simple squamous epithelium. The

respiratory membrane of the lungs is where gas exchange between the air and blood takes

place. It is mainly formed by the walls of the alveoli and surrounding capillaries but

there‘s some contribution by the alveolar ducts and respiratory bronchioles. The

respiratory membrane is very thin to facilitate the diffusion of gases. It consists of:

1. A thin layer of fluid lining the alveolus

2. The alveolar epithelium composed of simple squamous epithelium

3. The basement membrane of the alveolar epithelium

4. A thin interstitial space

5. The basement membrane of the capillary endothelium

6. The capillary endothelium composed of simple squamous epithelium

The elastic fibers surrounding the alveoli allow them to expand during inspiration

and recoil during expiration. The lungs are very elastic, and when inflated, they are

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capable of expelling air and returning to their original, uninflated state. Specialized

secretory cells within the walls of the alveoli secrete a chemical called surfactant that

reduces the tendency of alveoli to recoil.

Pleural Cavities

The lungs are contained within the thoracic cavity. In

addition, each lung is surrounded by a separate pleural

cavity. Each pleural cavity is lined with a serous membrane

called the pleura. The pleura consist of a parietal and

visceral part. The parietal pleura, which lines the walls of

the thorax, diaphragm, and mediastinum, is continuous with

visceral pleura, which covers the surface of the lung.

The pleural cavity, between the parietal and visceral

pleurae, is filled with a small volume of pleural fluid produced by the pleural membranes.

The pleural fluid performs two functions: (1) it acts as a lubricant, allowing the visceral

and parietal pleurae to slide past each other as the lungs and thorax change shape during

respiration, and (2) it helps hold the pleural membranes together. The pleural fluid acts

like a thin film of water between two sheets of glass (the visceral and parietal pleurae);

the glass sheets can slide over each other easily; but it is difficult to separate them.

Lymphatic Supply

The lungs have two lymphatic supplies. The superficial lymphatic vessels are

deep to the visceral pleura and function to drain lymph from the superficial lung tissue

and the visceral pleura. The deep lymphatic vessels follow the bronchi and associated

connective tissues. No lymphatic vessels are located in the walls of the alveoli. Both the

superficial and deep lymphatic vessels exit the lungs at the main bronchi.

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Phagocytic cells within the lungs phagocytize carbon particles and other debris

from inspired air and move them to the lymphatic vessels. In older people, the surface of

the lungs can appear gray to black because of the accumulation of theses particles,

especially if the person smoked or lived most of his life in a city with air pollution.

Cancer cells from the lungs can also spread to other parts of the body through the

lymphatic vessels.

Ventilation and Lung Volumes

Ventilation, or breathing, is the

process of moving air into and out of the

lungs. There are two phases of ventilation: (1)

inspiration, or inhalation, is the movement

of air into the lungs; (2) expiration, or

exhalation, is the movement of air out of the

lungs. Changes in the thoracic volume, which

produce of changes in air pressure within the

lungs, are responsible for ventilation

Changing Thoracic Volume

Muscles associated with ribs are responsible

for ventilation. The muscles of inspiration include the

diaphragm and muscles that elevate the ribs and

sternum, such as the external intercostals. The

diaphragm is a large dome of skeletal muscle that

separates the thoracic cavity from the abdominal

cavity. The muscles of expiration, such as the internal intercostals, depress the ribs and

sternum.

At the end of a normal, quiet expiration, the respiratory muscles are relaxed.

During quiet inspiration, contraction of the diaphragm causes the top of the dome to

129

move inferiorly, which increases the volume of the thoracic cavity. The largest change in

thoracic volume results from movement of the diaphragm. Contraction of the external

intercostals also elevates the ribs and sternum, which increases thoracic volume by

increasing the diameter of the thoracic cage.

Expiration during quiet breathing occurs when the diaphragm and external

intercostals relax and elastic properties of the thorax and lungs cause a passive decrease

in thoracic volume.

There are several differences between normal, quiet breathing and labored

breathing. During labored breathing, all of the inspiratory muscles are active and they

contract more forcefully than during quiet breathing, causing a greater increase in

breathing, forceful contraction of the internal intercostals and the abdominal muscles

produces a more rapid and greater decrease in thoracic volume would be produced by the

passive recoil of the thorax and lungs.

Pressure Changes and Airflow

The flow of air into and out of the lungs is governed by two physical principles:

1. Changes in volume result in changes in pressure. As the volume of a container

increases, the pressure within the container decreases. As the volume of a

container decreases, the pressure within the container increases. The muscles of

respiration change thoracic volume and therefore pressure within the thoracic

cavity.

2. Air flows from areas of higher to lower pressure. If the pressure is higher at one

end of a tube than at the other, air or fluid flows from the area of higher pressure

toward the area of lower pressure. The greater the pressure difference, the greater

rate of airflow. Air flows through the respiratory passages because of pressure

differences between the outside of the body and the alveoli inside the body. These

pressure differences are produced by changes in thoracic volume.

130

The volume and pressure changes responsible for one cycle of inspiration and

expiration can be described as follows.

1. At the end of expiration, alveolar pressure, which is the air pressure within the

alveoli, is equal to atmospheric pressure, which is the air pressure outside the

body. There is no movement of air into or out of the lungs because alveolar

pressures are equal.

2. During inspiration, contraction of the muscles of inspiration Increases the volume

of the thoracic cavity. The increased thoracic volume causes the lungs to expand,

resulting in an increase in alveolar pressure becomes less than atmospheric

pressure, and air flows from outside the body through the respiratory passages to

the alveoli.

3. At the end of inspiration, the thorax and alveoli stop expanding. When the

alveolar pressure and atmospheric pressure become equal, airflow stops.

4. During expiration, the thoracic volume decreases, producing a decrease in

alveolar volume. Consequently, alveolar pressure increases above the air pressure

outside the body, and air flows from the alveoli through the respiratory passages

to the outside.

As expiration ends, the decrease in thoracic volume stops and the process repeats

beginning at step 1.

Lung Recoil

During quiet expiration, thoracic volume and lung decrease because of passive

recoil of the thoracic wall and lungs. The recoil of the thoracic wall results from the

elastic properties of the thoracic wall tissues. Lung Recoil is the tendency for an

expanded lung to decrease in size. It occurs for two reasons: (1) the elastic fibers in the

connective tissue of the lungs and (2) surface tension of the film of fluid that lines the

alveoli. Surface tension exists because the oppositely charged ends of water molecules

attract each other. As the water molecules pull together, they also pull on the alveolar

walls, causing the alveoli to recoil and become smaller. Two factors keep the lungs fro

collapsing: (1) surfactant, and (2) pressure in the pleural cavity.

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ENDOCRINE SYSTEM

The role of the endocrine

system is to maintain the body in balance

through the release

of hormones (chemical signals) directly

into the bloodstream. Hormones transfer

information and instructions from one set

of cells to another. Many different

hormones move through the bloodstream,

but each type of hormone is designed to

affect only certain cells.

A gland is a group of cells that produces and secretes chemicals. A gland selects

and removes materials from the blood, processes them, and secretes the finished chemical

product for use somewhere in the body. The endocrine gland cells release a hormone into

the blood stream for distribution throughout the entire body. These hormones act as

chemical messengers and can alter the activity of many organs at once.

The parts of the endocrine system are grouped together because they release

hormones into the blood without going through a duct (which is basically a tube) first.

This is different to an exocrine gland, which releases what it creates through a tube to

somewhere other than the blood.

Hormones can act on some specific cells because they themselves do not actually

cause an effect. It is only through binding with a receptor (part of the cell specifically

designed to recognize the hormone) like a key into a lock - that causes a chain reaction to

occur, changing the activity of the cells. If a cell does not have a receptor for a hormone

then there will be no effect. Also, there can be different receptors for the same hormone,

and so the same hormone can have different effects on different cells.

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Pancreas: A fish-shaped spongy grayish-pink organ about 6 inches (15 cm) long that

stretches across the back of the abdomen, behind the stomach. The head of the pancreas

is on the right side of the abdomen and is connected to the duodenum (the first section of

the small intestine). The narrow end of the pancreas, called the tail, extends to the left

side of the body.

The pancreas makes pancreatic juices and hormones, including insulin. The

pancreatic juices are enzymes that help digest food in the small intestine. Insulin controls

the amount of sugar in the blood.

As pancreatic juices are made, they flow into the main pancreatic duct. This duct

joins the common bile duct, which connects the pancreas to the liver and the gallbladder.

The common bile duct, which carries bile (a fluid that helps digest fat,) connects to the

small intestine near the stomach.

The pancreas is thus a compound gland. It is "compound" in the sense that it is

composed of both exocrine and endocrine tissues. The exocrine function of the pancreas

involves the synthesis and secretion of pancreatic juices. The endocrine function resides

in the million or so cellular islands (the islets of Langerhans) embedded between the

exocrine units of the pancreas. Beta cells of the islands secrete insulin, which helps

control carbohydrate metabolism. Alpha cells of the islets secrete glucagon that counters

the action of insulin.

http://www.medterms.com/script/main/art.asp?articlekey=6098

http://www.medterms.com/script/main/art.asp?articlekey=6098

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RENAL SYTEM

The Kidneys

The kidneys are two bean shaped organs of

the renal system located on the posterior wall of the

abdomen one on each side of the vertebral column

at the level of the twelfth rib. The left kidney is

slightly higher than the right. Why do you think that

the right kidney is lower than the left (Q1). Human

kidneys are richly supplied with blood vessels

which give them their reddish brown color.

The kidneys measure about 10cm in length and, 5cm in breadth and about 2.5 cm

in thickness.The kidneys are protected by three highly specialized layers of protective

tissues. The outer layer consists mainly of connective tissue which protects the kidneys

from trauma and infection. This layer is often called the renal fascia or fibrous

membrane. The technical name for this layer is the renal capsule.

The next layer (second layer from the exterior) is called the fascia and it makes a

fibrous capsule around the kidneys. This layer connects the kidneys to the abdominal

wall. The inner most layers is made up of adipose tissue and is essentially a layer of fatty

tissue which forms a protective cushions the kidney; and the renal capsule (fibrous sac)

surrounds the kidney and protects it from trauma and infection.

Blood Nerve and Supply

The kidneys receive their oxygenated blood supply from the renal arteries which

come off the abdominal portion of the aorta. Venous blood from the kidneys drains into

the renal veins to join the abdominal portion of the inferior vena cava.The hilum of the

kidneys is located toward the smaller curvature. The opening in the hilum allows for the

entry and exit of blood vessels and nerves. The funnel shaped extension of the kidneys is

http://healthmad.com/healthcare-industry/kidney-anatomy-and-physiology/#_blank

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called the renal pelvis and it connects the kidneys to the two ureters. This structure

facilitates the collection of the urine from the kidneys and drainage to the urinary

bladder.The functional parts of the kidneys are divided into two distinct regions. The

outer region is reddish brown in color and is called the renal cortex. This is where the

nephrons of the kidney are located. The inner layer of the kidney is more pinkish in color

and is called the renal medullat. The renal cortex houses the functional units of the

kidneys called nephrons. The inner area of the kidneys is supplied by a small blood vessel

network called the vasa recta.

The Nephron

The nephron is a functional part of the

kidneys. The Glomerulus is a collection of

capillaries which are surrounded by the

Bowman‘s capsule. The afferent arteriole enters

this capsule and the efferent arteriole leaves it.

In the glomerulus the blood pressue is high and

it pushes small structured molecules out (water,

salts, glucose and urea). However larger molecules (proteins and glycogen) stay within

the capillary network. The particles which are pushed out with water (filtrate) enter the

proximal convoluted tubule. This portion is convoluted and broad. The following portion

is straight and narrow; hence it is called the straight collecting tubule, also referred to as

the Loop of Henle. This portion is located in the Renal medulla.

The collecting tubule upon re-entry into the renal cortex passes by the efferent

arteriole. The macula densa is the final part of the ascending collecting tubule very

closely. The filtrate is selectively reabsorbed in the distal broad convoluted and the

proximal narrow straight tubules. Water and salts are reabsorbed in the Loop of Henle.

Urine concentration occurs here.

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Proximal tubule is broad and convoluted. It is located in the renal cortex. Distal

tubule is narrow and straight. It forms the Loop of Henle and is located in the renal

medulla. When the filtrate arrives in the distal tubule water is reabsorbed. However,

hydrogen ions, ammonia, histamines, and certain antibiotics are excreted into the distal

tubule. This process is selective and involves the expansion of energy i.e. ATP is used up.

It is called tubular excretion.

Functions of the Renal System

The renal system has many functions. The following are the best known. Each is

discussed under a separate subtitle because the functions are varied and complex:

Excretion of urea, a by product of protein metabolism

Regulations of the amount of water which stays in the body

Kidneys maintain the pH balance of the human body

Produce EPO hormone which has a role in the production of Red blood cells

Produce the enzyme rennin. This enzyme has a role in the maintenance of blood

pressure.

a. Urine production and b. water regulation: These are important functions of the

different parts of the nephrons. They filter blood of its small molecules and ions and

make urine. During this process it reclaims useful minerals and sugars. In one day (24hrs)

the kidneys reclaim 1,300 g of NaCl, 400 g of NaHCO3 and 180 g of glucose and 180

liters of water. These are the constituents which entered the tubules during the filtration

process.

b. Maintain pH value of human body: The human body is designed to function

optimally at a pH value of 7.35 to 7.45. Death will occur if pH drops below 6.8 or rises

above 7.8. It is for this reason that pH values are checked frequently during acute

illnesses. pH is maintained by buffers dissolved in the blood. However, the kidneys and

the lungs play a vital role in removing the H+ ion from the body. Metabolic Acidosis

occurs when the kidneys fail to remove the H+ ions. Respiratory acidosis occurs when

the lungs fail to remove the excess of CO2 from circulation.

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d. Hormone production: Kidneys produce two hormones known as erythropoietin

(EPO), and calcitriol. They also produce the enzyme known as rennin.

Erythropoietin (EPO): Is a hormone which is produced by the kidneys. It is

needed in the bone marrow for the formation of red blood cells. Chemically EPO is a

glycoprotein with a molecular weight of 34,000. A glycoprotein is a protein with an

attached sugar molecule.

Highly specialized cells of the kidney which are sensitive to low oxygen levels in

the blood produce EPO. The EPO subsequently stimulates the bone marrow to produce

RBCs to increase O2 carrying capacity. This also leads to greater production of hb. Hb is

the molecule which facilitates the transport of oxygen by the cardiovascular system.The

EPO gene is located on chromosome 7, band 7q21. Some EPO is also produced in

the liver. Normal levels of EPO are 0 to 19mU/ml (milliunits per milliliter). Elevated

levels of EPO indicate polycythemia. Lower levels are seen in chronic renal failure. EPO

is often prescribed to treat patients with Acute or Chronic Renal Failure.

Kidneys have a role in the manufacture of vitamin D (Calcitrol)

Calcitriol is 1,25[OH]2 = Vitamin D3, the active form of vitamin D.

Vitamin D3 (Cholecalciferol): Is synthesized in skin when it is exposed to sunlight.

Vitamin D2 (Ergocalciferol) is a synthetic vitamid D derivative

Both vitamin D2 and D3 are hydroxylated in the kidneys into Calcitriol.

Vitamin D regulates Calcium and Phosphorus levels in blood by promoting their

absorption from the food in the intestines and promoting re absorption of Calcium in the

kidneys.

e. Renin : Is an enzyme which is in the juxtaglomerular cells of the juxaglomerualr

apparatus of the renal system. This occurs when: a. the circulating blood volume is low or

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b. or serum NaClconcentrarion is low. Overproduction causes hypertension and

underproduction causes hypotension.

Sympathetic stimulation of Beta 1 and Alpha 1 adrenergic receptors on the JGA cells also

bring about the production of renin. Normal concentration is 1.0 to 2.5 mg/ml.

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CARDIOVASCULAR SYSTEM

The cardiovascular

system consists of the

heart, blood vessels, and

the approximately 5 liters

of blood that the blood

vessels transport.

Responsible for

transporting oxygen,

nutrients, hormones, and

cellular waste products

throughout the body, the

cardiovascular system is

powered by the body‘s hardest-working organ — the heart, which is only about the size

of a closed fist. Even at rest, the average heart easily pumps over 5 liters of blood

throughout the body every minute.

The Heart

The heart is a muscular pumping

organ located medial to the lungs along the

body‘s midline in the thoracic region. The

bottom tip of the heart, known as its apex, is

turned to the left, so that about 2/3 of the heart is located on the body‘s left side with the

other 1/3 on right. The top of the heart, known as the heart‘s base, connects to the great

blood vessels of the body: the aorta, vena cava, pulmonary trunk, and pulmonary veins.

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Circulatory Loops

There are 2 primary circulatory loops in the human body: the pulmonary circulation

loopand the systemic circulation loop.

1. Pulmonary circulation transports deoxygenated blood from the right side

of the heart to the lungs, where the blood picks up oxygen and returns to the left

side of the heart. The pumping chambers of the heart that support the pulmonary

circulation loop are the right atrium and right ventricle.

2. Systemic circulation carries highly oxygenated blood from the left side of

the heart to all of the tissues of the body (with the exception of the heart and

lungs). Systemic circulation removes wastes from body tissues and returns

deoxygenated blood to the right side of the heart. The left atrium and left ventricle

of the heart are the pumping chambers for the systemic circulation loop.

Blood Vessels

Blood vessels are the body‘s highways that allow blood to flow quickly and

efficiently from the heart to every region of the body and back again. The size of blood

vessels corresponds with the amount of blood that passes through the vessel. All blood

vessels contain a hollow area called the lumen through which blood is able to flow.

Around the lumen is the wall of the vessel, which may be thin in the case of capillaries or

very thick in the case of arteries.

All blood vessels are lined with a thin layer of simple squamous epithelium

known as the endothelium that keeps blood cells inside of the blood vessels and prevents

clots from forming. The endothelium lines the entire circulatory system, all the way to the

interior of the heart, where it is called the endocardium.

There are three major types of blood vessels: arteries, capillaries and veins. Blood

vessels are often named after either the region of the body through which they carry

blood or for nearby structures. For example, the brachiocephalic artery carries blood

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into the brachial (arm) and cephalic (head) regions. One of its branches, the subclavian

artery, runs under the clavicle; hence the name subclavian. The subclavian artery runs

into the axillary region where it becomes known as the axillary artery.

1. Arteries and Arterioles: Arteries are blood vessels that carry blood away

from the heart. Blood carried by arteries is usually highly oxygenated, having just

left the lungs on its way to the body‘s tissues. The pulmonary trunk and arteries of

the pulmonary circulation loop provide an exception to this rule – these arteries

carry deoxygenated blood from the heart to the lungs to be oxygenated.

Arteries face high levels of blood pressure as they carry blood being

pushed from the heart under great force. To withstand this pressure, the walls of

the arteries are thicker, more elastic, and more muscular than those of other

vessels. The largest arteries of the body contain a high percentage of elastic

tissue that allows them to stretch and accommodate the pressure of the heart.

Smaller arteries are more muscular in the structure of their walls. The

smooth muscles of the arterial walls of these smaller arteries contract or expand

to regulate the flow of blood through their lumen. In this way, the body controls

how much blood flows to different parts of the body under varying

circumstances. The regulation of blood flow also affects blood pressure, as

smaller arteries give blood less area to flow through and therefore increases the

pressure of the blood on arterial walls.

Arterioles are narrower arteries that branch off from the ends of arteries

and carry blood to capillaries. They face much lower blood pressures than

arteries due to their greater number, decreased blood volume, and distance from

the direct pressure of the heart. Thus arteriole walls are much thinner than those

of arteries. Arterioles, like arteries, are able to use smooth muscle to control their

aperture and regulate blood flow and blood pressure.

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2. Capillaries: Capillaries are the smallest and thinnest of the blood vessels

in the body and also the most common. They can be found running throughout

almost every tissue of the body and border the edges of the body‘s avascular

tissues. Capillaries connect to arterioles on one end and venules on the other.

Capillaries carry blood very close to the cells of the tissues of the body in

order to exchange gases, nutrients, and waste products. The walls of capillaries

consist of only a thin layer of endothelium so that there is the minimum amount

of structure possible between the blood and the tissues. The endothelium acts as

a filter to keep blood cells inside of the vessels while allowing liquids, dissolved

gases, and other chemicals to diffuse along their concentration gradients into or

out of tissues.

Precapillary sphincters are bands of smooth muscle found at the arteriole

ends of capillaries. These sphincters regulate blood flow into the capillaries.

Since there is a limited supply of blood, and not all tissues have the same energy

and oxygen requirements, the precapillary sphincters reduce blood flow to

inactive tissues and allow free flow into active tissues.

3. Veins and Venules: Veins are the large return vessels of the body and act

as the blood return counterparts of arteries. Because the arteries, arterioles, and

capillaries absorb most of the force of the heart‘s contractions, veins and venules

are subjected to very low blood pressures. This lack of pressure allows the walls

of veins to be much thinner, less elastic, and less muscular than the walls of

arteries.

Veins rely on gravity, inertia, and the force of skeletal muscle contractions

to help push blood back to the heart. To facilitate the movement of blood, some

veins contain many one-way valves that prevent blood from flowing away from

the heart. As skeletal muscles in the body contract, they squeeze nearby veins

and push blood through valves closer to the heart.

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When the muscle relaxes, the valve traps the blood until another

contraction pushes the blood closer to the heart. Venules are similar to arterioles

as they are small vessels that connect capillaries, but unlike arterioles, venules

connect to veins instead of arteries. Venules pick up blood from many capillaries

and deposit it into larger veins for transport back to the heart.

Coronary Circulation

The heart has its own set of blood vessels that provide the myocardium with the

oxygen and nutrients necessary to pump blood throughout the body. The left and right

coronary arteries branch off from the aorta and provide blood to the left and right sides of

the heart. The coronary sinus is a vein on the posterior side of the heart that returns

deoxygenated blood from the myocardium to the vena cava

Hepatic Portal Circulation

The veins of the stomach and intestines perform a unique function: instead of

carrying blood directly back to the heart, they carry blood to the liver through

the hepatic portal vein. Blood leaving the digestive organs is rich in nutrients and other

chemicals absorbed from food. The liver removes toxins, stores sugars, and processes the

products of digestion before they reach the other body tissues. Blood from the liver then

returns to the heart through the inferior vena cava.

Blood

The average human body contains about 4 to 5 liters of blood. As a liquid

connective tissue, it transports many substances through the body and helps to maintain

homeostasis of nutrients, wastes, and gases. Blood is made up of red blood cells, white

blood cells, platelets, and liquid plasma.

Red Blood Cells: Red blood cells, also known as erythrocytes, are by far

the most common type of blood cell and make up about 45% of blood volume.

Erythrocytes are produced inside of red bone marrow from stem cells at the

astonishing rate of about 2 million cells every second. The shape of erythrocytes

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is biconcave—disks with a concave curve on both sides of the disk so that the

center of an erythrocyte is its thinnest part. The unique shape of erythrocytes

gives these cells a high surface area to volume ratio and allows them to fold to fit

into thin capillaries. Immature erythrocytes have a nucleus that is ejected from the

cell when it reaches maturity to provide it with its unique shape and flexibility.

The lack of a nucleus means that red blood cells contain no DNA and are not able

to repair themselves once damaged.

Erythrocytes transport oxygen in the blood through the red pigment

hemoglobin. Hemoglobin contains iron and proteins joined to greatly increase the

oxygen carrying capacity of erythrocytes. The high surface area to volume ratio of

erythrocytes allows oxygen to be easily transferred into the cell in the lungs and

out of the cell in the capillaries of the systemic tissues.

White Blood Cells: White blood cells, also known as leukocytes, make up

a very small percentage of the total number of cells in the bloodstream, but have

important functions in the body‘s immune system. There are two major classes of

white blood cells: granular leukocytes and agranular leukocytes.

1.Granular Leukocytes: The three types of granular leukocytes are

neutrophils, eosinophils, and basophils. Each type of granular leukocyte is

classified by the presence of chemical-filled vesicles in their cytoplasm that

give them their function. Neutrophils contain digestive enzymes that

neutralize bacteria that invade the body. Eosinophils contain digestive

enzymes specialized for digesting viruses that have been bound to by

antibodies in the blood. Basophils release histamine to intensify allergic

reactions and help protect the body from parasites.

2.Agranular Leukocytes: The two major classes of agranular leukocytes are

lymphocytes and monocytes. Lymphocytes include T cells and natural killer

cells that fight off viral infections and B cells that produce antibodies against

infections by pathogens. Monocytes develop into cells called macrophages

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that engulf and ingest pathogens and the dead cells from wounds or

infections.

Platelets : Also known as thrombocytes, platelets are small cell fragments

responsible for the clotting of blood and the formation of scabs. Platelets form in

the red bone marrow from large megakaryocyte cells that periodically rupture and

release thousands of pieces of membrane that become the platelets. Platelets do

not contain a nucleus and only survive in the body for up to a week before

macrophages capture and digest them.

Plasma: Plasma is the non-cellular or liquid portion of the blood that

makes up about 55% of the blood‘s volume. Plasma is a mixture of water,

proteins, and dissolved substances. Around 90% of plasma is made of water,

although the exact percentage varies depending upon the hydration levels of the

individual. Theproteins within plasma include antibodies and albumins.

Antibodies are part of the immune system and bind to antigens on the surface of

pathogens that infect the body. Albumins help maintain the body‘s osmotic

balance by providing an isotonic solution for the cells of the body. Many different

substances can be found dissolved in the plasma, including glucose, oxygen,

carbon dioxide, electrolytes, nutrients, and cellular waste products. The plasma

functions as a transportation medium for these substances as they move

throughout the body.

Cardiovascular System Physiology

Functions of the Cardiovascular System

The cardiovascular system has three

major functions: transportation of materials,

protection from pathogens, and regulation of

the body‘s homeostasis.

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Transportation: The cardiovascular system transports blood to almost all

of the body‘s tissues. The blood delivers essential nutrients and oxygen and

removes wastes and carbon dioxide to be processed or removed from the body.

Hormones are transported throughout the body via the blood‘s liquid plasma.

Protection: The cardiovascular system protects the body through its white

blood cells. White blood cells clean up cellular debris and fight pathogens that

have entered the body. Platelets and red blood cells form scabs to seal wounds

and prevent pathogens from entering the body and liquids from leaking out.

Blood also carries antibodies that provide specific immunity to pathogens that

the body has previously been exposed to or has been vaccinated against.

Regulation: The cardiovascular system is instrumental in the body‘s

ability to maintain homeostatic control of several internal conditions. Blood

vessels help maintain a stable body temperature by controlling the blood flow to

the surface of the skin. Blood vessels near the skin‘s surface open during times

of overheating to allow hot blood to dump its heat into the body‘s surroundings.

In the case of hypothermia, these blood vessels constrict to keep blood flowing

only to vital organs in the body‘s core. Blood also helps balance the body‘s pH

due to the presence of bicarbonate ions, which act as a buffer solution. Finally,

the albumins in blood plasma help to balance the osmotic concentration of the

body‘s cells by maintaining an isotonic environment.

The Circulatory Pump

The heart is a four-chambered ―double pump,‖ where each side (left and right)

operates as a separate pump. The left and right sides of the heart are separated by a

muscular wall of tissue known as the septum of the heart. The right side of the heart

receives deoxygenated blood from the systemic veins and pumps it to the lungs for

oxygenation. The left side of the heart receives oxygenated blood from the lungs and

pumps it through the systemic arteries to the tissues of the body. Each heartbeat results in

the simultaneous pumping of both sides of the heart, making the heart a very efficient

pump.

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Regulation of Blood Pressure

Several functions of the cardiovascular system can control blood pressure. Certain

hormones along with autonomic nerve signals from the brain affect the rate and strength

of heart contractions. Greater contractile force and heart rate lead to an increase in blood

pressure. Blood vessels can also affect blood pressure. Vasoconstriction decreases the

diameter of an artery by contracting the smooth muscle in the arterial wall. The

sympathetic (fight or flight) division of the autonomic nervous system causes

vasoconstriction, which leads to increases in blood pressure and decreases in blood flow

in the constricted region. Vasodilation is the expansion of an artery as the smooth muscle

in the arterial wall relaxes after the fight-or-flight response wears off or under the effect

of certain hormones or chemicals in the blood. The volume of blood in the body also

affects blood pressure. A higher volume of blood in the body raises blood pressure by

increasing the amount of blood pumped by each heartbeat. Thicker, more viscous blood

from clotting disorders can also raise blood pressure.

Hemostasis

Hemostasis, or the clotting of blood and formation of scabs, is managed by the

platelets of the blood. Platelets normally remain inactive in the blood until they reach

damaged tissue or leak out of the blood vessels through a wound. Once active, platelets

change into a spiny ball shape and become very sticky in order to latch on to damaged

tissues. Platelets next release chemical clotting factors and begin to produce the protein

fibrin to act as structure for the blood clot. Platelets also begin sticking together to form a

platelet plug. The platelet plug will serve as a temporary seal to keep blood in the vessel

and foreign material out of the vessel until the cells of the blood vessel can repair the

damage to the vessel wall.

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B. PATHOPHYSIOLOGY

a. Schematic Diagram (Book-Centered)

DM Type II

Modifiable Factors: Non-modifiable Factors

- Obesity - Genetics

- Sedentary Lifestyle - Age

- Ethnicity

Defective Insulin Receptors

Hyperglycemia Hypersecretion of Insulin

Toxic to Pancreatic Beta Cells Hyperinsulinemia

Destruction of Pancreatic Beta Cells Production of Glucagon HHNK Increased Ketones

Decreased Secretion of Insulin Gluconeogenisis from Fats and Proteins DKA Acetone

Breath

Hyperglycemia Chronic Hyperglycemia Wasting of Lean Body Mass Weight Loss Fatigue

Increased Osmolality Due to Hyperglycemia Non-Enzymatic Glycosylation

Polydipsia Polyuria Cellular Starvation Polyphagia Advanced Glycation End-Products

A B C D E F G

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Weight loss Dehydration Immunosupression Diabetic Neuropathies Macrovascular Problems Microvascular Problems

Hypovolemia Infection Autonomic Sensory Stroke (Ischemic) Retinopathy

Neuropathy Neuropathy

Persistent Candidiasis Peripheral Vascular Nephropathy

Infection GI Disturbances Paresthesia

Cardiovascular Dse

Recurrent Skin Bladder Dysfunction Loss of Protective

Infection Sensation

Other Risk Factors: Tachycardia

- Poverty Malignant Otitis Diabetic Foot Ulceration Disregulated Detection

- Malnutrition Externa of Serum Osmolality

- Contact with Infected Person Postural HTN by Atrium and Kidney

- Alcohol Abuse Increased Pressure in Arteries

- Immunosuppression Necrotizing Fasciitis

-Smoking Sexual Dysfunction Stimulation of RAAS

-Exposure to Chemicals (Pesticides) Hypertrophy and Hyperplasia

-Employment Genital Pruritus of Smooth Muscle Cells

Aldosterone Secretion

Tuberculosis Fibromuscular Thickening and

Endothilial Damage Fluid Retention

Entrance of Myobacterium Tuberculosis

Lipid Deposition in Lesions

Migration to Alveoli Elevation in

Atherosclerosis Blood Pressure

Low Grade Fever

Pneumonitis

Night Sweats Increased Peripheral Resistance

Inflammation Process Malaise

A B C D E F G

H I J

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Activation of Macrophages and Neutrophils Hemoptysis Loss of Appetite

Formation of Tubercles Chronic Collapse of Small Airway Weight Loss Hyperglycemia

Tubercle on Expiration

Formation

Caseation Necrosis Anorexia Increased Glomerular

Chronic Bronchitis Flow Rate

Scar Tissue Formation

Bronchiectasis Other Risk Factors: Hyperfiltration

-Exposure to Rotten Fruits

Calcification of Tubercles

Predisposed to Fungal Invasion Glomerular Damage

Release of Myobacterium Tuberculosis

Fungus Ball Formation Glumerularnecrosis

Reactivation of Microorganism

Thickening and Harderning

of Blood Vessels

Serum Creatinine Decreased Blood Flow Microalbuminuria

Renal Damage Fluid Shifting

Serum BUN

Untreated or Prolonged Renin-Angiotensin Puffy Face Edema

Imbalance

Increased Scarring of Bleeding Hematuria

Kidney Tissues

Dec. Hemoglobin Fatigue

Decreased Filtering Surface Renal Failure

H I J

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b.1. Definition of the Disease

Tuberculosis (TB) is an infection caused by a rod-shaped, non-spore-forming,

aerobic bacterium Myobacterium tuberculosis. This bacilli has a unique cell wall

structure that is crucial for its survival, its wall contains a considerable amount of fatty

acids that is capable of producing an extraordinary barrier that is able to resist antibiotics

and host defense mechanisms and is also responsible for its virulence growth rate

(Knechel, 2009). This organism has also been labeled as an opportunistic infection

because it is likely to develop in someone with a weakened immune system (Madara &

Denino, 2008). The disease process starts once the bacilli is inhaled into the lungs and

migrating to the alveoli causing inflammation. Pulmonary macrophages and white cell

migrate to the infected area, surrounding and isolating the bacilli and producing a lesion

called a tubercle. A scar tissue then grows around the tubercle to prevent further

multiplication. The bacilli within the tubercle become inactive that forms into a

cheeselike substance called caseation necrosis. These isolated bacilli remain dormant for

life but if a client‘s immune system becomes impaired due to other underlying diseases,

live bacilli will escape into the bronchial tree thus starting another cycle that if left

untreated may ultimately lead to respiratory damage that is beyond repair.

As TB progresses, different stages are realized, these stages are: latency, primary

disease, primary progressive disease and extrapulmonary disease. As explained by

Knechel (2009), in latent TB signs and symptoms of the disease are not apparent hence

the client do not feel sick and at this stage is not yet infectious. Primary pulmonary

tuberculosis is often asymptomatic but diagnostic tests will result positive as the only

evidence of being infected by the bacilli but it has been reported as well that there is a

possibility of pleural effusion because the bacilli is able to infiltrate the pleural space

from adjacent area, though these effusions may remain small and able to resolve

themselves some may become large enough to produce symptoms such as fever, pleuritic

chest pain, and dyspnea. Primary progressive TB have early signs and symptoms that are

often nonspecific which includes manifestations such as progressive fatigue, malaise,

weight loss, and low grade fever accompanied by chills and night sweats. This phase can

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also present wasting due to lack of appetite and altered metabolism associated with the

inflammatory and immune response, also, productive cough may be present that would

have purulent sputum, hemoptysis can be due to destruction of a patent vessel located in

the wall of the cavity, rupture of a dilated vessel in a cavity, or the formation of an

aspergilloma in an old cavity.

In response of the body to these alterations in the body, hematologic studies may

reveal anemia which causes fatigue and weakness, leukocytosis will also present as

response to the infection. Extrapulmonary TB is a complication of TB wherein if TB is

not immediately prevented has the capability to infiltrate to other systems of the body one

of which is the central nervous system that can result in meningitis as the fatal case and

miliary TB where the bacilli will spread throughout the body via the bloodstream that

will lead to multiorgan involvement. If this disease is not properly managed or an

individual would have another episode of having a weak immune system, recurrence may

take place.

b.2. Predisposing/Precipitating Factors (Book-Centered)

Non-Modifiable Factors:

1. Age: As people age, their immune system weakens, specifically those in the age

group of age 65 and above. Myobacterium tuberculosis being an infectious

microorganism, it can easily invade a weaken immunity and able to reproduce

with ease.

Modifiable Factors:

1. Exposure to Chemicals: It has been studied by Dr. Repetto & Baliga (2009) that

exposure to pesticides has its own implications, one of which is it suppression of

the immune system thus leaving an individual to contract infectious diseases.

Pesticides have been found to reduce the numbers of white blood cells and

disease-fighting lymphocytes and impair their ability to respond to and kill

bacteria and viruses.

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2. Diabetes: According to WHO (2011), through the years of being a diabetic, it is

inevitable that a client may develop a weakened immune system and a chance of

2-3 times higher risk of acquiring TB compared to individuals who do not have

DM and it was collated that 10% of TB cases globally are linked to DM. It was

also reported by the International Union Against Tuberculosis and Lung Disease

(IUATLD, 2012) that with people who have DM that coexist with TB have a 4

time higher rate of death during treatment and higher risk of TB relapse after

treatment, also that TB is associated with worsening glycemic control with people

who have DM. Copstead & Bansik (2010) also reported that Tuberculosis

infection and reactivation can be a particular problem in diabetic residents.

3. Alcohol Abuse: The Mayo Clinic (2013) as well as Madara & Denino (2008)

concluded that with alcohol abuse, the immune defense is altered and exposing an

individual to be easily contracted by microorganisms and Myobacterium

tuberculosis being labeled as an opportunistic infection.

4. Smoking: Schneider & Novotny (2008) and the Public Health Agency of Canada

(2010) that smoking damages the lungs and interacts at an immunologic and

cellular level to reduce treatment efficacy. Smoking suppresses the innate and

adaptive immune response with decreased levels of pro-inflammatory cytokines

and circulating immunoglobulins, and reduces activity of alveolar macrophages,

dendritic cells and natural killer cells thus predisposing an individual to acquire

TB.

5. Contact with an Infected Person: Tuberculosis is a disease caused by bacteria

that are spread through the air from person to person. Myobacterium tuberculosis

bacilli in particular are put into the air when a person with TB disease of the lungs

or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these

bacteria and become infected (CDC, 2013).

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6. Immunosuppression: Since the bacteria that cause TB, immunosuppressed

individuals are more prone to contract this disease especially when they are

exposed to infected patients. In particular these immunosuppressed clients may

have HIV, under chemotherapy and those who are taking steroids (The Mayo

Clinic, 2012).

7. Malnutrition and Diet: In order to have an effective immune system, proper

nutrition is necessitated. For the body to properly maintain its defense

mechanisms, energy is needed and only through proper nutrition that this needed

energy can be acquired (NHS, 2012).

8. Employment: Another factor that needs to be considered is the surrounding

environment. Some individuals may have to work in settings that may not be

conducive to their health that leaves them prone to acquire infectious diseases

without their knowledge (CDC, 2013).

9. Poverty: This factor may be attributed to the inability of an individual to avail

needed nutrition that is needed to maintain suitable immunity. Also, their inability

to avail necessary healthcare needs may not be met thus aggravates the low

immunity that may have already developed (WHO, 2011).

10. Mode of Transmission: Mycobacterium tuberculosis is spread by small airborne

droplets, called droplet nuclei, generated by the coughing, sneezing, talking, or

singing of a person with pulmonary or laryngeal tuberculosis. These minuscule

droplets can remain airborne for minutes to hours after expectoration. Meaning

that if an infected person is living within a household that has small living space,

those who are living with him may easily acquire this bacterium.

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a. Schematic Diagram (Patient-Centered)

DM Type II Non-Modifiable Factors:

- Genetics

- Age (58 y/o)

- Ethnicity (Asian)

Defective Insulin Receptors

Hyperglycemia

Over Stimulation of Pancreatic Beta Cells (Causes Toxicity)

Destruction of Pancreatic Beta Cells

Decreased Secretion of Insulin

Hyperglycemia Chronic Hyperglycemia Non-Enzymatic Glycation

Advance Glycation End-Products

Immunosuppression Macrovascular Problems Microvascular Problems

Infection Cardiovascular Disease Diabetic Nephropathy

Tuberculosis Hyperglycemia

A B

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Other Risk Factors: Entrance of Myobacterium Tuberculosis Increased Pressure in the Arteries Disregulated Increased Glomerular

- Smoking (76 pack years) Detection of Serum Flow Rate

- Exposure to Chemicals Osmolality by Atrium

(Pesticides) Migration to Alveoli Hypertrophy and Hyperplasia and Kidney

- Employment (Tricycle Driver) of Smooth Muscle Cells Hyperfiltration

Pneumonitis Stimulation of RAAS

Fibromuscular Thickening and Glomerular Damage

Chronic Tubercle Endothilial Damage

Formation Inflammation Process Aldosterone Secretion

Glomerularnecrosis

Lipid Deposition in Lesions

Further Damage to Activation of Macrophages Fluid Retention

Lung Parenchyma and Neutrophils Thickening and Hardening

Atherosclerosis of Blood Vessels

Elevation in BP

Formation of Tubercles (160/100 mmHg

Increased Peripheral Resistance 11/06/13) Decreased Blood Flow

Collapse of Small

Airway on Expiration Caseation Necrosis

Creatinine Renal Damage Microalbunemia

(3.29-11/06/13

Chronic Bronchitis Scar Tissue Formation 3.61-11/07/13)

Hemoptysis Fluid Shifting

(07/2013 and 09/2013) Serum BUN

Bronchiectasis Calcification of Tubercles (46.27-11/07/13)

Edema

(11/06/13)

Predisposed to Fungal Invasion Release of Myobacterium

Tuberculosis

Fungus Ball Formation Reactivation of Microorganism

(11/05/13-Lobectomy)

Other Risk Factors: Rotten Fruits (Mangoes)

A B

156

b.2. Predisposing/Precipitating Factors (Patient-Centered)

Modifiable Factors:

1. Exposure to Chemicals: The client that was chosen for the study has a history of

working as a farmer for 32 years. In those years, it has been noted that the client

was not utilizing any kind of protection such as facial masks from pesticides that

was being used in farming. With this occurring for a long period, the client‘s

immune system has been compromised leaving him exposed to any invading

pathogens. As studied by Dr. Repetto & Baliga (2009), this is implicated to

reduce the function of the immune system.

2. Diabetes Mellitus: The client under study has a history of being diabetic, with

diabetes, immunity as well is weakened and with a high glucose content that the

blood has, it is a perfect thriving environment for pathogens thus leaving Mr.

Baga prone to acquire infectious diseases.

3. Smoking: Given that Mr. Baga was a 76 pack year smoker, with the

accumulation of nicotine in his system, significant changes have occurred in the

physiology and immunity of his pulmonary system.

4. Employment: It was also shared by Mr. Baga that he is also a tricycle driver

when farming season is over. Given the other risk factor that Mr. Baga has, to

come across someone who is infected with TB is possible that may lead Mr. Baga

to acquire this bacteria as well.

b.3. Signs and Symptoms (Book-Centered)

1. A bad cough that lasts for 3 weeks or longer: Due to the invading bacteria in

the lungs, a compensatory mechanism that is coughing is activated but with the

persistent activity of the bacteria, this coughing reflex lasts longer than the usual

course of coughing.

157

2. Hemoptysis: As explained by Knechel (2009), hemoptysis or coughing of blood

may be caused by destruction of a patent vessel located in the wall of the cavity,

rupture of a dilated vessel in a cavity, or the formation of an aspergilloma in an

old cavity. In response of the body to these alterations in the body, hematologic

studies may reveal anemia which causes fatigue and weakness, leukocytosis will

also present as response to the infection.

3. Chest pain, dyspnea or othopnea: With damage being made by the bacteria

responsible, pain is felt through these destructions may also be attributed to the

increased in interstitial volume that leads to a decrease in lung diffusion capacity.

4. Loss of appetite: This symptom has been attributed to nausea that may cause an

individual to loss of appetite.

5. Low grade fever, chills and night sweats: These are being experienced due to

the invading bacteria in the body as part of the inflammation process.

6. Wasting: Is classical symptom that is due to lack of appetite and the altered

metabolism associated to the inflammatory and immune responses.

7. Fatigue: This symptom is due to loss of body fat and lean tissue associated to

wasting that decreases muscle mass as well.

b.3. Signs and Symptoms (Client-Centered)

a. Hemoptysis: This symptom was experienced by this particular client while

farming on 2008 and recurred on July of 2013 as well as September of 2013.

b. Fatigue: This instance occurred simultaneously when the episode of hemoptysis

happened on 2008 even of the recurrence dates of July and September 2013.

158

LIST OF PROBLEMS Pre-operative

PROBLEM #1: INEFFECTIVE AIRWAY CLEARANCE r/t RETAINED SECRETIONS

PROBLEM #2: DECREASED CARDIAC OUTPUT RELATED TO ALTERED STROKE VOLUME

PROBLEM #3: CONSTIPATION r/t DECREASE PHYSYCAL ACTIVITY

Operative PROBLEM #1: DECREASED CARDIAC OUTPUT RELATED TO ALTERED STROKE VOLUME

PROBLEM #2: RISK FOR INFECTION r/t INADEQUATE PRIMARY DEFENSE AEB SURGICAL INCISION

PROBLEM #2: RISK FOR IMPAIRED GAS EXCHANGE R/T ALVEOLAR-CAPILLARY CHANGES

Post-operative PROBLEM #1 ACUTE PAIN r/t SURGICAL INCISION

PROBLEM #2: HYPERTHERRMIA

PROBLEM #3: INEFFECTIVE AIRWAY CLEARANCE r/t RETAINED SECRETIONS

PROBLEM #4: INEFFECTIVE BREATHING PATTERN r/t POOR LUNG COMPLIANCE AEB CTT INSERTION

PROBLEM #5: DECREASED CARDIAC OUTPUT RELATED TO ALTERED STROKE VOLUME

PROBLEM #6: INEFFECTIVE TISSUE PERFUSION R/T HYPERTENSION SECONDARY TO DIABETES

PROBLEM #7: FLUID AND ELECTROLYTR IMBALANCE R/T FLUID RETENSION AEB PITTING EDEMA AND OLIGURIA

PROBLEM #8: FLUID VOLUME EXCESS R/T INABILITY TO MAINTAIN FLUID BALANCE AEB DECREASED OUTPUT SECONDARY TO DIABETIC NEPHROPATHY

PROBLEM #9: IMPAIRED URINARY ELIMINATION R/T FLUID RETENTION SECONDARY TO DIABETIC NEPHROPATHY

PROBLEM #10: IMPAIRED SKIN INTEGRITY r/t SURGICAL INCISION

PROBLEM #11: RISK FOR INFECTION r/t INADEQUATE PRIMARY DEFENSE AEB SURGICAL INCISION

PROBLEM #12: CONSTIPATION r/t DECREASE PHYSYCAL ACTIVITY

PROBLEM #13: IMPAIRED PHYSICAL MOBILITY r/t WEAKNESS

PROBLEM #14: RISK FOR IMPAIRED GAS EXCHANGE R/T ALVEOLAR-CAPILLARY CHANGES

PROBLEM #15: ACTIVITY INTOLERANCE R/T POSTOPERATIVE THORACOTOMY, LOBECTOMY AND PRESENCE OF CTT

PROBLEM #16: FATIGUE r/t ALTERED OXYGEN SUPPLY AND DEMAND

159

B. PLANNING (NURSING CARE PLAN)

ACUTE PAIN r/t SURGICAL INCISION

ASSESSMENT NURSING

DIAGNOSI

S

SCIENTIFIC

EXPLANATIO

N

OBJECTIVE

S

NURSING

INTERVENTION

S

RATIONALE EVALUATIO

N

S: “Masakit ya ing

tahi ku” (my suture is

painful) as verbalized

by the client

O: The client

manifested the

following:

Complains of

pain on CTT

site upon

moving and

coughing

P: pain upon

movement; Q:

quality is

stabbing; R:

localized on

surgical site;

S: 7/10

severity; T:

pain occurs

upon

movement and

relieved at rest

Acute Pain

related to

surgical

incision

AEB CTT

insertion

Pain is an

uncomfortable

feeling that tells

an individual that

something is

wrong with the

individual body.

Pain is the

body‘s way of

sending warning

to the brain. The

spinal cord and

the nerves

provide the

pathways for

messages to

travel to and

from the brain

and other parts of

the body. There

are thousands of

receptor cells in

and beneath the

skin that senses

heat, cold,

pressure, touch

Short term:

After 4 hours

of nursing

interventions,

the client will

demonstrate

use of

relaxation

skills &

diversional

activities as

indicated to

minimize if

not relieve

pain.

Long term:

After 3 days of

nursing

interventions,

the client will

demonstrate

behaviors to

relieve pain

and pain scale

will decrease

1.Assess client‘s

general condition

2.Assess for

referred pain

3.Observe non-

verbal cues and

other objectives

4.Perform pain

assessment each

time pain occurs,

not and investigate

changes from

previous reports

5.Note when pain

occurs

1.To obtain

baseline data

2.To determine

characteristics,

location and

severity of pain

3.To observe

verbal reports

that may or

may not be

congruent that

indicates needs

for further

evaluation

4.To identify

the factors that

may contribute

to pain

5.To provide

non-

Short term:

The client shall

have

demonstrated

use of

relaxation skills

& diversional

activities as

indicated.

Long term:

The client shall

have

demonstrated

behaviors to

relieve pain and

pain scale will

decrease to

below 3.

160

with deep

regular rhythm

of breathing

with use of

accessory

muscles

(+) grimace

VS are as follows:

BP: 140/70mmHg

T:36

RR:18cpm

PR:64bpm

The client may

manifest the

following:

Guarding

behavior

Sleep

disturbance

Demonstrate

protective

gestures

Facial mask

and pain. Upon

the insertion of

the CTT,

affectation to

these pain

receptors cannot

be avoided thus

causing

discomfort and

pain to the client.

to below 3.

6.Encourage

diversional

activities such as

watching TV o

socialization

7.Provide comfort

measures such as

repositioning, touch

or providing quiet

environment

8.Encourage

adequate rest

periods

9.Discuss with

SO‘s ways in which

they can assist

clients and reduce

precipitating factor

that may cause or

increase pain.

pharmacologic

al pain

management

6. To rule out

worsening of

underlying

conditions/

development of

complications

7.Timely

intervention is

more likely to

be successful in

alleviating pain

8.To prevent

fatigue

9.To provide

support to the

client

161

10.Provide for

individualized

physical therapy/

exercise program

that can be

continued by the

client

11.Administer

analgesics, as

ordered

10.To enhance

self-concept

and sense of

independence

and to promote

active and not

passive role

11.To maintain

acceptable

level of pain

162

HYPERTHERMIA

ASSESSMENT

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES

NURSING

INTERVENTIONS

RATIONALE

EVALUATION

S: Client may verbalize

headache

O: Client manifested

an increase in body

temperature, flushed

skin and warm to touch

Client may also

manifest:

Tachypnea

Tachycardia

Confusion

Convulsion

Hyperthermia Hyperthermia is an

elevation of body

temperature above

normal range.

There have been

occurrences that lab

results have shown

that this particular

client had an

elevation of white

blood cells would

also mean there are

pathogens trying to

invade his body and

with the presence of

stress due to the

operation that has

just been

undergone, there is

a compromised

immune system an

opportunity for

these microbes that

triggers the

inflammation

response, one of

Short Term:

After 1-2 hours

of nursing

interventions, the

client will be

able to

participate in

techniques on

lowering body

temperature such

as TSB

Long Term:

After 2-3 days of

nursing

interventions, the

client will be

able to maintain

core temperature

within normal

range

1. Monitor body

temperature

2. Promote surface

cooling by cool,

tepid sponge bath

3. Administer

replacement fluids

and electrolytes

4. Maintain bed rest

5. Provide high-

caloric diet

1. Toe evaluate

degree of

hyperthermia

2. To assist

with measures

to reduce body

temperature

3. To support

circulating

volume and

tissue

perfusion

4. To reduce

metabolic

demands and

oxygen

consumption

5. To meet

increased

metabolic

demands

Short Term:

The client shall

have been able to

participate in

techniques on

lowering body

temperature such

as TSB

Long Term:

The client shall

have been able to

maintain core

temperature

within normal

range

163

which is an increase

in temperature to

keep these

pathogen at bay.

6. Emphasize

importance of

adequate fluid intake

7. Administer

antipyretics as

indicated

6. To prevent

dehydration

7. To assist

with measures

to reduce body

temperature

164

INEFFECTIVE AIRWAY CLEARANCE r/t RETAINED SECRETIONS

ASSESSMENT NURSING

DIAGNOSI

S

SCIENTIFIC

EXPLANATIO

N

OBJECTIVE

S

NURSING

INTERVENTION

S

RATIONAL

E

EVALUATIO

N

S: Ø

O: The client manifest

the following:

Restlessness

DOB after

talking

presence of

crackles on

both lung

fields upon

auscultation

with regular

depth and

rhythm of

breathing

amount of

CTT

The client may

manifest the

following:

Ineffective

airway

clearance r/t

retained

secretions

Normally lungs

are free from

secretions. Due

to infected lungs

a substance and

discharged are

formed by a cell

and tissues in the

lungs which

indeed blocks the

passage way of

oxygen, since

oxygen cannot

truly pass and

enter to it, this

result for the

clients to

experience

difficulty of

breathing and for

him to have

ineffective

airway clearance

for the reason of

the present

secretions.

Short term:

After 4 hours

of nursing

interventions,

the client will

expectorate/

clear

secretions

readily.

Long term:

After 3 days of

nursing

interventions,

the client will

maintain

airway

patency.

1.Monitor

respiration and

breath sounds,

noting rate and

sounds

2.Evaluate client‘s

cough/gag reflex

and swallowing

ability

3.Encourage deep

breathing and

coughing exercises

4.Position head

appropriate for age

and condition

5.Encourage

adequate fluid

intake with strict

1.Inidicative

of respiratory

distress and/or

accumulation

of secretions

2.To

determine

ability to

protect own

airway

3.To

maximize

effort

4.To open or

maintain open

airway in at-

rest or

compromised

individual

5.Hydration

can help

liquefy

Short term:

The client shall

have

expectorated/

cleared

secretions

readily.

Long term:

The client shall

have

maintained

airway patency.

165

Dyspnea

Difficulty

vocalizing

Orthopnea

Changes in

respiratory

rate/rhythm

aspiration

precaution

6.Encourage and

provide

opportunities for

rest; limit activities

to level of

respiratory

tolerance

7.Observe for signs

and symptoms of

infection

8.Suction

naso/tracheal/oral

as necessary

viscous

secretions and

improve

secretion

clearance

6.To prevent/

reduce fatigue

7.To identify

infectious

process and

promote

timely

interventions

8.To clear

airway when

excessive or

viscous

secretions are

blocking

airway or

client is

unable to

166

9.Administer

analgesic, as

ordered

10.Assist with use

of respiratory

devices and

treatments

swallow or

cough

effectively

9.To improve

cough when

pain is

inhibiting

effort.

10.Various

therapies/

modalities

may be

required to

acquire and

maintain

adequate

airways,

improve

respiratory

function

167

INEFFECTIVE BREATHING PATTERN r/t POOR LUNG COMPLIANCE AEB CTT INSERTION

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EVALUATION

S: Ø

O: The client

manifested the

following:

Use of

accessory

muscles to

breathe

Complains of

DOB after

activity or

talking

Complained

pain upon

breathing or

coughing

with regular

depth and

rhythm of

breathing

VS are as follows:

Ineffective

breathing

pattern r/t

poor lung

compliance

secondary to

bronchiectasis

after

lobectomy

Breathing pattern

refers to the rate,

volume, rhythm

and relative ease

or effort of

respiration.

Ineffective

breathing pattern

refers to the

inspiration and

expiration that

does not provide

adequate

ventilation. As the

client have

suffered from

having

tuberculosis an

episode of

bronchiectasis

have happend,

there is an

impairment in the

air passage with

the addition of a

lobectomy

procedure, the

Short term:

After 4 hours

of nursing

interventions,

the client will

take part in

efforts to wean

within

individual

capacity.

Long term:

After 3 days of

nursing

interventions,

the client will

establish a

normal,

effective

respiratory

pattern AEB

absence of

cyanosis and

other signs and

symptoms of

hypoxia.

1.Auscultate chest

2.Encourage

slower/deeper

respirations, use of

pursed lip technique

3.Note muscles for

breathing

4.Maintain calm

attitude while

dealing with client

5.Stress importance

of good posture and

effective use of

accessory muscles

6.Encourage

adequate rest

periods between

1.To evaluate

presence/character

of breath sounds

and secretions

2.To assist client

in taking control

of the situation

3.To identify that

may signify an

increase in work

of breathing

4.To limit level of

anxiety

5.To maximize

respiratory effort

6.To limit fatigue

Short term:

The client shall

have taken part

in efforts to

wean within

individual

capacity.

Long term:

The client shall

have established

a normal,

effective

respiratory

pattern AEB

absence of

cyanosis and

other signs and

symptoms of

hypoxia.

168

BP: 140/80mmHg

T:36

RR:23cpm

PR:64bpm

The client may

manifest the following:

Alterations in

deep depth of

breathing

Decreased

inspiratory or

expiratory

pressure

Nasal flaring

With abnormal

ABG

lung capacity is

further

diminished thus

decreasing lung

compliance even

more.

activities

7.Elevate head of

bed and/or have

client sit up in chair,

as appropriate

8.Administer O2

regulated at 2Lpm

via nasal cannula as

ordered

9.Advise client to

avoid overeating/gas

forming foods, as

ordered

10.Advise regular

medical evaluation

with primary care

provider

11.Administer

analgesics,

antibiotic,

bronchodilators and

nebulization as

ordered

7.To promote

physiological and

psychological

ease of maximal

inspiration

8.To manage of

underlying

pulmonary

condition and

respiratory

distress

9.This may cause

abdominal

distention

10.To determine

effectiveness of

current

therapeutic

regimen and to

promote general

well-being

11.to promote

deeper respiration

and use of

pharmacological

drugs

169

DECREASED CARDIAC OUTPUT RELATED TO ALTERED STROKE VOLUME

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS


S: Ø

O: The client

manifested the

following:

-altered heart

rate and rhythm

-restlessness

-decreased

peripheral

pulses

-unstable VS:

>T: 36.2 °C

>P: 66bpm

>R: 24cpm

>BP: 140/70

mmHg

Decreased

cardiac

output related

to altered

stroke

volume

Decreased cardiac

output results

from the

inadequate blood

pumped to meet

metabolic

demands of the

body. Onset of

diabetic

hyperglycemia

causes a

significant and

progressive

decrease in

cardiac output

because of the

viscosity of the

blood that

circulates

sluggishly that in

turn equates to a

systemic vascular

resistance.

Short Term

Goal:

Within 8 hours

of nursing care,

client will be

able to

participate in

activities that

reduce the

workload of the

heart such as

therapeutic

medication

regimen, and

balanced

activity/rest

plan.

Long Term

Goal:

Within 3-5

days of nursing

care, client will

be able to

demonstrate

activities that

will lessen the

1. evaluate client

reports and evidence

of extreme fatigue,

intolerance for

activity, and

progressive

shortness of breath

2. determine vital

signs/hemodynamic

parameter and

response to activities

or procedures and

time required to

return to baseline

3. keep client on bed

or chair in rest

position of comfort

4. decrease stimuli,

provide quiet

environment

5. instruct client to

avoid or limit

1. to assess for

signs of poor

ventricular

function

2. provide

baseline for

comparison to

follow trends and

evaluate response

to interventions

3. to decrease

oxygen

consumption and

risk or

decompression

4. to promote

adequate rest

5. for this can

cause change in

Short Term

Goal:

The client shall

have

participated in

activities that

reduce the

workload of the

heart such as

therapeutic

medication

regimen, weight

reduction, and

balanced

activity/rest

plan.

Long Term

Goal:

The client shall

have

demonstrated

decreased

restlessness

170

workload of the

heart

activities that may

stimulate Valsalva

response

6. encourage

relaxation

techniques

7. administer

oxygen via nasal

cannula as indicated

8. administer

analgesics as

appropriate

cardiac pressures

and impede blood

flow

6. to promote

comfort or rest

7. to increase

oxygen available

for cardiac

function tissue

perfusion

8. to promote

comfort and rest

171

INEFFECTIVE TISSUE PERFUSION R/T HYPERTENSION SECONDARY TO DIABETES

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION OBJECTIVES

NURSING

INTERVENTIONS RATIONALE

EXPECTED

OUTCOMES

S: Ɵ

O: The client

manifested

Altered blood

pressure

Low

hemoglobin and

hematocrit

count

Client may manifests:

Skin

temperature

changes

Skin

discolorations

Edema

Delayed healing

Weak/absent

pulses

Bruit

Diminished

arterial

pulsations

Altered

Ineffective

peripheral

tissue

perfusion

related to

hypertension

As part of a

physiologic

response of the

body to

hyperglycemia, in

order to move

viscous blood

throughout the

body, it has to

compensate by

increasing the

workload of the

heart. Also, due to

an episode of a

massive

hemoptysis, blood

volume has

decreased thus

diminishing RBC

count. RBC

contains the

hemoglobin,

which is known to

be the oxygen

carrying capacity

of the blood if

there would be

decreased RBC in

Short Term:

After 24° of

NI, the client

will have

tolerable

perfusion AEB

vital signs

within normal

range.

Long Term:

After 3 days of

NI, the client

will

demonstrate

behaviors that

will improve

lifestyle to

prevent further

complications

1. Assess client‘s

condition

2. Monitor and

record VS

3. Provide foam

padding,

bed/foot cradle.

4. Elevate head of

bed

5. Encourage early

ambulation,

when possible.

6. assess motor and

sensory function

1. To assess

causative

factors

2. To

establish

baseline

data

3. To protect

the

extremities

.

4.To increase

gravitational

blood flow.

5.Enhances

venous return

6. Problems

with

ambulation or

loss of

sensation,

numbness or

tingling are

Short Term:

The client

shall have

improved

perfusion aeb

vital signs

within normal

range.

Long Term:

The client

shall have

demonstrated

behaviors that

will improve

lifestyle to

prevent

further

complications

172

sensations

the blood it will

lead to decreased

perfusion because

of the decreased

hemoglobin.

7. Assist or instruct

client to change

positions in timed

intervals rather than

using sense

presence of pain as

signal to change

position

8. Provide

education about

relationship

between smoking

and peripheral

vascular circulation

9. Administer

fluids, electrolytes,

nutrients and

oxygen as indicated

changes that

may indicate

neurovascular

dysfunction

or limb

ischemia

7. To promote

circulation and

limit

complications

associated

with poor

perfusion and

tissue injury

8. Smoking

contributes to

development

and

progression of

peripheral

vascular

disease

9. to promote

optimal blood

flow, organ

perfusion and

function

173

FLUID AND ELECTROLYTR IMBALANCE R/T FLUID RETENSION AEB PITTING EDEMA AND OLIGURIA

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS


S: Ø

O: The client

manifested:

Pitting edema

on upper

extremities

Oliguria

Fever (temp of

38.0)

The client may

manifest:

Generalized

weakness

Nausea and

vomiting

Changes in the

level of

consciousness

Muscle

twitching and

tremors

Fluid and

electrolyte

imbalance

related to

fluid

retention

AEB pitting

edema and

oliguria

Body fluid is

composed

primarily of water

and electrolytes.

The body is

equipped with

homeostatic

mechanisms to

keep the

composition and

volume of body

fluids within

narrow limits.

Organs involved

in this mechanism

include the

kidneys, lungs,

heart, blood

vessels, adrenal

glands,

parathyroid

glands, and

pituitary gland.

Due to decreased

urine output,

client will retain

more sodium in

the body thus

Short term:

After 8 hrs of

nursing

interventions,

the client will

prevent/

minimize

complication.

Long term:

After 5 days of

nursing

interventions,

the client will

restore

homeostasis

AEB absence

of edema and

intake should

equal to fluid

output

1. Assess general

condition

2. Monitor intake

and output

every shift

3. Assess

cardiovascular

and respiratory

status

4. Review

laboratory tests

and results

5. Weight client

on a daily basis

with the same

time

6. Note location

and extent of

to determine

individual

needs

to assess

clients ability

to excrete

fluids from the

body

to determine

degree of

imbalance and

the affected

systems

to monitor

imbalances

to assess

effectiveness

of

management

rendered

to assess fluid

retention and

Short Term

The client shall

have prevented/

minimized

complication.

Long term:

The client shall

have restored

homeostasis

AEB absence of

edema and

intake should

equal to fluid

output

174

decreasing

potassium.

edema

7. Assess level of

consciousness

and mental

status

8. Position client

appropriately

9. Schedule rest

periods

10. Provide health

teaching on

how to

conserve

energy

11. Administer

prescribed

medications

such as diuretic

progress of

condition

to assess

degree of

imbalances

and effect to

mental status

to promote

comfort and

prevent skin

ulcers

to minimize

energy

requirement

to minimize o2

demand

to aid in fluid

excretion

175

FLUID VOLUME EXCESS R/T INABILITY TO MAINTAIN FLUID BALANCE AEB DECREASED OUTPUT

SECONDARY TO DIABETIC NEPHROPATHY

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS


S: Ø

O: The client

manifested the

following:

Edema

Intake exceeds

output

Presence of

crackles on both

lung fields upon

auscultation

Decrease I & O

or imbalance

The client may manifest

the following:

Weight gain

over short period

of time

Hypertension

Fluid volume

excess r/t

inability to

maintain

fluid balance

AEB

decreased

output and

edema

Fluid volume

excess is a

circumstance

where an

individual

experiencing or at

risk of excess

intracellular or

interstitial fluid.

With DM as one

of the disease

being managed,

this disease has

reached to effect

the kidneys a

complication

called diabetic

nephropathy

where in there has

been damage

done to the

kidneys and is

now able to pass

albumin through

the urine where

albumin is needed

to preserve the

Short term:

After 4 hours

of nursing

interventions,

the client will

demonstrate

behaviors to

monitor fluid

status and

reduce

recurrence of

fluid excess

Long term:

After 3 days of

nursing

interventions,

the client will

stabilize fluid

volume as

evidenced by

balanced I&O

and absence of

signs of

ingestions

1.Auscultate breath

sounds

2.Measure

abdominal girth

3.Evaluate

mentation

4.Assess

neuromuscular

reflexes

5.Observe skin and

mucous membrane

6.Stress need for

1.For presence

of crackles,

congestion

2.For changes

that may

indicate

increasing fluid

retention/edema

3.For

confusion,

personality

changes

4.To evaluate

for presence of

electrolyte

imbalances

such as

hypernatremia

5.For presence

of decubitus

and ulceration

6.To prevent

Short term:

The client shall

have

demonstrated

behaviors to

monitor fluid

status and

reduce

recurrence of

fluid excess

Long term:

The client shall

have stabilized

fluid volume as

evidenced by

balanced I&O

and absence of

signs of

ingestions

176

Specific gravity

changes

oncotic pressure

so not to let water

escape into the

interstitial space

of the cells.

mobility and/or

frequent position

changes

7.Place in semi-

fowler‘s position, as

appropriate

8.Record intake and

output

9.Restrict sodium

and fluid intake, as

indicated

10.Set an

appropriate rate of

stasis and

reduce risk of

tissue injury

7.To facilitate

movement of

diaphragm,

thus improving

respiratory

effort

8.Accuarte I

and O is

necessary for

determining

renal function

and fluid

replacement

needs and

reducing risk of

fluid overload

9.Fluid

management is

usually

calculated to

prevent further

fluid retention

10.To prevent

peaks and

177

fluid intake or

infusion throughout

24-hour period

11.Administer

diuretics, as ordered

valleys in fluid

level and thirst

11.To excrete

excess fluid

178

IMPAIRED URINARY ELIMINATION R/T FLUID RETENTION SECONDARY TO DIABETIC NEPHROPATHY

ASSESSMENT NURSING

DIAGNOSI

S

SCIENTIFIC

EXPLANATIO

N

PLANNING NURSING

INTERVENTION

S

RATIONAL

E

EVALUATIO

N

S: Ɵ

O: The client manifests

the following:

Weakness

Activity

intolerance

Dysuria

Oliguria

Edema

The client may

manifest the following:

Incontinence

Retention

Impaired

urinary

elimination

r/t fluid

retention

secondary to

diabetic

nephropathy

With damage

made to the

kidneys due to

diabetic

nephropathy and

a decreased blood

flow due to

hypertension

there is an

impairment in the

glomerular

filtration that

diminishes the

ability of the

kidney to excrete

urine effectively.

Short term:

After 8 hours

of nursing

interventions

, the client

will

demonstrate

behaviors

and

techniques to

prevent

urinary

infection

Long term:

After 3 days

of nursing

interventions

, the client

will achieve

normal

elimination

pattern or

participate in

measures to

correct or

1.Determine client‘s

usual daily fluid

intake

2.Ascertain client‘s

previous pattern of

elimination

3.Demonstrate

proper positioning

of catheter drainage

tubing and bag

4. Check frequently

for bladder

distention and

observe for flow

5. Help client keep a

voiding diary for 3

days to record fluid

intake, voiding

times, precise urine

output and dietary

1.To help

determine

level of

hydration

2.For

comparison

with current

situation

3.To facilitate

drainage and

prevent reflux

4. to reduce

risk of

infection

5. Helps

determine

baseline

symptoms,

severity of

frequency or

Short term:

The client shall

have

demonstrated

behaviors and

techniques to

prevent urinary

infection

Long term:

The client shall

have achieved

normal

elimination

pattern or

participate in

measures to

correct or

compensate for

defects

179

compensate

for defects

intake

6. Discuss possible

dietary restrictions

such as coffee and

carbonated drinks

7. Implement and

monitor

interventions for

specific elimination

problem and

evaluate client‘s

response

8. Maintain acidic

environment of the

bladder by use of

agents such as

vitamin C

urgency, and

whether diet is

a factor

6. To assist in

treating or

preventing

urinary

alteration

7. To monitor

and modify

treatment if

needed

8. To

discourage

bacterial

growth

180

IMPAIRED SKIN INTEGRITY r/t SURGICAL INCISION

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS


S: Ø

O: The client

manifested the

following:

Complains of

pain on the CTT

site

With dry and

intact dressing

on the CTT site

The client may manifest

the following:

Inflammation of

the CTT site

Impaired skin

integrity r/t

surgical

incision

secondary to

presence of

CTT

Skin is the

primary defense

of the body; it

protects the

body against

infections and

diseases brought

about by the

invasion of

microbes in the

body. Hence, the

client has

undergone a

surgical

procedure, the

intactness of the

skin has been

compromised that

may be a portal of

entry by

microbes.

Short term:

After 4 hours

of nursing

interventions,

the client will

participate in

prevention

measures and

treatment

program such

as keeping the

affected part

clean and dry

Long term:

After 2 days of

nursing

interventions,

the client will

demonstrate

proper

techniques to

keep the

affected area

clear of signs

of infection

1. Keep the area

clean and dry,

carefully dress

wounds, support

incision, prevent

infection and

stimulate circulation

to surrounding areas

2.Use appropriate

barrier dressings or

wound coverings

3.Apply appropriate

dressing

4. Reposition the

client on regular

schedule, involving

client in reasons for

and decisions about

times and positions

1 .To assist

body‘s natural

process of

repair

2. To protect

the wound

and/or

surrounding

tissues

3. For wound

healing and to

best meet

needs of client

and caregiver

or care setting

4. To enhance

understanding

and

cooperation

Short term:

The client shall

have

participated in

prevention

measures and

treatment

program such as

keeping the

affected area

clean and dry

Long term:

The client shall

have

demonstrated

proper

techniques to

keep the

affected area

clear of signs of

infection

181

5. Encourage early

ambulation or

mobilization

6. Provide optimum

nutrition, including

vitamins, as ordered

7. Inspect

surrounding skin for

erythema, induration

or maceration

8. Review

medication and

therapy regimen

5. Promotes

circulation and

reduce risks

associated

with

immobility

6. To provide

a positive

nitrogen

balance to aid

in skin and

tissue healing

and to

maintain

general good

health

7. To asses

progress of

healing or any

signs of

infection

8. To promote

timely healing

and prevent

infection

182

RISK FOR INFECTION r/t INADEQUATE PRIMARY DEFENSE AEB SURGICAL INCISION

ASSESSMENT

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS


S: Ø

O: The client

manifested the

following:

Presence of

surgical

incision on the

CTT site at

left anterior

posterior area

The client may

manifest the

following:

Decreased

tissue

perfusion

Decreased

wound

healing time

Nutritional

imbalances

Risk for

infection r/t

impaired

immunity

secondary to

DM

Since DM is

being faced by the

client as one of

the major

diseases, there is

impairment in the

mobilization of

WBC into the site

of infection due to

the viscous

consistency of the

blood. Also,

hyperglycemia is

a conducive

environment for

pathogens to

flourish and with

the presence of an

incision site, there

is a portal of entry

for microbes thus

predisposing the

client to acquire

infection

Short term:

After 4 hours

of nursing

interventions,

the client will

identify

interventions to

prevent or

reduce risk of

infection

Long term:

After 3 days of

nursing

interventions,

the client will

be free from

any signs and

symptoms of

infection

1.Note risk factors

for occurrences of

infection in the

incision

2.Observe for

localized sign of

infection at insertion

sites of surgical

incision

3.Stress proper hand

hygiene by all

caregivers between

therapies and clients

4.Maintain adequate

hydration

5.Provide regular

urinary catheter and

genital care

1.To help the

client identify

the present risk

factors that

may add up to

the infection

2.To evaluate

if the character,

presence and

condition of

the presence of

infection

3.A first line

defense against

health care

associated

infections

4.To avoid

bladder

distention and

urinary stasis

5.To reduce

risk of

ascending

Short term:

The client shall

have identified

interventions to

prevent or

reduce risk of

infection

Long term:

The client shall

have been free

from any signs

and symptoms

of infection

183

6.Make health

teachings especially

in identification of

environmental risk

factors that could add

up on infection

7.Recommend

routine body shower

or scrubs, as ordered

8.Administer/monitor

medication regimen

urinary tract

infection

6.To help the

client

modify/change/

avoid some of

the

environmental

factors present

which could

reduce the

incidence of

infection

7.To prevent

bacterial

colonization

8.To determine

effectiveness

of therapy or

presence of

side effects

184

CONSTIPATION r/t DECREASE PHYSYCAL ACTIVITY

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES INTERVENTIONS RATIONALE EXPECTED

OUTCOMES

S > Ø

O:The client

manifested:

Weakness

Immobility

Fatigue

Acute pain

The client may

manifest:

Abdominal

pain

Change in

bowel patterns

Decreased

frequency and

stool volume

Straining and

possibly pain

during

defecation

Iinability to

increase intra-

abdominal

pressure

Constipation

r/t decrease

physical

activity

Constipation is the

decrease in normal

frequency of

defecation. It

occurs when the

movement of feces

through the large

intestine is slow,

thus allowing time

for additional re-

absorption of fluid

from the large

intestine

accompanied by

difficult or

incomplete

passage of stool

and/or passage of

excessively hard

and dry stool. Due

to decrease

physical activity

the movement of

feces through the

large intestine is

Short Term: After 4-6 hours

of nursing

interventions,

the client will

verbalize

understanding

of etiology and

appropriate

interventions or

solutions for

individual

situation in

order to initiate

proper bowel

movement.

Long Term:

After 1-2 days

of nursing

interventions,

the client will

establish normal

pattern of bowel

elimination

1. Assess client‘s

condition

2. Instruct client to

increase fluid intake

as indicated

3. Instruct client to

eat foods rich in

fiber such as bread,

whole grains. Fruits

and vegetables

4. Encourage

ambulation within

individual‘s ability

5. Provide privacy

and routinely

1. To determine

what

intervention will

be perform

2. To facilitate

absorption of

sufficient

amount of fluid

in the intestines

3. To facilitate

expulsion of soft

consistency of

stools. Fiber

absorbs water

which add

softness to stools

4. To facilitate

feces expulsion

5. So client can

Short Term:

The client shall

have verbalized

understanding of

verbalize

understanding of

etiology and

appropriate

interventions or

solutions for

individual situation.

Long Term:

The client shall

have established

normal bowel

functioning

185

low, thus, the may

client manifest

difficulty or

decrease

frequency in

defecation.

scheduled time for

defacation

6. Identify specific

actions to be taken if

problem recurs

7. Administer

medication as

ordered

respond to the

urge to defacate

6. To promote

timely

intervention,

enhancing

client‘s

independence

7. To facilitate

expulsion of soft

stools

186

IMPAIRED PHYSICAL MOBILITY r/t WEAKNESS

ASSESSMENT

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES

NURSING

INTERVENTIONS

RATIONALE

EVALUATION

S: Ø

O: The client

manifested:

Slowed

movement

Limited range

of motion

Needs

assistance when

moving

Body weakness

DOB after

activity

Client may manifest:

Difficulty in

turning

Difficulty

initiating

movement

Postural

instability

during

Impaired

physical

mobility

related to

weakness

Bronchiectasis, as

defined is the

permanent dilation

of bronchial tree

caused by

destruction of the

muscle and elastic

tissues, will result

to airway

obstruction and

impaired clearance

of secretions. This

will also entail

impairment in the

client‘s normal

respiratory patterns

and effort that is

needed to supply

the body with the

necessary oxygen

concentration,

When the client‘s

mechanism to

compensate for

changing oxygen

SHORT

TERM:

After 3 hours of

nursing

Interventions the

client will

demonstrate a

change in

behavior in the

health teachings

provided.

LONG TERM:

After 8 hours of

nursing

Interventions the

client will

manifest an

improvement on

physical

mobility.

1. Assist the client in

positioning self

2. Instruct the client

to use side rails, over

head trapeze, roller

pads in moving

3. Schedule

activities with

adequate rest periods

during the day

4. Encourage

participation in self

care occupational

diversional or

recreational

activities

1. To prevent

the formation

of pressure

sores or bed

sores

2. For position

changes and

transfers

3. Limits

fatigue,

conserves

energy and can

enhance coping

ability

4. Promotes

well being and

maximizes

energy

production

SHORT TERM:

The client shall

demonstrated a

change in

behavior in the

health teachings

provided.

LONG TERM:

The client shall

have manifested

an improvement

on physical

mobility.

187

performance of

ADLs

Bed sores

demands is

impaired, the body

will not be supplied

with sufficient

oxygen to support

normal functioning.

When left

unmanaged, the

client will not be

able to resume his

daily activities due

to weakness and

easy fatigability

caused by oxygen

supply and demand

mismatch.

Furthermore,

client‘s condition

required insertion

of CTT which will

further impede

client‘s ability to

move due to

equipment

placement.

5. Instruct and

demonstrate the use

of adjunctive

devices such as

walkers, canes

6. Instruct the client

to provide regular

skin care to include

pressure area

management

7. Support affected

body parts or joints

using pillows, rolls,

foot supports

8. Administer

medications prior to

activities as needed

for pain

5. Promotes

independence

and enhances

safety

6. To maintain

the optimal

skin integrity

and to prevent

the formation

of pressure

sores

7. To maintain

position of

function and

reduce risk of

pressure ulcers

8. To permit

maximal effort

and

involvement in

activities

188

RISK FOR IMPAIRED GAS EXCHANGE R/T ALVEOLAR-CAPILLARY CHANGES

ASSESSMENT

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES

NURSING

INTERVENTIONS

RATIONALE

EVALUATION

S: The client may

verbalize dyspnea and

headache upon

awakening

O: The client may

manifest:

Restlessness

Abnormal

breathing

The client may also

manifest:

Confusion

Irritability

Cyanosis

Diaphoresis

Tachycardia

Risk for

impaired gas

exchange

related to

alveolar-

capillary

changes

An impairment in

gas exchange

means that there is

an excess or deficit

in oxygenation and

carbon dioxide

elimination at the

alveolar-capillary

membrane. As a

result of the

procedure that has

undergone, which

was lobectomy,

there is an

alteration in the

respiratory function

of the client

Short Term:

After 1-2 hours

of nursing

interventions, the

client will be

able to

participate in the

treatment

regimen such as

breathing

exercises with

the use of

spirometer

within level of

ability

Long Term:

After 2-3 days of

nursing

interventions, the

client will be

able to

demonstrate

improved

ventilation and

adequate

1. Note respiratory

rate, depth, use of

accessory muscles

and areas of pallor

2. Auscultate breath

sounds, note areas of

decrease breath

sounds as well as

fremitus

3. Elevate head of

bed and position

client appropriately

4. Encourage

frequent changes in

position and deep

breathing and

coughing exercises,

use incentive

spirometry

5. Provide

supplemental

oxygen at lowest

1. To assess

level of

compromise

2. To evaluate

respiratory

status

3. To maintain

airway patency

4. To promote

optimal chest

expansion and

drainage of

secretions

5. To improve

existing

deficiencies

Short Term:

The client shall

have been able to

participate in the

treatment regimen

such as breathing

exercises with the

use of spirometer

within level of

ability

Long Term:

The client shall

have been able to

demonstrate

improved

ventilation and

adequate

oxygenation of

tissues by ABG‘s

within client‘s

189

oxygenation of

tissues by

ABG‘s within

client‘s normal

limits and

absence of

symptoms of

respiratory

distress

concentration as

indicated

6. Encourage

adequate rest and

limit activities to

within client

tolerance

7. Keep

environment

allergen and

pollutant free

8. Discuss

implication of

smoking related to

the illness condition

9. Administer

medications as

indicated such as

analgesics that

restricts optimal

respiratio

6. Helps limit

oxygen needs

and

consumption

7. To reduce

irritant effect

of dust and

chemicals on

airways

8. To promote

wellness

9. To help

improve client

respiratory

efforts

normal limits and

absence of

symptoms of

respiratory

distress

190

ACTIVITY INTOLERANCE R/T POSTOPERATIVE THORACOTOMY, LOBECTOMY AND PRESENCE OF CTT

ASSESSMENT

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES

NURSING

INTERVENTIONS

RATIONALE

EVALUATION

S: Client may verbalize

reports of fatigue

O: Client may manifest

abnormal heart rate

and blood pressure

response to activity

Client may also

manifest:

Pressure ulcers

Weakness

Pallor

Cyanosis

Constipation

Activity

intolerance r/t

postoperative

thoracotomy,

lobectomy and

presence of ctt

Activity intolerance

is an insufficient

physiological or

psychological

energy to endure or

complete required

or desired daily

activities. Given

that client have

undergone

lobectomy, there is

a decrease in the

lung capacity that

decreases oxygen

availability to the

cells. Also, with the

incision site giving

discomfort, the

client would rather

stay in one position

of comfort that

moving around and

feeling the pain of

the affected area.

Prolonged bed rest

as well can promote

Short Term:

After 1-2 hours

of nursing

interventions, the

client will be

able to use

identified

techniques to

enhance activity

intolerance such

as gradual

increase in

activity within

the client‘s limits

Long Term:

After 2-3 days of

nursing

interventions, the

patient will be

able to report

measurable

increase in

activity tolerance

1. Evaluate client‘s

actual and perceived

limitations, and

severity of deficit in

light of usual status

2. Note client‘s

reports of pain,

fatigue, weakness

difficulty

accomplishing task

3. Ascertain ability

to stand and move

about, and degree of

assistance necessary

or use of equipment

4. Adjust activities,

1. Provides

comparative

baseline and

information

about needed

education or

interventions

regarding

quality of life

2. Symptoms

may be result

or contribute to

intolerance of

activity

3. To

determine

current status

and needs

associated with

participation in

needed/ desired

activities

4. To prevent

Short Term:

The patient shall

have been able to

use identified

techniques to

enhance activity

intolerance such

as gradual

increase in

activity within the

client‘s limits

Long Term:

The patient shall

have been able to

report measurable

increase in

activity tolerance

191

activity intolerance

and this may be due

to the existence of

pain.

reduce intensity or

discontinue activities

that cause undesired

physiological

changes

5. Increase

exercise/activity

gradually

6. Plan care to

carefully balance

rest periods with

activities

7. Promote comfort

measures and

provide relief of pain

8. Provide and

monitor response to

supplemental

oxygen, medication

and changes in

treatment regimen

overexertion

5. To conserve

energy

6. To reduce

fatigue

7. to enhance

ability to

participate in

activities

8. To assist

client to deal

with

contributing

factors and

manage

activities

within

individual

limits

192

FATIGUE r/t ALTERED OXYGEN SUPPLY AND DEMAND

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS


S: “Mapapagal ku

patse magsalitaku” (

I get easily tired even

when talking) as

verbalized by the

client

O: The client

manifested the

following:

needs

assistance

with changing

position and

activity with

good muscle

strength

Lethargy

With good

capillary refill

less than 2

seconds

with regular

Fatigue related

to altered

oxygen supply

and demand

Fatigue is an

overwhelming,

sustained sense of

exhaustion and

decreased capacity

for physical and

mental work at

usual level. This

problem has

materialized due to

the impairment in

the respiratory tract

that deceases the

ability of the body

to acquire enough

oxygen needed for

metabolism so as to

be able to perform

activities desired.

Short term:

After 4 hours of

nursing

interventions, the

client will

identify basis of

fatigue and will

demonstrate

way/interventions

to prevent it

Long term:

After 3 days of

nursing

interventions, the

client will

perform activities

of daily living

and participate in

desired activities

at level of ability

1.Assess vital signs

2.Determine

presence/degree of

sleep disturbances

3.Assess the client‘s

ability to perform

activities of daily

living

4.Assist the client to

develop a schedule

for daily activity and

rest

5.Obtain SO‘s

1.To evaluate fluid

status and

cardiopulmonary

response to activity

2.Fatigue can be a

consequence of,

and/or exacerbated

by, sleep deprivation

3.Fatigue can limit

the person‘s ability

to participate in self-

care and perform his

role responsibilities

4.A plan that

balances periods of

activity with periods

of rest can help the

client complete

desired activities

without adding to

levels of fatigue

5.To assist in

Short term:

The client shall

have identified

basis of fatigue

and demonstrated

way/interventions

to prevent it

Long term:

The client shall

have performed

activities of daily

living and

participated in

desired activities

at level of ability

193

depth and

rhythm of

breathing

with use of

accessory

muscle

The client may

manifest the

following:

Disinterest in

surroundings

description of

fatigue

6.Note daily energy

patterns

7.Esatablish realistic

activity goals with

client and encourage

forward movement

8. Plan interventions

to allow individually

adequate rest periods

9.Instruct client in

ways to monitor

responses to activity

and significant

signs/symptoms

10.Assist client to

identify appropriate

coping behaviors

11.Encourage to

nutritionally dense,

easy to prepare and

evaluating impact on

client‘s life

6.To help in

determining

pattern/timing of

activity

7.To enhance

commitment to

promoting optimal

outcomes

8.To maximize

participation

9.To indicate the

need to alter activity

level

10.To promote sense

of control and

improves self-

esteem

11.to promote

energy

194

consume foods and

avoidance of

caffeine and high

sugar foods and

beverages, as

ordered

12.Refer to

occupation or

physical therapy for

programmed daily

exercise, as ordered

13.Provide

supplemental

oxygen, as ordered

14.Review

medication

use/regimen

12.To improve

stamina, strength,

and muscle tone and

to enhance sense of

well-being

13.To reduce

oxygen available for

cellular uptake and

contributes to

fatigue

14.To determine

medications that

cause and/or

exacerbate fatigue

195

C. IMPLEMENTATION

1. MEDICAL MANAGEMEN

a. IVF, OXYGEN THERAPY, NEBULIZATION, INSULIN DRIP, DOPAMINE DRIP, CTT,

NEPHROSTERIL, FOLEY CATHETER, BT

Medical

Management

Date ordered

Date Performed

Date Changed

General Description Indications Client’s Response to

Treatment

PNSS 1L x 80

cc/hr

DO: 11/03/13

11/04/13

11/05/13

DP: 11/03/13

11/04/13

11/05/13

DC: 11/05/13

Shifted to D5 LRS

1L x 80cc/hr

An aqueous solution of 0.9

percent sodium chloride,

isotonic with the blood and

tissue fluid, used in medicine

chiefly for bathing tissue and,

in sterile form.

It can be used for hydration

since it has minimal or no

effect to tissues and as a

solvent for drugs that are to be

administered parenterally.

The fluid was shifted to D5

LRS, a dextrose (5%)

containing fluid, because the

patient‘s CBG level was 97

mg/dL (11/05/13; 9:00 am)

and the patient was on NPO

The intravenous fluid was

administered properly, with

expected effects achieved,

no untoward reactions, and

the patient neither

experienced dehydration

nor fluid overload.

After shifting the fluid

from PNSS to D5 LRS and

holding mixtard, the

patient‘s CBG level

reached 286 mg/dL.

196

PNSS 1L x 100

cc/hr

DO: 11/06/13

11/07/13

11/08/13

11/10/13

11/11/13

status which may further

result to decrease in blood

glucose levels. Furthermore,

the client was scheduled for

surgery on this given date,

additional glucose will be

needed in order to supply

caloric demands of the body

during stressful events

(surgery).

A day after surgery, PNSS

was resumed to maintain fluid

volume stability without

causing significant changes in

client‘s serum glucose level

since there is now a decrease

The doctor changed the

patient‘s fluid from D5

LRS to PNSS because the

CBG level of the latter

suddenly went up to

abnormally high levels.

11/06/13

6:00 am = 28

4 mg/dL

8:00 pm = 335 mg/dL

11:00 pm = 237 mg/dL


administered properly,

without signs of infiltration

and phlebitis. There were

no untoward reactions. The

patient manifested pitting

197

DP: 11/06/13

11/07/13

11/08/13

11/10/13

11/11/13

DC: 11/11/13

Shifted to PLRS

1L x 100 cc/hr

need for additional glucose.

edema on both upper

extremities, I/O of

868/80cc, and (-) crackles.


Prior the procedure:

Read the doctor‘s order

Check IV label

During the procedure:

Check for patency of tubing

Regulate as ordered

198

After the procedure:

Check IV infusion and amount every 2 hours

Monitor patient for evidence of IV infiltrations and thrombophlebitis.

Check for presence of air in the tubing if there is, remove immediately.

Monitor patient for fluid overload

Medical

Management

Date ordered

Date Performed

Date Changed


Treatment

D5LRS 1L x 80

cc/hr

DO: 11/05/13

DP: 11/05/13

DC: 11/06/13

Shifted to PNSS

1L x 100 cc/hr

These products are sterile,

nonpyrogenic solutions each

containing isotonic

concentrations of electrolytes

(with or without dextrose) in

water for injection. The solutions

containing dextrose and

electrolytes are hypertonic; those

containing only electrolytes are

isotonic.

The IVF of the patient

was shifted from PNSS 1L

x 80 cc to D5 LRS 1L x

80 cc while the on NPO

because the patient‘s CBG

level decreased to 97

mg/dL. It was shifted o a

Dextrose (5%) containing

fluid because of its

glucose content which is

The Hgt level of the

patient increased from

97mg/dL to:

8pm = 335mg/dL

11pm= 237mmg/dL

6am= 284mg/dL

On 11/06/13 (a day after

surgery), it was again

199

still needed by the patient

during surgery and to

prevent hypoglycemia

from occurring.

shifted to PNSS 1L x 80

cc/hr.




Check IV label



Regulate as ordered





Monitor patient for fluid overload.

Record all procedure done

200

Medical

Management

Date ordered

Date Performed

Date Changed


Treatment

PLRS 1L x 100

cc/hr

DO: 11/11/13

11/12/13

11/13/13

DP:

11/12/13

11/13/13

DC: 11/13/13

Shifted to PNSS

1L x KVO

Lactated Ringer's is sterile,

nonpyrogenic and is used to

supply water

and electrolytes (e.g., calcium,

potassium, sodium, chloride). It

contains no bacteriostatic or

antimicrobial agents. This

product is intended for

intravenous administration in a

single dose container. It is also

used as a mixing solution

(diluent) for other IV

medications

Lactated Ringer's provides

electrolytes and is a

source of water for

hydration. It is capable of

inducing diuresis

depending on the clinical

condition of the patient.

This solution also contains

lactate which produces a

metabolic alkalinizing

effect.



with expected effects

achieved, no untoward

reactions, and the patient

neither experienced

dehydration nor fluid

overload with intake of

2640cc and output of

2620cc.

http://www.medicinenet.com/electrolytes/article.htm

201

PLRS 1L x 100

cc/hr

DO: 11/13/13

DP: 11/13/13

DC: 11/14/13

Terminated IVF

PNSS was terminated and

administration of PLRS

was resumed for the same

purpose.



with expected effects

achieved, no untoward

reactions, and the patient

neither experienced

dehydration nor fluid

overload.




Check IV label



Regulate as ordered





Monitor patient for fluid overload.

202

Nursing Responsibilities for Oxygen Therapy

Before:

Identify the patient by asking his name. Identify oneself to allow for a good working relationship.

Explain the importance of the procedure to the significant other.

Medical

Management or

Treatment

Date Ordered

Date Given

Date Change

General Description Indication or Purpose Client’s Response

OXYGEN

THERAPY (3

LPM via face

mask)

DO: 11/05/13

DP: 11/05/13

DC: 11/08/13

Oxygen therapy is the delivery

of extra oxygen to the lungs. It is

done to increase the level of

available oxygen in the body.

It is to improve oxygen

flow to major organs and

tissues, such as the heart,

lungs and brain, and to

decrease the work of

breathing. Oxygen is used

in situations such as

shortness of breath,

cardiac arrest and heart

attacks.

As a standard operating

procedure, supplemental

oxygen is given to patients

undergoing any surgical

operation mainly because

anesthesia depresses

respiration thus justifying

he need for oxygen

therapy. As a result, the

patient did not manifest

any signs of cyanosis.

203

During:

Assess the general condition of the patient.

Review recorded vital signs.

Administer nebulization to liquefy secretions, as ordered.

Position client in a comfortable position, preferably sitting or in an orthopneic position.

Ready an emesis basin for expectoration.

Instruct client to inhale as much air as possible, then, exhale forcefully, allowing secretions to be expectorated.

Instruct client to practice coughing whenever secretions are about to be expelled.

After:

Document the time the exercises were performed.

Note color of secretions to note the progress of the disease. Report hematuria, and the like as soon as possible.

If specimen is needed, obtain specimen and send to laboratory for testing immediately.

Allow client to practice oral hygiene after exercising.

204

NEBULIZATION

Medical

Management

Date ordered

Date Performed

Date Changed


Treatment

Nebulization with

duavent/combivent

every 6 hours

DO: 11/04/13

DP: 11/04/13 to

11/10/13

DC: 11/11/13

terminated

Nebulization is the process of

medication administration via

inhalation. It utilizes a nebulizer

which transports medications to

the lungs by means of mist

inhalation. It aids bronchial

hygiene by restoring and

maintaining mucus blanket

continuity, hydrating dried

secretions, promoting secretion

expectoration, humidifying

inspired oxygen, and delivering

drugs

Nebulization therapy is

used to deliver

medications along the

respiratory tract and is

indicated to relieve

client‘s chest tightness

and respiratory congestion

due to excessive and thick

mucus secretions, and

bronchiectasis.

Combivent is a

combination of albuterol

and ipratropium.

Albuterol and ipratropium

The treatment was

administered properly and

effectively. The patient

did not manifest any

untoward reaction and no

signs and symptoms of

respiratory distress were

further noted. During the

entire course of therapy,

crackles, chest pain (on

surgical site) and use of

accessory muscles upon

inspiration and expiration

were noted. On 11/11/13,

the patient did not

205

are bronchodilators that

relax muscles in the

airways and increase air

flow to the lungs.

Duavent is given as

management of reversible

bronchospasm associated

w/ obstructive airway

diseases e.g. bronchial

asthma, COPD.

manifest any signs and

symptoms of respiratory

distress or difficulty of

breathing (respiratory rate

within normal range), no

crackles were noted, and

chest pain (on surgical

site) was minimal.



Verify the doctor‘s order

Check client‘s identity, drug label, and dosage

Prepare necessary equipment

Assess patient‘s vital signs and respiratory status

Assist patient in a sitting or high-fowler‘s position

Turn on machine and check for outflow port for proper misting

206


Encourage the patient to take slow, even breath to derive maximum benefit

Monitor for over hydration, especially in patients with delicate fluid balance

Stay with the patient during the procedure

Watch out for any untoward reaction

Depending on the equipment, adjust flow rate, or change the nebulizer cup or tubing according to hospital policy


Reassess patient‘s vital signs and respiratory status

Perform suctioning as ordered or chest physiotherapy as appropriate

Encourage the patient to cough


207

INSULIN DRIP

Medical Management

Date ordered

Date Performed

Date Changed


Treatment

Insulin drip 100 “u” HR

in 100 cc of PNSS @ 10

“u” per hour.

DO: 11/6/13

DP: 11/6/13

Humulin R (HR) is a rapid

acting insulin. The

primary activity of insulin

is regulation of glucose

metabolism. Insulin binds

to insulin receptors on

muscle and adipocytes,

and lowers blood glucose

by facilitating the cellular

uptake of glucose. Insulin

simultaneously inhibits

output of glucose from the

liver

Insulin drip was ordered

to provide continuous

control of CBG level.

8:00 pm = 423mg/dL

9:00 pm = 369mg/dL

10:00 pm = 341mg/dL

11:00 pm = 312mg/dL

The CBG levels of the

patient was persistently

elevated, so the doctor

ordered increase in

regulation of insulin drip

from 10 ―u‖ /hr to

12‖u‖/hr

208


in 100 cc PNSS at 15

“u”/hr

Insulin Drip 100 “u”

HR in 100 cc of PNSS x

5 “u”/hr

DO: 11/07/13

DP: 11/07/13

DO: 11/07/13

DP: 11/07/13

This was ordered because

the CBG level of the

patient was persistently

elevated, the regulation

was increased from 10

―u‖/hr to 15 ―u‖/hr

The insulin drip was

resumed to 5 ―u‖/hr

because of the CBG level

was elevated, from

114mg/dL from time of

holding the drip to:

4:00 am = 147mg/dL

5:00 am = 137mg/dL

6:00 am = 226mg/dL

The CBG levels of the

patient went down to:

12:00mn= 254mg/dL

1:00am= 208mg/dL

2:00am= 181md/dL

The drug was temporarily

stopped at 3:00 am

because the CBG of the

patient went down to

114mg/dL

The result of the CBG

levels went down from

226 to 210mg/dL with

continuous insulin drip at

5 ―u‖/hr.

209

Insulin drip 100 “u”/hr

in 100cc PNSS x 12

“u”/hr


+ 100 cc PNSS x 5

“u”/hr

DO: 11/07/13

DP: 11/07/13

DO:11/07/13

DP: 11/07/13

(11am,1pm,2pm)

The regulation was

increased from 5 ―u‖ to 12

―u‖ because the CBG

result of the patient went

downt to:

8:00 am = 199mg/dL

9:00am = 165mg/dL

8:00 am = 144mg/dL

The regulation was

decreased from 12 ―u‖ to

5 u‖‖ because D50-50 1

vial + HR 10 ―u‖ x 3

doses was also given to

help the patient manage

CBG level within normal

limits and prevent sudden

drop in CBG levels.

The CBG result of the

patient at 11:00 am went

up to 178mg/dL with the

help of administration of

D50-50 1 vial + HR 10

―u‖ x 3 hours, 1 hour

interval.

The CBG result of the

patient at 12:00 MN was

182mg/dL

210


+ 100 cc PNSS x 13

“u”/hr


in 100 cc PNSS at 8

“u”/hr

Hold Insulin Drip

DO: 11/07/13

DP: 11/07/13

(3pm to 5pm)

DO: 11/07/13

DP: 11/07/13

DO: 11/08/13

DP: 11/08/13

The regulation was

increased from 5 ―u‖/hr to

13 ―u‖/hr because the

CBG of the patient at 2:00

pm went to 265mg/dL

The regulation was

decreased from 13 ―u‖ to

8 ―u‖ because the CBG of

the patient at 9:00 pm was

86mg/dL

Insulin drip was

temporarily stopped due

to sudden decline in

client‘s Hgt level, 78mg/d

This was ordered due to

increased Hgt level,

223mg/dL

After changing regulation,

the CBG went down to:

3:00 pm = 185mg/dL

4:00 pm = 146mg/dL

The CBG of the patient

went up from 86 to 132

mg/dL

After 6 hours of

terminating insulin drip,

the patient Hgt level

increased to 200mg/dL

After 6 hours of

administration, the Hgt

level slightly declined to

221mg/dL

211




Check client‘s identity, drug label, and dosage and have another nurse to countercheck

Have a baseline blood glucose level



Ensure proper regulation upon administration

Check BP, I & O ratio, and blood glucose level every hour

Monitor for hypoglycemia during the time of its peak of action

Secure IV Glucagon at bedside in case of severe hypoglycemia

Check IV site and observe for infiltration of medication


Reassess client‘s BP, I & O ratio, and blood glucose level


212

D5050

Medical

Management

Date ordered

Date Performed

Date Changed


Treatment

D5050 DO: 11/06/13

DP: 11/06/13 and

11/07/13

This fluid is considered to be

hypertonic, is a caloric agent

that is able to rapidly increase

the blood glucose level for

emergency care to treat

hypoglycemia and also has an

osmotic diuretic ability.

Mainly indicated for

patients who are

hypoglycemic as well as

with those who have an

altered level of

consciousness, coma of an

unknown etiology and

seizure disorders of

unknown etiology also. But

this fluid can also be given

to reduce serum potassium

when insulin is given

subsequently by shifting

potassium extracellularly

into intracellularly.

From 03/05/13 to 03/07/13,

the client‘s serum studies

revealed hyperkalemia. In a

procedure known as

temporization where insulin

is given to induce a

secondary effect which is to

facilitate cellular reuptake of

excess extracellular

potassium, D5050 is given to

counteract its primary effect

of decreasing blood sugar

level (possible

hypoglycemia).

213




Check IV label



Regulate as ordered





Monitor patient‘s HGT and serum potassium

214

DOPAMINE DRIP

Medical

Management

Date ordered

Date Performed

Date Changed


Treatment

Dopamine Drip

5mcg/kg/min

DO: 11/05/13

DP: 11/05/13

DC: 11/06/13

Decreased to 3

mcg/kg/min

Dopamine Hydrochloride

Injection, USP is a clear,

practically colorless, aqueous,

additive solution for intravenous

infusion after dilution.

Dopamine (dopamine

hydrochloride) HCl, a naturally

occurring catecholamine, is

an inotropic vasopressor agent.

This medication was used

to improve kidney blood

supply especially in the

case of the client who has

renal impairment (CKD

Stage III) so as to aid in

the elimination/excretion

of anesthetic by-products

and other medications

given during surgery.

During surgery and few

days of post-operative

period, no complications

related to improper

excretion or retention of

medications/anesthetic

agents were reported or

noted. The patient

responded by displaying

BP within his normal

range (140/70 mmHg), but

the patient manifested

ECG changes as

manifested by sinus

bradycardia.

http://www.rxlist.com/script/main/art.asp?articlekey=20210

http://www.rxlist.com/script/main/art.asp?articlekey=38653

215

Dopamine Drip

3mcg/kg/min

DO: 11/06/13

DP: 11/06/13

DC: 11/08/13

Hold

A day after the surgery,

the doctor ordered a

decrease in dose due to

the possible detrimental

effects if used

continuously (sinus

bradycardia,

hypertension).

Patient displayed vital

signs within normal range.




Check client‘s identity, drug label, and dosage and have another nurse to countercheck

Check client‘s Blood Pressure, Heart Rate, Urine output (and other available hemodynamic parameters)

216



Ensure proper regulation upon administration

Monitor Blood Pressure, Heart Rate, and Urine Output

Monitor for any untoward reaction

Assess IV site for possible infiltration


Reassess client‘s BP, I & O ratio, and blood glucose level

Do not abruptly discontinue drug, begin downward titration as ordered by the physician


217

HAESTERIL

Medical

Management

Date ordered

Date Performed

Date Changed


Treatment

Haesteril DO: 11/05/14

DP: 11/05/14

Haesteril is a brand name for

Pentastarch, a subgroup of

hydroxyethyl starch that is used for

fluid resuscitation.

Therapy and prophylaxis

of volume deficiency

(hypovolemia) and shock

(volume replacement

therapy) in connection

with surgery (lobectomy).

With the surgical

procedure made, the client

did not manifest any signs

of hypovolemia or

dehydration and the

standby order for blood

transfusion was not

initiated because it was

necessitated.




Check IV label

218



Regulate as ordered





Monitor patient for fluid overload

219

NEPHROSTERIL

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to

medication and actual

side effect

Generic Name:

Nephrosteril

Brand Name:

Nephrosteril

infusion 7%

Date ordered:

11-07-13

Date given:

11-07-13

Date changed:

11-09-13

(8:15am)

500ml x 12°

OD single Dose

500ml x 12°

OD

Nephrosteril is

parenteral nutrition for

kidney function

The amino acids

contained in

Nephrosteril are all

naturally occurring

physiological

compounds. As with

the amino acids derived

from the ingestion and

assimilation of food

proteins, parenterally

Nephrosteril was given

to the patient to

facilitate parenteral

nutrition in kidney and

in haemofiltration and

haemodialysis. Also,

the patient‘s creatinine

level on 11/07/13 (6:27

am) is 3.29mg/dL.

Nephrosteril is given

because the patient has

low output level

The patient‘s creatinine

level goes up

(3.61md/dL) and

abnormal I&O

(3200/880) with doctor

notes of Unknown

cause of CKD @ Nov.

7 (10:40am).

Patient‘s creatinine

level was within the

normal range

(1.54mg/dL) and I&O

220

administered amino

acids enter the body

pool of free amino

acids and all

subsequent metabolic

pathways.

compare to the intake

level.

of 2030/2000. The

patient did not manifest

any signs and

symptoms of renal

insufficiency but the

drug is still continued.


PRIOR:

Prepare all equipment needed.

Assess for renal impairment.

Check doctors order and follow appropriate administration.

DURING:

May take with or without meals

Obtain regular weight to monitor fluid changes

Note for sign and symptoms of toxicity

Maintain proper drop rate.

AFTER:

Instruct pt to immediately report any nausea, vomiting and chills

221

BLOOD TRANSFUSION

Medical

Management

Date ordered

Date Performed

Date Changed


Treatment

4 “u” of Full

Blood Type O

properly cross-

matched

DO: 10/28/13

DP: Was not

administered

Is the introduction of whole blood

or component of the blood, e.g.

plasma or erythrocytes into venous

circulation.

Transfusion of whole

blood from one individual

to another is indicated for

two main reasons: firstly,

when the volume of blood

within the circulation

system of the patient is

less than that required to

sustain life and, secondly,

when the red blood cells

are deficient either in

quantity or quality.

The order was not

administered, instead,

Haesteril, a plasma volume

expander, was used during

the surgical procedure. Hitt

(2012) and Liumbruno et al

(2009) explains that BT is

indicated if hemoglobin

level has reached below 60-

70 mg/dL where in the

lowest level of hemoglobin

concentration this client had

was 107 mg/dL that did not

necessitate the order to be

executed.

222

Nursing Responsibilities

Before the procedure:

Verify the physician‘s written order and make a treatment card according to hospital policy

Explain the procedure/rationale for giving blood transfusion

Secure consent.

Get patient histories regarding previous transfusion.

Ensure proper blood typing and cross matching.

Using a clean lined tray, get compatible blood from hospital blood bank.

Wrap blood bag with clean towel and keep it at room temperature.

Have another nurse countercheck the compatible blood to be transfused against the crossmatching sheet noting the ABO

grouping and RH, serial number of each blood unit, and expiry date with the blood bag label and other laboratory blood exams

as required before transfusion.

Get the baseline vital signs before transfusion.

Give pre-meds 30 minutes before transfusion as prescribed.

Do hand hygiene before procedure

Prepare equipment needed for BT (IV injection tray, compatible BT set, IV catheter/ needle G 19/19, plaster, torniquet, blood,

blood components to be transfused, Plain NSS 500cc, IV set, needle gauge 18 (only if needed), IV hook, gloves, sterile 2×2

gauze or transplant dressing, etc.)

223


Maintain asceptic technique

Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the needle, from BT administration ser and secure with

adhesive tape.

Close the roller clamp of IV fluid of Plain NSS and regulate to KVO while transfusion is going on.

Transfuse the blood via the injection port and regulate at 10-15gtts/min initially for the first 15 minutes of transfusion and refer

immediately to the MD for any adverse reaction.

Observe/Assess patient on an on-going basis for any untoward signs and symptoms such as flushed skin, chills, elevated

temperature, itchiness, urticaria, and dyspnea. If any of these symptoms occur, stop the transfusion, open the IV line with Plain

NSS and regulate accordingly, and report to the doctor immediately.

Ensure that blood transfusion is completed within 4 hours (from the time the blood was withdrawn from the bank)

When blood is consumed, close the roller clamp, of BT, and disconnect from IV lines then regulate the IVF of plain NSS as

prescribed.


Continue to observe and monitor patient post transfusion, for delayed reaction could still occur.

Reasses Hgb and Hct, bleeding time, serial platelet count within specified hours as prescribed and/or per institution‘s policy.

Discard blood bag and BT set and sharps according to hospital policy.

Fill-out adverse reaction sheet as per institutional policy.

224

Medical

Management

Date ordered

Date Performed

Date Changed


Treatment

Connect

Anterior and

Posterior CTT

bottles to

emerson pump

at 20 mmHG

Maintain

Anterior and

Posterior CTT

DO: 11/05/13

DP: 11/05/13

DC: 11/08/13

Removed

Emerson pump

DO: 11/08/13

DP: 11/08/13

DC: 11/09/13

Chest tube thoracostomy is done to

drain fluid, blood, or air from the

space around the lungs.

Chest drains are inserted to remove

pathological collections of air or

fluid in the pleural space, to allow

the re-creation of the essential

negative pressures in the chest, and

to permit complete expansion of

the lung, thereby restoring normal

ventilation.

To drain air on the

anterior CTT and to drain

fluid and blood on the

posterior CTT; used to

drain secretions and air

post-lobectomy.

The patient responded to

treatment well and did not

manifest any signs and

symptoms of respiratory

distress.

Intermittent fluctuation

and periodic bubbling

were observed.

Good fluctuation and (-)

bubbling were observed.

225

Maintain

Posterior CTT

Anterior CT

removed

DO: 11/09/13

DP: 11/09/13

DC: 11/14/13

Posterior CTT

removed

Good fluctuation and (-)

bubbling were observed.



Verify consent

Prepare equipment

Assess patient‘s knowledge on procedure; provide clarifications if there are questions.

Position client as appropriate (upright or side-lying)


Assist with tube insertion as needed

226

Apply local anesthetic as per doctor‘s order

Instruct patient to relax and breathe slowly during inspiration


Once tube is inserted and secured, check for fluctuations and bubbling


Assess respiratory status every 4 hours

Instruct patient to perform deep breathing and coughing exercises.

Keep the collection apparatus below the level of the chest

Maintain a closed system, Tape all connections, and secure the

chest tube to the chest wall

Place CTT bottles on a secured area

Check tubes frequently for kinks or loops

Instruct patient to perform deep breathing and coughing exercises.

Measure drainage every 8 hours, marking the level on the

drainage chamber.

Periodically assess water level in the suction control chamber,

adding water as necessary.

When the chest tube is removed, immediately apply a sterile

occlusive petroleum jelly dressing


227

FOLEY CATHETER

Medical

Treatment

Date Ordered

Date Started

Date Removed

General Description

Indication or Purpose

Client’s response to

treatment

Foley Catheter

DO: 11/05/13

DS: 11/05/13

DR: 11/08/13

An indwelling urinary catheter is

one that is left in the bladder. You

may use an indwelling catheter for

a short time or a long time.

An indwelling catheter collects

urine by attaching to a drainage

bag. A newer type of catheter has

a valve that can be opened to

allow urine to flow out.

Urinary output is also a sensitive

indicator of volume status and

renal perfusion.

By inserting a Foley

catheter, you are gaining

access to the bladder and

its contents. Thus

enabling you to drain

bladder contents,

decompress the bladder,

obtain a specimen, and

introduce a passage into

the GU tract.

Since the patient is post-

surgery, there has been a

change in the bladder

The patient’s urine was

able to drain smoothly on

the foley catheter without

obstruction.

228

function of the patient

that may lead to urinary

retention. Hence, a

routine foley catheter as

per hospital protocol is

needed after surgery.


Before:

• Inform patient of any interventions you intend to carry out and gain consent prior.

• Offer reassurance as necessary and allow patient to verbalize concerns or queries.

• Ensure good hygiene measures are taken to prevent infection ascending the Catheter tubing.

During:

• Regularly check tubing to ensure no erosion, kinks or occlusions are present that could prevent good urine flow.

• Ensure catheter bag is changed twice weekly to prevent infection.

• Ensure catheter tubing is kept away from skin to prevent friction sores on skin.

After:

• Monitor urine output frequently and document appropriately, i.e. Fluid Balance

Chart. Inform Doctor if urine output <0.5 ml/kg/hr.

• Ensure catheter is replaced after 12 weeks if still in situ.

• Monitor bowel movements and document frequency to ensure constipation does not affect patency of catheter

229

B. Drugs

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Cefepime

Brand Name:

Cepiram

Date ordered:

11-03-13

Date given:

11-03-13

to

11-09-13

Date stopped:

11-09-13

1gm IV q 12O

ANST (-)

General Action:

Anti-infectives

Functional

Classification:

Fourth Generation

Cephalosporin

Mechanism of action:

Cefepime has

antibacterial activity

against both gram-

negative and gram-

positive pathogens

including those

Cefepime was given to

treat

Bacterial infections

caused by

Staphylococcus aureus

and other

microorganisms like

Streptococcus

pyogenes, E. coli and

Klebsiellapneumoniae.

Moreover it was

indicated for the

treatment of susceptible

With the use of this

medication, the patient

responded well to

treatment, further

infections were

prevented and did not

experience any adverse

reactions of the drug.

The patient showed

improvement in

condition AEB

decreased respiratory

infection such as

230

resistant to other B

Lactam antibiotics.

High affinity for the

multiple penicillin-

binding proteins that

are essential for cell

wall synthesis.

infections of the lower

respiratory tract.

It was given to the

patient to treat

underlying infection in

the lungs and as

prophylaxsis for

upcoming lobectomy.

Also it is given for 7

days to prevent

infection after surgery

and infection on CTT

and to prevent micro

organisms resistance.

absence of fever but

WBC are slightly

above the normal limits

as evidence by WBC:

12.36x109/L and

Neutropils of 0.88, and

within normal range in

Eosinophil of 0.01 on

November 7, 2013. The

drug was shifted into

an oral antibiotic

Cefixime200 mg/tab

BID for continuous

antibiotic therapy and

prevention of

susceptible infections.


Prior:

Assess patient for infection (vital signs, wound appearance, sputum, urine, stool, and WBC) at beginning of and throughout

therapy.

231

Obtain a history before initiating therapy to determine previous use and reactions to penicillins or cephalosporins. Persons with

a negative history of penicillin sensitivity may still have an allergic response.

Obtain specimens for culture and sensitivity before therapy. First dose may be given before receiving results.

Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and

notify the physician or other health care professional immediately if these occur. Keep epinephrine, an antihistamine, and

resuscitation equipment close by in the event of an anaphylactic reaction.

During:

Instruct patient to take medication round the clock and to finish the drug completely as directed, even if feeling better. Advise

patients that sharing of this medication can be dangerous.

Advise patient to report the signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-

smelling stools) and allergy.

After:





Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus.

Advise patient not to treat diarrhea without consulting health care professional. May occur up to several weeks after

discontinuation of medication.

Instruct the patient to notify health care professional if symptoms do not improve.

232

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Cefixime

Brand Name:

Suprax

Date ordered:

11-09-13

Date given:

11-10-13

to

11-13-13

200mg/tab BID

General Action:

Anti-infectives

Functional

Classification:

Third Generation

Cephalosporin


Cefiximeis used to treat

a wide variety of

bacterial infections.

Bactericidal action of

cefixime results from

Cefixime

was indicated for the

treatment of bacterial

infections and other

susceptible infections

of the lower respiratory

tractcaused by certain

microorganisms such

as S.pneumoniae,

S.pyogenes and E.coli.

This was indicated to

With the use of this

medication, further

infection was prevented

and no adverse

reactions were noted as

evidenced by incision

site intact with no signs

of infection. The pt. did

not manifest adverse

reaction of the

medicine AEB absence

of GI upset such as

233

inhibition of cell-wall

synthesis.

the patient because the

patient‘s IV antibiotic

was consumed already

and the doctor ordered

cefixime tablet to

continue antibiotic

therapy to prevent

infection on respiratory

tract and the incision

site for the CTT.

nausea and vomiting,

headache or dizziness.


Prior:

Assess patient for infection (vital signs, wound appearance, sputum, urine, stool, and WBC) at beginning of and throughout

therapy.

Obtain a history before initiating therapy to determine previous use and reactions to penicillins or cephalosporins. Persons with

a negative history of penicillin sensitivity may still have an allergic response.

Obtain specimens for culture and sensitivity before therapy. First dose may be given before receiving results.

234

Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and

notify the physician or other health care professional immediately if these occur. Keep epinephrine, an antihistamine, and

resuscitation equipment close by in the event of an anaphylactic reaction.

During:





After:

Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus.

Advise patient not to treat diarrhea without consulting health care professional. May occur up to several weeks after

discontinuation of medication.

Instruct the patient to notify health care professional if symptoms do not improve.

235

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Brand Name:

Mixtard 30 HM

Date ordered:

11-03-13

Date given:

11-03-13

to

11-05-13

40 units AM

22 units PM

SQ

Type of insulin:

Premixed Insulin

70% Isophane

30% Regular

Onset: 30 minutes

Peak: 2-8 hours

Duration:18 hours


Diabetes is a disease in

which the body does

Mixtard30 was given to

control the glucose

level of the patient.

Since during the CBC

monitoring there is

persistently increase

level of blood glucose .

This drug is also his

maintenance Insulin at

home.

Hyperglycemic events

were managed however

there were still various

alterations in the

patients‘ CBG results

indicating high blood

glucose however

proper orders and

dosing of the type of

insulin (Mixtard 30 or

236

Date changed:

(Date Held)

11-05-13

( ↓ frequency):

11-06-13

11:06 am

Hold mixtard

temporarily

while patient is

on NPO.

20 units now

20 units AM

20 units PM

not produce enough

insulin to control the

blood glucose.

Mixtardis a

replacement insulin

which is identical to the

insulin made by the

pancreas. The active

substance in Mixtard,

insulin human (rDNA),

is produced by a

method known as

‗recombinant

technology‘: the insulin

is made by a yeast that

has received a gene

(DNA), which makes it

able to produce

insulin. The

replacement insulin

Mixtard was hold

during NPO because

because the glucose

level of the patient

went down to 97

mg/dL.

Mixtard 30‘s

decreased to 20 units

because the glucose

level results of the

patient is high (287

Humulin R) to be given

were made to manage

such.

The patient‘s glucose

level went down to 97

mg/dL, thus the doctor

change his IVF from

PNSS to D5LRS

80cc/hr while pt. is on

NPO the CBG of the

patient went up to 286

mg/dL.


level went up to 287

mg/dL and after giving

the dose patient glucose

level goes slightly

237

(Date held)

11-06-13

5:00 pm

Hold mixtard

temporarily

acts in same way as

naturally produced

insulin and helps

glucose enter cells from

the blood.

mg/dL) and the patient

is on insulin drip

already. A stat 20 unit‘s

mixtard was given to

the pt. because his

CBG result at this time

was 287 mg/dL. The

dose was decrease to

20 units in AM and PM

because the pt. was on

insulin drip already

Mixtard was hold

during the

administration of

D5050 1 vial + HR 10

units HR post meal

because the glucose

level results of the

patient is slightly high

down (264 mg/dL) with

the help also of the

Insulin Drip.


level becomes 331

mg/dL after 1 hour.

238

Date resumed:

11-07-13

( ↑frequency):

Date ordered:

11-08-13

(7:50pm)

Date given:

11-08-13 to

11-12-13

20 units AM

20 units PM

44 unit 8AM

22 units 8PM

(194 mg/dL).

Mixtard30 was given to

control the glucose

level of the patient

(226mg/dL @ 6am).

Mixtard dose was

increased to 22 units at

PM because the

glucose level results of

the patient is slightly

high (181 mg/dL) and

activity of patient is

much lesser at night.

And also 44 units at pm

because utilization of

glucose much greater at

morning and

consumption of food.


level of the patient was

managed (165mg/dL @

9am).




the dose patient glucose

level goes slightly

down (113 mg/dL).

Thus, the patient

glucose level was

managed.

239

(↑frequency):

Date ordered:

11-12-13

(9:00am)

Date given:

11-12-13

Date ordered:

11-12-13

(1:20pm)

Date given:

11-12-13

Date ordered:

11-14-13

(7:00pm)

Date given:

11-14-13

48 units AM

24 units PM

6 units STAT

50 units AM

25 units PM

Mixtard dose was

increased as to

maintain the glucose

level of the pt. to near

the normal levels.

Another 6 units of

mixtard was given

because the HGT result

of the pt. was

267mg/dL.

The CBG results of the

pt. is persistently

increased so the dose of

Mixtard was increased.

The patient glucose

level increased to

267mg/dL @ 12nn

which made the doctor

ordered for mixtard stat

dose.

The patient glucose

level was managed

from 267mg/dL @

12nn to 144mg/dL @

6pm.

The patient glucose

level was managed.

240


Prior:

Prepare the equipments required.

Ensure prescription is complete, correct, legible and unambiguous prior to administration.

Check the name of the insulin and dose against the insulin prescription chart in the patient‘s record.

Confirm the identity of the patient prior to administering the insulin.

Check the insulin has not already been administered by someone else.

Wash hands and put on gloves.

Check the blood glucose level according to institution‘s guideline on blood glucose monitoring and record the result prior to

administering the insulin.

Check correct storage of insulin.

Check expiry date.

During:

Prepare the insulin syringe or pen device.

Select injection site - remember to rotate injection sites, never use the same site for consecutive injections.

Insulin should be injected into subcutaneous tissue or soft fat, not muscle. To avoid intramuscular injection, evidence suggests

that raising the skin is best practice and, in some cases, use of a smaller needle will be recommended by the specialist clinician.

Continue to raise the skin and hold the insulin syringe in place for a count of 10 to ensure that the insulin disperses from the

site of the injection.

241

Remove the needle and insulin syringe and dispose as per safe disposal of sharps.

After:

Record the dose, timing and site of insulin injection on the chart.

Report to a supervisor if the patient bleeds from an injection site, insulin appears at the site of an injection or the patient

complains that the injection is painful. If this is the case injection technique may need reassessment.

242

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Brand Name:

Humulin R

Date ordered:

11-05-13

Type of insulin:

Neutral

(regular or soluble)

SHORT ACTING

Onset: 30 minutes

Peak: 1-3 hours

Duration: 8 hours


Humulin R is a fast-

acting form of the

hormone insulin. It

works by helping your

body to use sugar

properly. This lowers

Humulin R was given

for the treatment of

hyperglycemia thus, by

controlling the blood

glucose, the symptoms

and complications of

diabetes are reduced.

It was given to the

patient to rapidly

decrease the patient‘s

fluctuating high

glucose level.

Hyperglycemic events

were managed however

there were still various

alterations in the

patients‘ CBG results

indicating high blood

glucose however

proper orders and

dosing of the type of

insulin (Mixtard 30 or

Humulin R) to be given

were made to manage

such.

243

Date given:

11-05-13

(6:00pm)

(9:10pm)

11-06-13

(12:00nn)

8 units SQ stat

10 units IV stat

12 units IV stat

12 units SQ stat

the amount of glucose

in the blood, which

helps to treat diabetes.

Patient‘s HGT level

was 286mg/dL so the

doctor order 8 ―u‖ of

HR stat SQ.


was 335mg/dL so the


HR stat IV.


was 264mg/dL so the


HR stat IV and 12 ―u‖

of HR stat SQ.

The patient glucose

level increased to

335mg/dL @ 8pm


ordered for HR IV stat

dose @ 9:10pm).


level becomes 237

mg/dL after 3 hour.


level went up to

264mg/dL and after

giving the dose patient

glucose level goes

down (199 mg/dL).

244

11-08-13

(3:15 pm)

(5:20pm)

11-09-13

(12:52 pm)

3 units SQ stat

8 units SQ stat

5 units SQ stat


was 200mg/dL so the


HR stat SQ.


was 213mg/dL so the


HR stat SQ.


was 207mg/dL so the


HR stat SQ.

Thus, the patient

glucose level was

managed.


level slightly goes up

(213 mg/dL) after 2

hours.


level goes down (152

mg/dL) after 2 hours.

The patient glucose

level slightly increased

to 216mg/dL @ 4pm


ordered for additional

HR SQ stat order.

245

(5:20 pm)

11-10-13

(12:40 pm)

(6:12 pm)

6 units SQ stat

6 units IV stat

6 units SQ stat

5 units SQ stat


was 216mg/dL so the


HR stat SQ.


was 223mg/dL so the


HR stat IV and 6 ―u‖ of

HR stat SQ.


was 221mg/dL so the


HR stat SQ.


level was manage (187

mg/dL) after 4 hours.

The patient glucose

level slightly decreased

to 221mg/dL @ 6pm



HR SQ stat order.

The doctor ordered

decreased HGT

monitoring to q 6 in

which the patient‘s

glucose level results

shows increased to

230mg/dL @ 12mn

246

11-11-13

(12:30 am)

(12:30 pm)

(6:43 pm)

3 units SQ stat

6 units SQ stat

6 units IV stat

5 units SQ stat


was 230mg/dL so the


HR stat SQ.


was 290mg/dL so the


HR stat IV and 6 ―u‖ of

HR stat SQ.


was 272mg/dL so the




HR SQ stat order.

The patient glucose

level was managed

(189mg/dL) after 6

hours.

The patient glucose

level slightly decreased

to 272mg/dL after 6

hours which made the

doctor ordered for

additional HR SQ stat

order.




247

HR stat SQ. the dose patient glucose

level goes down (130

mg/dL) with the help

also of Mixtard.


Prior:



Check the name of the insulin and dose against the insulin prescription chart in the patient‘s record.

Confirm the identity of the patient prior to administering the insulin.

Check the insulin has not already been administered by someone else.

Wash hands and put on gloves.

Check the blood glucose level according to institution‘s guideline on blood glucose monitoring and record the result prior to

administering the insulin.

Check correct storage of insulin.

Check expiry date.

248

During:

Prepare the insulin syringe or pen device.

Select injection site - remember to rotate injection sites, never use the same site for consecutive injections.

Insulin should be injected into subcutaneous tissue or soft fat, not muscle. To avoid intramuscular injection, evidence suggests

that raising the skin is best practice and, in some cases, use of a smaller needle will be recommended by the specialist clinician.

Continue to raise the skin and hold the insulin syringe in place for a count of 10 to ensure that the insulin disperses from the

site of the injection.

Remove the needle and insulin syringe and dispose as per safe disposal of sharps.

After:

Record the dose, timing and site of insulin injection on the chart.

Report to a supervisor if the patient bleeds from an injection site, insulin appears at the site of an injection or the patient

complains that the injection is painful. If this is the case injection technique may need reassessment

249

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Tramadol

Brand Name:

Ultram

Date ordered:

11-03-13

Date given:

11-05-13

to

11-07-13

Date ordered:

11-11-13

(4:30am)

Date given:

11-11-13

100 mg very

slow IV q6O x

2 days then shit

to Algesia

500mg IV stat

General Action:

analgesic

Functional

Classification:

Centrally-acting

analgesic


Binds to u-opioid

receptors and inhibits

reuptake of serotonin

and norepinephrine in

the CNS.

Tramadol was

prescribed for the

treatment of the

patient‘s pain on the

operative site

experienced during

respiration and

movement.

Patient complained of

pain on the operative

site

Patient‘s pain on the

operative site was

relieved on November

5-7, 2013. No

complaints of pain

noted and did not

experience any adverse

reactions of the drug.

Patient was relived

from pain on the

operative site and did

not complain of such in

the following days.

250

Brand Name:

Algesia

Brand Name:

Tramal Retard

Date ordered:

11-03-13

Date given:

11-06-13

Date stopped:

11-08-13

Date ordered:

11-08-13

1 tab QID x 3

days then PRN

for pain

100 mg tab TID

Tramadol IV was

shifted to algesia an

oral form of analgesic

to control pain felt of

the pt. in the CTT site.

Tramadol was

prescribed to replace

algesia for continuous

Patient‘s pain was

managed as evidence

by the patient was able

to move slightly, no

guarding reflex and

grimace noted.

Algesia was

discontinued on Nov 8

and was shifted to

tramadol retard because

it was given already for

3 days and no adverse

reactions of the drug

noted.

Patient‘s pain was been

managed as evidence


251


Prior:

Assess type, location, and intensity of pain before and 2–3 hr (peak) after administration.

Assess blood pressure and respiratory rate before and periodically during administration. Respiratory depression has not

occurred with recommended doses.

Date given:

11-08-13

Date ordered:

11-09-13

(12:00 mn)

treatment and

management of the


operative site that is

brought about by an

inflammation due to the

break in the skin.

The doctor ordered stat

Tramal because the pt.

complained of pain in

incision site.


guarding reflex and

grimace noted with

pain scale from 7/10 to

3/10.

The patient‘s pain was

been managed and able

to sleep.

252

Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and

with laxatives to minimize constipating effects.

Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously

received opioids for more than 1 wk; may cause opioid withdrawal symptoms.

Prolonged use may lead to physical and psychological dependence and tolerance, although these may be milder than with

opioids. This should not prevent patient from receiving adequate analgesia. Most patients who receive tramadol for pain do not

develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve

pain.Monitor patient for seizures. May occur within recommended dose range. Risk is increased with higher doses and in

patients taking antidepressants (SSRIs, SNRIs, tricyclics, or MAO inhibitors), opioid analgesics, or other drugs that decrease

the seizure threshold. Also monitor for serotonin syndrome (mental-status changes (e.g, agitation, hallucinations, coma),

autonomic instability (e.g, tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g, hyperreflexia,

incoordination) and/or gastrointestinal symptoms (e.g, nausea, vomiting, diarrhea) in patients taking these drugs concurrently.

Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse some, but not all, of the symptoms

of overdose. Treatment should be symptomatic and supportive. Maintain adequate respiratory exchange. Hemodialysis is not

helpful because it removes only a small portion of administered dose. Seizures may be managed with barbiturates or

benzodiazepines; naloxone increases risk of seizures.

During:

Do not confuse tramadol with Toradol (ketorolac).

Tramadol is considered to provide more analgesia than codeine 60 mg but less than combined aspirin 650 mg/codeine 60 mg

for acute postoperative pain

253

Explain therapeutic value of medication before administration to enhance the analgesic effect. Regularly administered doses

may be more effective than prn administration. Analgesic is more effective if given before pain becomes severe.

Tramadol should be discontinued gradually after long-term use to prevent withdrawal symptoms.

After:

Instruct patient on how and when to ask for pain medication

May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to

medication is known.

Advise patient to change positions slowly to minimize orthostatic hypotension.

Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication. Advise patient to notify

health care professional before taking other RX, OTC, or herbal products concurrently.

Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.

254

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Dexketoprofen

trometamol

Brand Name:

Ketesse

Date ordered:

11-03-13

Date given:

11-05-13

Date stopped:

11-07-13

50 mg IV q 8 x

2 days

General Action:

Analgesic, antipyretic

Functional

Classification:

NSAID


The mechanism of

action of NSAIDs is

related to the reduction

of prostaglandin

synthesis by the

inhibition of

Ketesse was given in

support of the tramadol

in treatment of the


operative site that is

brought about by an

inflammation and

irritation of nerve

ending due to the break

in the skin.


managed as evidence



guarding reflex and

grimace noted with

pain scale from 7/10 to

3/10.

255

cyclooxygenase

pathway. Specifically,

there is an inhibition of

the transformation of

arachidonic acid into

cyclic endoperoxides,

PGG2 and PGH2,

which produce

prostaglandins PGE1,

PGE2, PGF2α and

PGD2 and also

prostacyclin PGI2 and

thromboxanes (TxA2

and TxB2).

Furthermore, the

inhibition of the

synthesis of

prostaglandins could

affect other

inflammation mediators

256

eg, kinins, causing an

indirect action which

would be additional to

the direct action.


Prior:

Assess type, location, and intensity of pain before and 2–3 hr (peak) after administration.

Assess blood pressure and respiratory rate before and periodically during administration. Respiratory depression has not

occurred with recommended doses.

Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and

with laxatives to minimize constipating effects.

Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously

received opioids for more than 1 wk; may cause opioid withdrawal symptoms.

Prolonged use may lead to physical and psychological dependence and tolerance, although these may be milder than with

opioids. This should not prevent patient from receiving adequate analgesia. Most patients who receive tramadol for pain do not

develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve

pain.Monitor patient for seizures. May occur within recommended dose range. Risk is increased with higher doses and in

patients taking antidepressants (SSRIs, SNRIs, tricyclics, or MAO inhibitors), opioid analgesics, or other drugs that decrease

the seizure threshold. Also monitor for serotonin syndrome (mental-status changes (e.g, agitation, hallucinations, coma),

257

autonomic instability (e.g, tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g, hyperreflexia,

incoordination) and/or gastrointestinal symptoms (e.g, nausea, vomiting, diarrhea) in patients taking these drugs concurrently.

Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse some, but not all, of the symptoms

of overdose. Treatment should be symptomatic and supportive. Maintain adequate respiratory exchange. Hemodialysis is not

helpful because it removes only a small portion of administered dose. Seizures may be managed with barbiturates or

benzodiazepines; naloxone increases risk of seizures.

During:

Do not confuse tramadol with Toradol (ketorolac).

Tramadol is considered to provide more analgesia than codeine 60 mg but less than combined aspirin 650 mg/codeine 60 mg

for acute postoperative pain

Explain therapeutic value of medication before administration to enhance the analgesic effect. Regularly administered doses

may be more effective than prn administration. Analgesic is more effective if given before pain becomes severe.

Tramadol should be discontinued gradually after long-term use to prevent withdrawal symptoms.

After:

Instruct patient on how and when to ask for pain medication

May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to

medication is known.

Advise patient to change positions slowly to minimize orthostatic hypotension.

Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication. Advise patient to notify

health care professional before taking other RX, OTC, or herbal products concurrently.

Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.

258

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Paracetamol,

Acetaminophen

Brand Name:

Aeknil

Date ordered:

11-06-13

Date given:

11-06-13

11-07-13

(3:40 pm)

300 mg IV NOW

May give Aeknil

300mg IV Now

then q 4 for T ≥

38°C and

Paracetamol 1 tab

q 4 for ≥ 37.5C

General Action:

Non-narcotic

analgesic, Antipyretic

Functional

Classification:

Analgesic, Anti-pyretic


Decreases fever by

inhibiting the effects of

pyrogens on the

hypothalamus heat

regulating centers & by

a hypothalamic action

Aeknil was prescribed

because pt. had

episodes of fever with a

Tempearature of 38.0C

This was ordered

because the patient had

episodes of fever with

Temp of 38.2C. This

was also given to

control pt temp not to

shoot up to high levels.

The patient decreased

temp from 38.0C to

37.1C after 2 hours.

The patient decreased

temp from 38.2C to

36.4C after 2 hours.

259

Brand Name:

Biogesic

Date ordered:

11-08-13

Date given:

11-08-13

500 mg tab QID

leading to sweating &

vasodilatation. Relieves

pain by inhibiting

prostaglandin synthesis

at the CNS but does not

have anti-inflammatory

action because of its

minimal effect on

peripheral

prostaglandin

synthesis.

Paracetamol was

prescribed to replace

algesia and support

with Tramal Retard for

continuation treatment

of the patient‘s pain on

the operative site that is

brought about by an


managed as evidence



guarding reflex and

grimace noted.

260

Date ordered:

11-10-13

(4:30am)

50mg tab NOW

inflammation due to the

break in the skin.

Paracetamol and tramal

was combined for

faster onset and longer

duration of Aeknil

The doctor ordered stat

Biogesic because pt.

complained of pain on

incision site.


managed for the whole

day as evidence by the

patient was able to

move slightly, no

guarding reflex and

grimace noted. Patient

was able to sleep well

also.


Prior:

Assess patient‘s fever or pain: type of pain, location, intensity, duration, temperature, and diaphoresis.

261

Use cautiously to patients with fluid or electrolyte imbalance

Instruct the patient and SO regarding the action and side effects of the medication

During:

Monitor CBC, liver and renal functions.

Assess for fecal occult blood and nephritis.

Avoid using OTC drugs with Acetaminophen.

Take with food or milk to minimize GI upset.

Report N&V. cyanosis, shortness of breath and abdominal pain as these are signs of toxicity.

Report paleness, weakness and heart beat skips

Report abdominal pain, jaundice, dark urine, itchiness or clay-colored stools.

Report pain that persists for more than 3-5 days

Avoid alcohol.

This drug is not for regular use with any form of liver disease.

Give with food or milk if GI upset occurs

Establish safety precautions if CNS effects occur, protect patient from sun or bright lights if photophobia occurs


Monitor serum electrolytes and acid-base balance during course of drug therapy

262

After:

Assess allergic reactions: rash, urticaria; if these occur, drug may have to be discontinued.

Teach patient to recognize signs of chronic overdose: bleeding, bruising, malaise, fever, sore throat.

Advise patient or SO to take drug with meals if GI upset occurs

Arrange to have intraocular pressure checked periodically

Advise patient and SO that she may experience these side effects: dizziness, drowsiness, sensitivity to sunlight (use protective

sunglasses), GI upset

Instruct SO to report weight change for more than 3 pounds in 1 day, dizziness, fatigue, trembling

263

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Pantoprazole

sodium

Brand Name:

Pantoloc

Date ordered:

11-05-13

Date given:

11-05-13

Date stopped:

11-07-13

40 mg Tablet

OD x 3 days

General Action:

Suppress gastric acid

production

Functional

Classification:

Proton-pump inhibitor


Pantoprazole is a

proton pump inhibitor

(PPI) that suppresses

the final step in gastric

acid production by

covalently binding to

Pantoloc was given to

the patient to prevent

the occurrence of

stomach ulcers or

stomach pain

associated with NSAID

and because patient is

still on NPO the doctor

ordered IV Antacid.

The patient completed

the full course of the

drug and did not

manifest signs and

symptom of having

stomach ulcers, no

complains of stomach

pain, nausea and

vomiting.

264

the (H+, K+)-ATPase

enzyme system at the

secretory surface of the

gastric parietal cell.

This effect leads to

inhibition of both basal

and stimulated gastric

acid secretion,

irrespective of the

stimulus. The binding

to the (H+, K+)-

ATPase results in a

duration of

antisecretory effect that

persists longer than 24

hours


PRIOR:

Note reasons for therapy, onset, duration, triggers, characteristics of S&S.

265


DURING:


Assess for GI upset.



AFTER:

Advise patient or SO that drug may take with or without meal.

Instruct pt to avoid alcohol, aspirin or NSAIDs and foods that may cause GI irritation.

Instruct pt to report symptoms of liver damage (such as yellow skin or eyes, abdominal pain, dark urine, clay-coloured stools,

loss of appetite)

266

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Furosemide

Brand Name:

Lasix

Date ordered:

11-06-13

Date given:

11-06-13

(9:30am)

Date changed:

( dose):

11-06-13

(4:45pm)

20mg IV stat

40mg IV stat

General Action:

Rapid-acting potent

sulfonamide,

antihypertensive

Functional

Classification:

Loop diuretic


Furosemide is a potent

diuretic (water pill) that

is used to eliminate

water and salt from the

Furosemide was given

to the patient because

his output was 60cc

against input of 320cc

and BP of 140/70

mmHg. The patient

also has edema on

lower extremities.

The doctor ordered to

increased dose of

Furosemide to 40mg

because pt‘s I and O

was 868/80 cc and BP

The patient pt‘s I&O is

still not balance as

evidenced by I and O

of 868/80 at the end of

the shift (6-2) and a BP

of was 130/70mmHg.

.

The patient I&O was

still not balance and a

BP of 130/70mmHg.

267

11-07-13

(↓ frequency):

11-09-13

11-12-13

40mg IV now

then q 8°

40mg IV q 12°

40mg IV q 24°

body. In the kidneys,

salt (composed of

sodium and chloride),

water, and other small

molecules normally are

filtered out of the blood

and into the tubules of

the kidney. The filtered

fluid ultimately

becomes urine. Most of

the sodium, chloride

and water that is

filtered out of the blood

is reabsorbed into the

blood before the

filtered fluid becomes

urine and is eliminated

from the body.

Furosemide works by

blocking the absorption

of 140/70 mmHg . The

pt. also has edema on

lower extremities.

Furosemide was

increased dose of 40mg

because pt‘s I and O

was 3200/880 cc and

BP of 140/80mmHg.

Furosemide was

decrease frequency

because Input and

output is normal

(2030/2000) and BP of

130/80mmHg).

Furosemide was

decreased frequency

The patient pt‘s I&O is

still abnormal and a BP

of 140/70mmHg.

The patient pt‘s output

improves as evidenced

by the patient I and O

are balance (2640/2620

@ Nov. 10) and BP

remained at

130/80mmHg).

Thoracostomy drain is

added on the total

268

of sodium, chloride,

and water from the

filtered fluid in the

kidney tubules, causing

a profound increase in

the output of urine

(diuresis). The onset of

action after oral

administration is within

one hour, and the

diuresis lasts about 6-8

hours. The diuretic

effect of furosemide

can cause depletion of

sodium, chloride, body

water and other

minerals.

because Input and

output is normal

(2310/3780).

output which made

increased in the output

level of the patient. No

signs and symptoms of

dehydration was noted

to the patient.


PRIOR:

Assess for renal impairment or if receiving other ototoxic drugs, observe for ototoxicity

269

With history of gout, monitor uric acid levels. Monitor BP, weight, edema, breath sounds, I&O and electrolytes; observe for

S&Sx of hypokalemia.

With rapid diuresis, observe for dehydration and circulatory collapse; monitor pulse rate.

With chronic use, assess for thiamine deficiency; if used with zaroxlyn, assess for low phosphate levels.

DURING:

Assess closely for signs of vascular thrombosis and embolism, particularly in the elderly.




AFTER:

Advise patient or SO change positions from lying to standing slowly

Instruct pt to immediately report any muscle weakness/cramps, dizziness, ringing in the ears, sore throat, fever, severe

abdominal pain, numbness, or tingling.

Instruct pt to avoid alcohol and don‘t exercise heavily in hot weather

Monitor weights; report any gains of > 2 lbs. per day or > 10 lbs. per week. Supplement diet with vegetables and fruits that re

high in potassium (bananas, oranges, peaches, dried dates).

270

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Calcium Gluconate

Brand Name:

Kalcinate

Date ordered:

11-07-13

Date given:

11-07-13

(10:45am)

Date stopped:

11-07-13

1 vial stat

General Action:

Replacement solution

Functional

Classification:

Fluid and electrolytic

and water balance

agent


Soluble calcium is

predominantly

absorbed from the

small intestine by

Calcium antagonizes

the effects of

hyperkalemia in the

cellular level, thus,

lower the patient‘s

potassium level.

The patient‘s potassium

level decreased from

6.03 to 5.16 with the

help of Temporization

(D5050 + insulin).

271

active transport and

passive diffusion.

Small intestines by

active transport and

passive diffusion.


PRIOR:



DURING:

Assess for cutaneous burning sensations and peripheral vasodilation, with moderate fall in BP, during direct IV injection.

Monitor ECG during IV administration to detect evidence of hypercalcemia: decreased QT interval associated with inverted T

wave.

Observe IV site closely. Extravasation may result in tissue irritation and necrosis.

Monitor for hypocalcemia and hypercalcemia.

272

AFTER:

Lab tests: Determine levels of calcium and phosphorus (tend to vary inversely) and magnesium frequently, during sustained

therapy. Deficiencies in other ions, particularly magnesium, frequently coexist with calcium ion depletion.

Instruct pt to report S&S of hypercalcemia promptly to your care provider.

Encourage to take milk and milk products are the best sources of calcium (and phosphorus). Other good sources include dark

green vegetables, soy beans, tofu, and canned fish with bones. Calcium absorption can be inhibited by zinc-rich foods: nuts,

seeds, sprouts, legumes, soy products (tofu).

273

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Bisacodyl

Brand Name:

Dulcolax

Date ordered:

11-07-13

Date given:

11-07-13

(1:00pm)

11-11-13

Date stopped:

11-11-13

2 suppositories

anus now

suppositories

anus now

General Action:

Expands intestinal fluid

volume by increasing

epithelial permeability

Functional

Classification:

Stimulate laxative


Bisacodyl acts mainly

in the large intestine by

increasng its motility to

effect bowel

evacuation.

Ducolax was given

because patient had no

bowel movement for 5

days.

Drug is given to

improve patient‘s

bowel movement. The

pt. still complained of

problems with BM so

the doctor ordered stat

suppository.

The patient had no

bowel movement after

the administration of

the drug, which makes

the doctor ordered for

Lactulose.

The patient was able to

defecate well at Nov.

12.

274


PRIOR:



Instruct patient to have deep breathing exercise before administration to relax bowel.

DURING:

Provide privacy while giving the drug.

Instruct patient to hold the drug.

Use aseptic technique in administration of the drug.

AFTER:

Evaluate periodically patient‘s need for continued use of drug; bisacodyl usually produces 1 or 2 soft formed stools daily.

Monitor patients receiving concomitant anticoagulants. Indiscriminate use of laxatives results in decreased absorption of

vitamin K.

Add high-fiber foods slowly to regular diet to avoid gas and diarrhea. Adequate fluid intake includes at least 6–8 glasses/d.

275

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Lactulose

Brand Name:

Cephulac

Date ordered:

11-07-13

Date given:

11-08-13

Date stopped:

11-12-13

(9am)

5 ml OD @ HS

General Action:

Reduces blood

ammonia; appears to

involve metabolism of

lactose to organic acids

by resident intestinal

bacteria

Functional

Classification:

Hyperosmotic laxative


Lactulose promotes

Lactulose was given to

the patient to facilitate

Bowel movement with

the coordination with

Dulcolax, Also to avoid

straining that can cause

pain on incision site.


have bowel movement

and defecate well

without straining.

276

peristalsis by producing

an osmotic effect in the

colon with resultant

distention. In hepatic

encephalopathy, it

reduces absorption of

ammonium ions and

toxic nitrogenous

compounds, resulting

in reduced blood

ammonia

concentrations.


Prior:

Assess patient‘s fever or pain: type of pain, location, intensity, duration, temperature, and diaphoresis.



Mix with half a glass of water, milk or fruit juice to improve taste.

277

During:

Encourage pt increase fluid intake (>=1500–2000 mL/d) during drug therapy for constipation; older adults often self-limit

liquids. Lactulose-induced osmotic changes in the bowel support intestinal water loss and potential hypernatremia.

After:

Laxative action is not instituted until drug reaches the colon; therefore, about 24–48 h is needed.

Do not self-medicate with another laxative due to slow onset of drug action.

Notify physician if diarrhea (i.e., more than 2 or 3 soft stools/d) persists more than 24–48 h. Diarrhea is a sign of overdosage.

Dose adjustment may be indicated.

May take up to 48 hours to act.

Diarrhea may indicate the dose is too high.

Evaluate therapeutic response: decreased constipation or blood ammonia level.

Assess amount, colour and consistency of stool.

278

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Neprocan

Brand Name:

Nepro

Date ordered:

11-08-13

Date given:

11-08-13

1 can TID

General Action:

Medical nutritional

supplement

Functional

Classification:

Enteral Nutritional

formula


The protein content is

adequate to replace

protein and amino and

prevent catabolism of

To helps in slow down

the progression of

chronic kidney disease

(CKD) by giving

complete renal

nutrition. A fat blend

rich in

monounsaturated fatty

acids and omega-3 fatty

acids while CarbSteady

is a carbohydrate blend

that helps manage

blood glucose

responseo; and kidney-


take the formula and no

adverse effects are

noted.

279

tissue proteins. The

high quality protein

meets or surpasses the

standard amino acid

profile for protein of

high biological value.

Gluten-free, Calcium,

magnesium and sodium

caseinates, milk protein

and the fat blend is

combination meets the

American Heart

Association

recommendations of

<10% of calories from

both saturated and

polyunsaturated fatty

acids.

friendly levels of

phosphorus, potassium

and sodium appropriate

for those with CKD.

280

Generic Name:

Nutren DM

Brand Name:

Nutren DM

Date ordered:

11-11-13

Date given:

11-11-13

55 mg in 210

ml water

Neprocan was changed

to Nutren DM because

the pt. does not want

the taste of Neprocan .


take the formulas and

no adverse effects are

noted.


Prior:



If you are taking any of these enteral nutrition formulas without a prescription, carefully read and follow any precautions on

the label.

During:

Instruct patient to report GI upset (such as constipation, nausea and vomiting and diarrhea).

281

After:

Notify physician if diarrhea (i.e., more than 2 or 3 soft stools/d) persists more than 24–48 h. Diarrhea is a sign of overdosage.

Dose adjustment may be indicated.

Diarrhea may indicate the dose is too high.

Assess amount, colour and consistency of stool.

Store away from heat and direct sunlight

Enteral feedings must be handled properly to protect them from bacteria.

282

Name of the drug

Generic Name

Brand Name

Date ordered

Date given

Date changed

Date stopped

Route of

administration,

dosage and

frequency of

administration

General action,

functional

classification,

mechanism of action

Indication

Initial Reaction

Purpose

Client response to


side effect

Generic Name:

Linagliptin

Brand Name:

Trajenta

Date ordered:

11-11-13

Date given:

11-11-13

Date stopped:

Untill

Discharge

5 mg Tab OD

General Action:

Improves glycemic

control

Functional

Classification:

Antidiabetic Agent


Linagliptin belongs to

the group of diabetes

medications

called DPP-4

inhibitors. It works by

Linagliptin is given to

reduces blood sugar

(glucose) levels in

patients. Patient blood

glucose of 230mg/dL

@ 12:30am)

The patient blood

glucose remains high

(290mg/dL @ 12:30

pm), which made the

doctor give stat order

of HR.

283

increasing the amount

of incretin released by

the intestine. Incretin is

a hormone that raises

insulin levels when

blood sugar is high

(especially after a

meal) and decreases the

amount of sugar made

by the body.


Prior:



Check the blood glucose level

During:

Instruct patient to report side effects of the drug (stuffy or runny nose, sore throat, cough and diarrhea).

After:

Instruct pt do not drug if the pt is allergic to linagliptin or any ingredients of this medication, have ketoacidosis (a complication

of diabetes associated with high blood sugar, weight loss, nausea or vomiting)

284

c. Diet

Type of Diet Date

Ordered

Date Started

Date

Changed

General

Description

Indication or Purpose Special Food Taken Client Response

NPO

[Nothing per

orem]

Date

Ordered:

November 4,

2013

Date

Started:

November 5,

2013

Date

Changed:

November 5,

2013

This kind of diet

includes nothing by

mouth meaning the

patient is ordered not

to take any kind of

food or liquid.

NPO status was ordered

because the pt. was

scheduled to undergo

lobectomy on Nov. 5

NONE The patient together

with the S.O.

complied with the

prescribed diet but

complained of

moderate hunger.

The pt. underwent

the surgery and no

complication were

noted.

Nursing responsibilities:

Before

Review the doctor‘s order carefully. Note if special food are to be taken by the patient.

285

Collaborate with Dietary Services if possible.

Identify the patient by asking his name. Identify oneself to allow for a good working relationship.

Explain the importance (to prevent aspiration) of the diet to the significant other.

During

Assess the general condition of the patient.

Review recorded vital signs.

Do not allow client to take any food or fluid.

Perform needed interventions as with dyspnea.

After

Document the time when the diet was started.

Educate SO regarding the signs of dyspnea (difficulty of breathing, increased respirations, stuttering, restlessness, increased

heart rate).

Do not allow client to feed if such occurs.

286

TYPE OF

DIET

DATE

ORDERED,

DATE

STARTED,

DATE

CHANGED

GENERAL

DESCRIPTION

INDICATIONS OR

PURPOSES

SPECIFIC

FOODS TAKEN

CLIENT’S RESPONSE

AND/OR REACTION TO

DIET

Soft diet

D/O:

November 5,

2013

D/S:

November 5,

2013

D/C:

November 8,

2013

This diet incorporates

foods that are

moderately low in

fiber, have a soft

texture and are

moderately seasons.

varies from smooth,

creamy foods to foods

that are slightly

crispy. A diet which

contains easy to

swallow and digest

foods

Designed for the

patient who cannot

tolerate

general diet.

A transition diet for

pt. who was been on

NPO status.

Fruit drinks, fruit

like banana and

apple, rice

porridge, soup

Client easily tolerated the

ordered diet and was relieved

with the moderate hunger he

was complaining. No signs of

aspiration was also noted.

287

NURSING RESPONSIBILITIES:

BEFORE THE PROCEDURE:

Introduce self and verify client‘s identity

Explain the purpose and benefits of Soft diet intake

Explain the reason for compliance for soft diet

Set goals that will make soft diet more tolerable

DURING THE PROCEDURE:

Identify what kinds of soft diet is provided

Explain to the significant others the reason including the health precaution for the diet given

Assess client‘s reaction

Monitor if the patient complies with the diet given

Monitor intake and output

AFTER THE PROCEDURE:

Document findings in the client record

Encourage client‘s SO when possible to participate in complying with soft diet

Instruct to give soft diet only

Assess client‘s reaction

288

Type of Diet

Date Ordered

Date Started

Date Changed

General

Description

Indication(s)

Or Purpose(s)

Specific Foods

Taken

Client’s Response

and/or Reaction to

the Diet

DM Diet

D/O:

November 5, 2013

D/S:

November 5, 2013

D/S:

November 8, 2013

A diet designed to

control the

symptoms of

diabetes

Indicated for clients

with diabetes

mellitus

Malunggay,

ampalaya, lean

meat, fruits, non fat

milk

The client has

tolerated solid

foods and complied

with the diet

prescribed.

NURSING RESPONSIBILITIES

Prior:

Check the doctor‘s order to know the type of diet preferred.

Explain the diet to the pt.‘s SO

Inform the patient and S.O. of the foods that she is allowed to eat.

Explain the purpose of the diet.

289

During:

Advise SO to note that the pt.‘s diet can change depending on her tolerance

Check the food that the patient is about to eat.

Implement aspiration precaution

Instruct the patient not to eat while lying to prevent aspiration.

Assist the patient in eating as necessary

After:

Assess for bowel movement

Evaluate pt.‘s reaction to the diet

Check if the pt. complied to the diet

Monitor the patient closely for the compliance of the diet.

Proper documentation.

290

d. Exercise

TYPES OF

EXERCISE

DATE ORDERED,

DATE

PERFORMED,

DATE CHANGED

GENERAL

DESCRIPTION

INDICATION OR

PURPOSE(S)

CLIENT’S

RESPONSE TO

TREATMENT

Bed rest

D/O:

November 5, 2013

D/P:

November 5, 2013

D/C:

November 6, 2013

Restriction of a patient's

activities, either partially

or completely.

To decrease O2 consumption

thus, decrease the workload of

the heart because patient

undergone surgical operation.

The was given O2

after the operation and

was able to rest and

sleep without any

complaints of

difficulty in breathing.



Check the physician‘s order before the exercise

Identify the patient before the exercise or activity

Explain the procedure and importance to the patient‘ SO(s).

Ensure that the client‘s SO(s) understands the rationale for the said activity

291


Provide safety precaution

Provide comfort measures

Promote a quite environment conducive for rest.

Provide adequate rest periods


Monitor the position/activity of the patient every 2 hours.

Obtain initial assessment about the progress of the activity.

Encourage verbalization of feelings about the activity.

Assess for patient‘s condition, how he responds to the activity.

Document

292

TYPES OF

EXERCISE

DATE ORDERED,

DATE

PERFORMED,

DATE CHANGED

GENERAL

DESCRIPTION

INDICATION OR

PURPOSE(S)

CLIENT’S

RESPONSE TO

TREATMENT

Sit up on bed, Dangle

Legs

DO:

November 6, 2013

DS:

November 6, 2013

The patient is

encouraged to sit on bed

and dangle legs.

To improve circulation of

blood in the body system

especially on the lower

extremities. To prevent also

accumulation of secretions on

respiratory area and decrease

the presence of edema on the

upper extremities.

The patient was able

to tolerate sitting and

was able to dangle

legs. Was able to

expectorate secretion

and no presence of

edema was noted at

November 7.









293









Document.

TYPES OF

EXERCISE

DATE ORDERED,

DATE

PERFORMED,

DATE CHANGED

GENERAL

DESCRIPTION

INDICATION OR

PURPOSE(S)

CLIENT’S

RESPONSE TO

TREATMENT

Ambulate

DO:

November 6, 2013

Patient should stand or

walk with or without

assistance but should

have rest periods

To promote good circulation

of the blood in the body

The patient was able

to stand and walk

slowly going to

comfort room.

294

















Document.

295

2. Surgical Management

Lobectomy

A lobectomy is a surgical procedure performed to remove one of the lobes of the lungs.

The procedure may be performed when an abnormality has been detected in a specific part of the

lung. When only the affected lobe of the lung is removed, the remaining healthy tissue is spared

to maintain adequate lung function. A lobectomy is most often performed during a surgical

procedure called a thoracotomy (surgical incision of the chest). (HopkinsMedicine.Org)

Lobectomy is done to remove an infected or a diseased lobe in the lungs to prevent affecting

other parts of healthy lungs to prevent compromising optimal lung function. Diseases like

bronchiectasis and fungal infection in the lungs may require the patient to have an elective

lobectomy. The prognosis of bronchiectasis without surgical therapy is poor. (Forsee and

Klinger) According to Lilienthal in the article of Forsee and Klinger, "Chronic pulmonary

suppurations wholly or partially of the bronchiectatic type are rarely curable without the

extirpation of the pathologic focus.‖

Prior to surgery the patient was:

Cleared for CP

Secured consent

NPO post midnight

Infused with #5 PNSS IL X 80 CC/HR

Pre-medicated at OR complex

Inducted at Anesthesia Room

In performing Lobectomy, the surgeon may use any of the 2 approaches which are:

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgery. Your

surgeon will insert special instruments and a thoracoscope through three small incisions

in your chest. The thoracoscope is a thin, lighted instrument with a small camera that

transmits pictures of the inside of your body to a video screen. Your surgeon sees the

inside of your chest on the video screen while performing surgery. Minimally invasive

296

surgery generally involves a faster recovery and less pain than open surgery. This is

because it causes less trauma to tissues. Your surgeon will make small incisions instead

of a larger one used in open surgery. Surgical tools are threaded around muscles and

tissues instead of cutting through or displacing them as in open surgery. Some surgeons

use a surgical robot assist in minimally invasive surgery.

Open surgery (thoracotomy) involves making a large incision in the chest between

the ribs. Open surgery allows your surgeon to directly view and access the surgical area.

Open surgery generally involves a longer recovery and more pain than minimally

invasive surgery. Open surgery requires a larger incision and more cutting and

displacement of muscle and other tissues than minimally invasive surgery. Despite this,

open surgery may be a safer or more effective method for certain patients.

Left Upper Lobectomy

Pulmonary artery: apicoanterior, posterior, and lingular The interlobar fissure is developed

with a combination of sharp and electrocautery dissection. The posterior aspect of the fissure,

between the apicoposterior segment of the left upper lobe and the superior segment of the left

lower lobe, is completed (with a linear stapler if necessary) to expose the proximal portion of the

pulmonary artery. The left upper lobe is then retracted anteriorly and superiorly to expose the

pulmonary arteries supplying the lobe [see Figure 7]. The left upper-lobe pulmonary artery

anatomy is most variable among the lobes. The most common anatomy is three branches from

the pulmonary artery: apicoanterior, posterior, and lingular branches. However, not infrequently,

multiple posterior apical branches are encountered; in fact, as many as seven vessels supplying

the left upper lobe may be identified. Typically, the posterior segmental branch frequently arises

directly opposite the superior segmental branch to the lower lobe, as well as a more distally

situated lingular branch. These vessels should be identified, individually ligated, and divided.

Next, the whole lung is retracted inferiorly to expose the aortic arch. A large arterial branch

supplying the apicoposterior aspect of the upper lobe is usually encountered. Although the

superior and posterior aspects of this artery are easily dissected, the anterior aspect is frequently

obscured by an apical branch of the superior pulmonary vein; division of this venous branch may

http://www.acssurgery.com/acssurgery/secured/figTabPopup.action?bookId=ACS&linkId=part04_ch14_fig7&type=fig

297

improve exposure and facilitate control of the artery. Once the artery is encircled, it is ligated and

divided. To prevent avulsion of this vessel from the main pulmonary artery, care must be taken

not to exert excessive traction on the lung.

Pulmonary vein: superior pulmonary vein The superior pulmonary vein can then be identified

easily. If the apical branch was not previously ligated, the surgeon should make every effort not

to damage the pulmonary artery branches that lie posterior to this portion of the vein. The

majority of the superior pulmonary vein lies anterior to the left upper-lobe bronchus. Once this

vein is encircled, it is ligated and divided.

Left upper-lobe bronchus Attention is then redirected toward the fissure, and the peribronchial

nodal tissue surrounding the left upper-lobe bronchus is swept distally with blunt and sharp

dissection. The fissure between the lingula and the lower lobe is completed with serial

application of GIA staplers [see Figure 8]. The left upper-lobe bronchus is encircled and either

clamped or controlled with a TA stapler. To prevent inadvertent injury, the pulmonary artery

branches to the lower lobe should be gently retracted posteriorly during stapler placement. With

the stapler applied (or the clamp in place), the anesthesiologist ventilates the left lung to verify

that air is flowing freely to the entire left lower lobe. Once unobstructed airflow is confirmed, the

stapler is fired and the bronchus is divided.

Figure 6. Left

Upper

Lobectomy:

Anterior Left

Hilum

Figure 7. Left Upper

Lobectomy: Left

Interlobar Fissure

Figure 8. Left

Upper Lobectomy:

Left Fissure after

Division





















298

NURSING RESPONSIBILITIES:

Before:

Inform patient of the procedure to be performed

Secure consent for THORACOTOMY LEFT UPPER LOBECTOMY

Review results of ECG, sodium, potassium, and blood profile

Assist patient on the way to OR complex

Teach techniques to relieve from anxiety

Maintain NPO status

Continue infusion of PNSS 1L x 80 CC/HR

Proper draping of the patient before cutting

Maintaining sterile field sterile

Proper scrubbing of hands before gloving

Proper donning of gloves and surgical gown and other PPEs

Prepare instruments to be used prior to surgery

Counting of the instruments to be use and document

Remove earring, jewelries, prosthetic teeth, and nail polish

During:

Assist surgeon on handing instruments to be used

Maintain sterility of the sterile field

WOF signs of hypovolemic shock.

Monitor respiratory effort of the patient

Measure amount of blood loss to know if there is a need for BT

Recounting of instruments that have been used

Document

After:

Position patient left lateral to promote lung expansion of the right lung.

Monitor patient‘s vital signs and GCS.

299

Monitor patient until awaken

Document vital signs and GCS of the patient while still in the influence of anesthesia.

ACTUAL OR TECHNIQUE:

(Lifted from the Chart)

Patient in supine, induction of GETA using double lumen ET. Placed in lateral

decubitus, performed aseptic and antiseptic technique. Left posteriolateral thoracotomy thru 5th

ICS, Dislocation of left pleural cavity, noted (+) minimal pleural adhesion left upper lobe, (+)

palpable "mass" in hilar area left upper lobe. Opening of mediastinal pleural and helium,

exposure of superior pulmonary vein, opening of oblique fissure, exposure of individual

pulmonary artery branches LUL, division and ligation of individual pulmonary artery branches

and individual pulmonary vein. Exposure of LUL bronchus, LUL bronchus divided about 2cm

distal to LMB, bronchial stump closed in 2 layers of Vicryl 3.0 sutures, LUL delivered out. LLL

expanded and checked for all leak (-). Inferior pulmonary ligament divided. Achieved

hemostasis, Placement of anterior posterior CT's, incision is closed. Proper dressing of the

incision site.

HISTOPATHOLOGIC DIAGNOSIS:

November 13, 2013

Lung LUL: Left Upper Lobectomy

CONSISTENT WITH BROCHIECTASIS. ORGANIZED ACUTE

INFLAMMATION WITH FOCAL DYSPLASIA OF THE BRONCHIAL

EPITHELIUM. CHRONIC PASSIVE CONGESTION.

Gross/Microscopic Description:

The specimen submitted consist of a piece of dark brown rubbery to spongy tissue upper

lung lobe measuring 16.6 x 10.0 x 4.4 cm. Sections disclose branches of the bronchioles filled

300

with dark brown granular material. The lung parenchyma shows focal pale areas. No definite

mass is seen.

Representative sections are taken for microscopic studies and labeled as follows:

A – bronchial margin – 3 blocks

B- random sections of the lung – 3 blocks

Microscopic sections disclose dilated bronchioles with focal erosion of the lining

epithelium with acute inflammation and surrounding chronic inflammation and granulation tissue

formation. Some areas shows squamous metaplasia, with focal dysplastic changes. Some

bronchioles also show atypia of the glandular cells. No definite evidence of malignant change is

seen. The surrounding parenchyma shows mixed acute inflammation with atelectasis, focal

irregular emphysema and granulation tissue formation. No granulomas and fungal infections are

seen. There are also aggregates of pigment-laden macrophages, congestion and thickening of the

small and medium-sized pulmonary arteries.

CLOSED TUBE THORACOSTOMY (Anterior and Posterior)

Closed tube thoracostomy is done to drain fluid, blood, or air from the space around the

lungs. Some diseases, such as pneumonia and cancer, can cause an excess amount of fluid or

blood to build up in the space around the lungs (called a pleural effusion). Also, some severe

injuries of the chest wall can cause bleeding around the lungs. Sometimes, the lung can be

accidentally punctured allowing air to gather outside the lung, causing its collapse (called a

pneumothorax). Chest tube thoracostomy (commonly referred to as "putting in a chest tube")

involves placing a hollow plastic tube between the ribs and into the chest to drain fluid or air

from around the lungs. The tube is often hooked up to a suction machine to help with drainage.

The tube remains in the chest until all or most of the air or fluid has drained out, usually a few

days. Occasionally special medicines are given through a chest tube.

Contraindications:

The need for emergent thoracotomy is an absolute contraindication to tube thoracostomy.

301

Relative contraindications include the following:

Coagulopathy

Pulmonary bullae

Pulmonary, pleural, or thoracic adhesions

Loculated pleural effusion or empyema

Skin infection over the chest tube insertion site

Risks:

Some of the risks of chest tube thoracostomy include:

Pain during placement – Discomfort can result as the chest tube is inserted. Doctors try

to lessen the pain with a local numbing medicine (anesthetic like novocaine). The

discomfort can be severe at first but usually decreases once the tube is in place.

Bleeding – During insertion of the tube, a blood vessel in the skin or chest wall may be

accidentally nicked. Bleeding is usually minor and stops on its own. Bleeding can occur

as a bruise of the chest wall. Rarely bleeding can occur into or around the lung and may

require surgery.

Infection – Bacteria can enter around the tube and cause an infection around the lung.

The longer the chest tube stays in the chest, the greater the risk for infection. The risk of

infection is decreased by special care in bandaging the skin at the point where the tube

goes into the chest.

Equipments used:

Chest tube drainage device with water seal (autotransfuser unit is an option)

Suction source and tubing

Sterile gloves

Preparatory solution

302

Sterile drapes

Surgical marker

Lidocaine 1% with epinephrine

Syringes, 10-20 mL (2)

Needle, 25 gauge (ga), 5/8 in

Needle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for instilling local anesthesia

Blade, No. 10, on a handle

Large and medium Kelly clamps

Large curved Mayo scissors

Large straight suture scissors

Silk or nylon suture, 0 or 1-0

Needle driver

Vaseline gauze

Gauze squares, 4 x 4 in (10)

Sterile adhesive tape, 4 in wide

Chest tube of appropriate size

Man - 28-32F

Prior to surgery the patient was:

Cleared for CP

Secured consent

NPO post midnight

Infused with #5 PNSS IL X 80 CC/HR

Inducted at Anesthesia Room

Pre-medicated at OR complex

Technique

Obtain informed consent from the patient or patient‘s representative.

303

Assemble the drainage system and connect it to the suction source. The appearance of

bubbles in the water chamber is a sign that the chest tube drainage device is functioning

properly.

Identify the patient using two identifiers (eg, name and date of birth). If possible, match

the patient's identifiers at his or her bed side with the identifiers present on a chest x-ray

or CT scan that was recently performed (preferably, one performed at the patient's bed

side). Clearly mark the site of chest tube insertion (right or left).

Identify the fifth intercostal and the midaxillary line.

The skin incision is made in between the midaxillary and anterior axillary lines

over a rib that is below the intercostal level selected for chest tube insertion.

A surgical marker can be used to better delineate the anatomy

Shave excessive hair and apply a preparatory solution to a wide area of the chest wall as

shown below.

Skin preparation and marking.

Wear sterile gloves, gown, hair cover, and goggles or

face shield, and apply sterile drapes to the area.

Administer analgesia.

Administer a systemic analgesic (unless

contraindicated).

Use the 25-ga needle to inject 5 mL of the local anesthetic solution into the skin

overlying the initial skin incision, as shown below.

Local anesthesia.

Use the longer needle (23 or, preferably, 27 ga) to

infiltrate about 5 mL of the anesthetic solution to

a wide area of subcutaneous tissue superior to the

expected initial incision. Redirect the needle to

the expected course of the chest tube (following

the upper border of the rib below the fifth

304

intercostal space), and inject approximately 10 mL of the anesthetic solution into

the periosteum (if bone is encountered), intercostal muscle, and the pleura.

Aspiration of air, blood, pus, or a combination thereof into the syringe confirms

that the needle entered the pleural cavity.

Skin incision.

Use the No. 11 or 10 blade to make a skin incision

approximately 4 cm long overlying the rib that is below

the desired intercostal level of entry. The skin incision

should be in the same direction as the rib itself.

Blunt dissection down to the intercostal muscle.

Use a hemostat or a medium Kelly clamp to bluntly

dissect a tract in the subcutaneous tissue by intermittently

advancing the closed instrument and opening it, as shown.

Further blunt dissection own to the intercostal muscle.

Palpate the tract with a finger as shown, and make sure

that the tract ends at the upper border of the rib above the

skin incision.

305

Palpation of the selected intercostal space and the superior

margin of its inferior rib.

Adding more local anesthetic to the intercostal muscles

and pleura at this time is recommended.

Use a closed large Kelly clamp to pass through the

intercostal muscles and parietal pleura and enter into the

pleural space, as sho

A closed and locked Kelly clamp is used to enter the chest

wall into the pleural cavity. Make sure to guide the clamp

over the upper margin of the rib.

This maneuver requires some force and twisting

motion of the tip of the closed Kelly clamp.

This motion should be done in a controlled manner so the instrument does not

enter too far into the chest, which could injure the lung or diaphragm.

Upon entry into the pleural space, a rush of air or fluid should occur.

The Kelly clamp should be opened (while still inside the pleural space) and then

withdrawn so that its jaws enlarge the dissected tract through all layers of the

chest wall as shown. This facilitates passage of the chest tube when it is inserted.

Once the Kelly clamp enters the pleural cavity, the clamp

should be opened to further enlarge the opening.

Use a sterile, gloved finger to appreciate the size of the

tract and to feel for lung tissue and possible adhesions, as

shown in the image below. Rotate the finger 360º to

appreciate the presence of dense adhesions that cannot be

306

broken and require placement of the chest tube in a different site, preferably under

fluoroscopy (ie, by interventional radiology).

A finger is used to palpate the tract and feel for adhesions

before insertion of the chest tube.

Measure the length between the skin incision and the

apex of the lung to estimate how far the chest tube

should be inserted.

If desired, place a clamp over the tube

to mark the estimated length.

Some prefer to clamp the tube at a distal point, memorizing the estimated

length.

Grasp the proximal (fenestrated) end of the chest tube with the large Kelly clamp and

introduce it through the tract and into the thoracic cavity as shown.

The proximal end of the chest tube is held with a Kelly clamp

that is used to guide the chest tube through the tract. The

distal end of the chest tube should always be clamped until it

is connected to the drainage device.

Release the Kelly clamp and continue to advance the chest tube posteriorly and

superiorly. Make sure that all of the fenestrated holes in the chest tube are inside the

thoracic cavity.

Connect the chest tube to the drainage device as shown (some prefer to cut the distal end

of the chest tube to facilitate its connection to the drainage device tubing). Release the

cross clamp that is on the chest tube only after the chest tube is connected to the drainage

device.

307

Connection of the chest tube to a drainage system.

Before securing the tube with stitches, look for a

respiration-related swing in the fluid level of the water

seal device to confirm correct intrathoracic placement.

Secure the chest tube to the skin using 0 or 1-0 silk or

nylon stitches, as depicted below.

A 0 or 1-0 silk or nylon suture is used to secure the chest tube

to the skin.

Securing sutures: Two separate through-and-through,

simple, interrupted stitches on each side of the chest

tube are recommended. This technique ensures tight

closure of the skin incision and prevents routine patient

movements from dislodging the chest tube.

Each stitch should be tightly tied to the skin, then wrapped tightly around the chest tube

several times to cause slight indentation, and then tied again.

Sealing suture: A central vertical mattress stitch with ends left long and knotted

together can be placed to allow for sealing of the tract once the chest tube is removed.

Place petrolatum (eg, Vaseline) gauze over the skin incision as shown.

Apply petrolatum (eg, Vaseline) gauze over the skin incision.

Create an occlusive dressing to place over the chest tube

by turning regular gauze squares (4 x 4 in) into Y-shaped

fenestrated gauze squares and using 4-in adhesive tape to

secure them to the chest wall, as shown below. Make

sure to provide enough padding between the chest tube and the chest wall.

308

Preparation of a Y-shaped fenestrated drain gauze from

regular gauze (4 x 4 in).

Apply support gauze dressing around the chest tube and secure it to the chest wall with 4-

in adhesive tape.

Strap the emerging chest tube on to the lower trunk with a

"mesentry" fold of adhesive tape, as this avoids kinking of the

tube as it passes through the chest wall. It also helps reduce

wound site pain and discomfort for the patient. All

connections are then taped in their long axis to avoid

disconnections.

Obtain a chest radiograph, like the one below, to ensure

correct placement of the chest tube.

Chest tube in good position.

309

3. NURSING MANAGEMENT (ACTUAL SOAPIERS)

NOVEMBER 6, 2013

S>Ø

O> Received patient on a high fowler‘s position on bed with ongoing IV fluids of #7 PNSS 1L x

80cc/hr received at 650 cc level regulated at 26-27 gtts/min via soluset; with a side drip of

Dopamine 5mcg/kg/min regulated at 26 ugtts/min received at 50 cc level; with CTT anterior and

posterior hooked on an Emerson pump at 20 cm/hr, with the anterior CTT bottle at 400 cc level

draining bloody fluid while the posterior CTT bottle received at 350 cc level draining

serosanguinous fluid; with (+) fluctuations; with oxygen therapy via nasal cannula regulated at 3

LPM; with indwelling foley catheter draining well with dark yellow color of urine received at

100 cc urine ouput; with presence of pitting edema on both upper extremities;lethargic; with

the use of accessory muscles; afebrile; (-) hemoptysis; (-) episode of coughing; without signs of

respiratory distress; with regular depth and rhythm of breathing; with initial v/s taken as follows:

BP= 140/70 mmHg; T= 37.3; PR= 72 bpm; RR= 24 cpm;

A> Activity Intolerance related to post-operative thoracotomy and presence of CTT

P>After 6 hours of NI, the SO will verbalize understanding of the condition and proper

care for the patient especially care of CTT

I>

Assessed general condition

Ascertain to move about and degree of assistance needed by the patient

Assessed CTT‘s patency and recorded level of drainage

Plan care to carefully balance rest periods with activities

Monitored v/s every 1 hour and I/O strictly quantified

Instructed patient‘s relative not to leave patient unattended

Assist with ADLs

Assist patient in learning and demonstrating appropriate safety measures

Regulated IV fluids and oxygen therapy as ordered

310

Provided safety and comfort measures

Clamped tube while on transport and instructed importance to SO

E>Goal met AEB the SO understood the health teachings provided and proper

therapeutic regimen and CTT care.

A>Ineffective airway clearance r/t retained secretions

P>After 6 hours of NI, the patient will expectorate/ clear secretions readily

I>


Ascertained to move about and degree of assistance needed by the patient


Planned care to carefully balance rest periods with activities


Monitored respiration and breath sounds, noting rate and sounds


Assist with ADLs


Encouraged deep breathing and coughing exercises

Positioned head appropriate for age and condition

Encouraged adequate fluid intake with strict aspiration precaution

Encouraged and provided opportunities for rest; limit activities to level of respiratory

tolerance




E>Goal met AEB the patient was able to expectorate secretions

311

A>Fluid volume excess r/t inability to maintain fluid balance AEB decreased output

P>After 6 hours of NI, the patient will demonstrate behaviors to monitor fluid status and

reduce recurrence of fluid status of fluid excess

I>







Observed skin and mucous membrane


Assist with ADLs





tolerance

Stressed need for mobility and/or frequent position changes




Reinforced diet of low salt, low fat diet

E>Goal met AEB the patient demonstrated behaviors to monitor fluid status and


312

A>Impaired urinary elimination r/t diabetic neuropathy

P>After 6 hours of NI, the patient will participate in measures to correct or compensate

for defects

I>




Determined patient usual fluid intake





Assist with ADLs



tolerance






E>Goal met AEB the patient participated in measures to correct or compensate for

defects

A>Electrolyte imbalance r/t abnormal blood profile

P>After 6 hours of NI, the patient will be free of complications resulting from electrolyte

imbalance

I>


313






Monitored heart rate and rhythm by auscultation

Monitored for physical or mental disorders impacting fluid intake


Assist with ADLs


Evaluated motor strength and function





E>Goal met AEB the patient have been free of complications resulting from electrolyte

imbalance

A>Decreased cardiac output r/t altered stroke volume

P>After 6 hours of NI, the patient will display hemodynamic stability AEB VS are within

normal range

I>






Monitored cardiac rhythm continuously


Assist with ADLs

314


Decreased stimuli; provided quiet environment

Encouraged relaxation techniques

Elevated edematous extremities and avoided restrictive clothing

Encouraged changing positions slowly





E>Goal partially met AEB the patient did not display hemodynamic stability AEB VS

are within normal range

A>Constipation r/t electrolyte imbalance

P>After 6 hours of NI, the patient will verbalize understanding of risk factors and

appropriate interventions related to individual situation

I>








Ascertained frequency, color, consistency, amount of stools


Assist with ADLs



tolerance

Encouraged adequate fluid intake with strict precaution

315

Encouraged activity within limits of individual ability






E>Goal met AEB the patient verbalized understanding of risk factors and appropriate

interventions related to individual situation

A>Impaired physical mobility r/t body weakness

P>After 6 hours of NI, the patient will maintain position of function AEB absence of

footdrop, contractures, decubitus and so forth

I>



Turned patient frequently in good body alignment

Observed skin for reddened areas





Assist with ADLs


Provided diversional activities




E>Goal met AEB the patient maintained position of function AEB absence of footdrop,

contractures, decubitus and so forth

316

A>Risk for Impaired gas exchange r/t alveolar-capillary membrane changes

P>After 6 hours of NI, the patient will demonstrate improved ventilation an adequate

oxygenation

I>







Encouraged frequent position changes


Assist with ADLs






tolerance




E>Goal met AEB the patient demonstrate improved ventilation an adequate oxygenation

A>Impaired physical mobility r/t musculoskeletal impairment



I>


317








Instructed in use of side rails, overhead trapeze and roller pads

Assist with ADLs


Encouraged participation in self-care

Provided patient with ample time to perform activities







A>Ineffective tissue perfusion r/t abnormal blood profile

P>After 6 hours of NI, the patient will demonstrate behaviors and lifestyle changes to

improve circulation

I>






Measured capillary refill

Inspected lower extremities for skin texture

318

Palpated arterial pulses

Determined pulse equality


Assist with ADLs









E>Goal met AEB the patient demonstrate behaviors and lifestyle changes to improve

circulation

NOVEMBER 7, 2013

S>Ø

O> Received patient on high fowler‘s position, awake and coherent on bed, with ongoing IV

fluid of #9 PNSS 1L x 100cc/hr received at 700 cc level; with a side drip of Dopamine

3mcg/kg/min regulated at 16 gtts/min received at 50cc level; with a side drip of #1 Insulin drip

100 units HR in 100 cc PNSS regulated at 12 units/hr via soluset received at 150 cc level; with

indwelling foley catheter draining well with dark yellow color of urine received at 80 cc urine

output; with Oxygen therapy via nasal cannula regulated at 2-3 LPM; with CTT anterior and

posterior attached to Emerson pump; (+) fluctuations; Posterior CTT draining bloody fluid at 350

cc level; Anterior CTT draining serosanguinous fluid at 320 cc level; I/O ratio on 11/06/13 is

868/80; with HGT level of 199 mg/dL taken by SO; afrebile; (-) DOB; without respiratory

distress; on incentive spirometer 15 times per hour; (-) pain upon inhalation; with regular rhythm

and depth of breathing; without the use of accessory muscles; without episodes of hemoptysis; (-

319

) coughing; with initial v/s taken as follows: BP= 140/70 mmHg; T= 36.4; PR=64 bpm; RR=

22cpm

A> Fluid Volume Excess related to compromised regulatory mechanism AEB fluid retention

P>After 6 hours of NI, the patient and SO will verbalize understanding of importance of

strict fluid restrictions and health teachings provided.

I> Assessed general condition

Monitored and recorder v/s every 1 hour

Monitored and recorder HGT level every 1 hour

Monitored I/O every 1 hour

Assessed CTT bottles‘ level and CTT patency and fluctuations

Noted presence of pitting edema on both upper extremities

Instructed patient and SO diet at tolerated (DM diet) when fully awake

Instructed SO to assist patient in performing Incentive Spirometry, 15 repetitions/ hr

at 250 ml

Instructed patient and SO patient may dangle lower extremities if tolerated

Change position gradually

Instructed SO to clamp CTT tube when going to bathroom of bed side chair

Demonstrate deep breathing exercises

Fluid of PNSS was maintained KVO

E> Goal Met AEB patient and SO verbalized understanding of importance of strict fluid

restrictions and health teachings provided.




I>




320




Assist with ADLs





E>Goal met AEB the SO understood the health teachings provided and proper therapeutic

regimen and CTT care.



I>








Assist with ADLs





Encouraged and provided opportunities for rest; limit activities to level of

respiratory tolerance



321





for defects

I>









Assist with ADLs



tolerance







defects

322



imbalance

I>










Assist with ADLs








imbalance



normal range

I>




323





Assist with ADLs










E>Goal partially met AEB the patient did not display hemodynamic stability AEB VS

are within normal range

A>Risk for constipation r/t electrolyte imbalance



I>










324

Assist with ADLs
















I>









Assist with ADLs




325







oxygenation

I>









Assist with ADLs











326




I>










Assist with ADLs












improve circulation

I>



327









Assist with ADLs










circulation

NOVEMBER 8, 2013

S>“Masakit ya ing tahi ku”as verbalized by the patient

O>Received on high fowler‘s oriented to time and place, with an ongoing IVF of #9 1L PNSS x

100cc/hr. received at 100cc level infusing well on right hand with SD1 of Dopamine drip

3mcg/kg/min regulated at 16mgtts/min received at 210cc level and SD2 of insulin drip 100 units

HR in 100cc PNSS via soluset received at 65cc level with anterior and posterior CT bottle with

(+) fluctuation, (-) bubbling, with anterior CT level of 40cc with moderate, bloody consistency,

with posterior CT level of 30cc with serosanguinous consistency, with IFC connected to urine

bag draining well to a yellow colored urine received at 400cc level, with O2 inhalation via nasal

cannula at 3Lpm, (+) complains of pain on CT site, with deep regular rhythm of breathing

328

with use of accessory muscles, on HGT monitoring every two hours; P: pain upon movement

Q: quality is stabbing R: localized on surgical site S: 7/10 severity T: pain occurs upon

movement and relieved at rest, vital signs taken and recorded as follows: T=36 PR=64bpm

RR=18cpm BP=140/70mmHg .

A>Acute Pain related to surgical incision

P>After 4 hours of nursing interventions, the patient will repost understanding of health

teachings to relieve pain and patient will verbalize pain is relieved from 7/10 to 3/10

I>


Provided comfort measures

Provided relaxation techniques to relieve pain such as deep breathing exercises

Reiterated adequate rest periods

Reiterated to gradually change position

Reiterated to dangle legs as ordered and as tolerated

Instructed to clamp CTT tube when patient goes out of bed

Maintained fowler‘s position

Reiterated DM diet

Encouraged adequate fluid intake

Monitored HGT every two hours

9:00am insulin drip was stopped due to high result of 71mg/dl

9:30am patient started on bladder training but patient is unable to tolerate it

E>Goal met as evidenced by patient verbalized understanding of health teachings given

and verbalized pain has decreased from 7/10 to 3/10



I>



329






Assist with ADLs











A>Fluid volume excess r/t inability to maintain fluid balance AEB decreased output

P>After 6 hours of NI, the patient will demonstrate behaviors to monitor fluid status and


I>









Assist with ADLs

330











E>Goal met AEB the patient demonstrated behaviors to monitor fluid status and reduce

recurrence of fluid status of fluid excess



for defects

I>









Assist with ADLs





331






defects



imbalance

I>Assessed general condition









Assist with ADLs








imbalance

332



normal range

I>








Assist with ADLs










E>Goal partially met AEB the patient did not display hemodynamic stability AEB VS are within

normal range

A>Risk for constipation r/t electrolyte imbalance



I>



333








Assist with ADLs
















I>






334




Assist with ADLs








A>Impaired gas exchange r/t alveolar-capillary membrane changes


oxygenation

I>









Assist with ADLs





335









improve circulation

I>











Assist with ADLs









336


circulation

NOVEMBER 12, 2013

S>―Masakit ya ing sugat ku...” as verbalized by the patient

O> Received patient sitting on bed, patient is oriented to time, place and person, with ongoing

IVF #12 PNSS 1L x 100 cc/hr received @ 50 cc level infusing well with no signs of infiltration

noted with posterior CTT received @ 3500 ml level with light yellow output with fluctuation, (-)

bubbling, with regular depth and rhythm of breathing without use of accessory muscles, (-)

guarding behavior, (+) grimace, patient complaints of pain on CTT site pain occurs during

movement and coughing, characterized as sharp pain, with pain scale of 7/10, presence of

crackles on both lung fields upon auscultation,with stable vital signs of BP: 130/70 mmHg,

Temp: 36.1, RR:22, PR:60.

A>Acute Pain related to surgical incisions.

P>After 3-4 hours of NPI the patient will be relieve from pain AEB pain scale of 7/10

(moderate) to 3/10 (mild)

I>


Monitored and recorded Vital signs

Provided comfort and safety measures

Provided adequate rest periods

Instructed to clamp CTT tube when patient goes out of bed

Maintained fowler‘s position

Encourage adequate fluid intake

Provided relaxation techniques such as deep breathing and diversional activities

Reinforced NPO @ 10 am for 12pm GHT then DM diet with SAP

Maintained CTT below patient‘s chest area

E> Goal met as evidenced by the patient was relieved from pain.

337



I>








Assist with ADLs













imbalance

I>





338






Assist with ADLs








imbalance




I>









Assist with ADLs



339








oxygenation

I>









Assist with ADLs











340




I>










Assist with ADLs










NOVEMBER 13, 2013

S>“Mapapagalkupatsemagsalitaku” as verbalized by the patient

O> received patient in sitting position, oriented to time, place and person; with an ongoing IVF

of #14 PLRS 1L received @100cc level, regulated @33-34gtts/min, infusing well over right

hand; with CTT on posterior part left thorax, attached to drainage bottle, draining well patent to a

341

yellow fluid @320cc level, with fluctuations, (-) bubbling; afebrile;(-) DOB at rest, no signs of

respiratory distress, with regular depth and rhythm of respirations; (-) coughing, needs

assistance with changing position and activity; with good muscle strength, needs assistance

with ADLs, with complains of DOB after activity and talking; presence of crackles on both

lung fields upon auscultation; with the following VS taken and recorded as follows: T-36.4C

P-64bpm R-23cpm BP:140/80

A> Fatigue related to altered oxygen supply and demand

P>After 8hrs of nursing interventions, the patient will identify basis of fatigue and will

demonstrate ways to conserve energy during activity

I>


Noted age, ascertained patient‘s belief about what is causing the fatigue

Assessed factors that may affect reports of fatigue level

Interviewed SO regarding the changes of patient‘s activities

Monitored VS periodically especially during and after activity

Provided health teachings on how to conserve energy like having rest periods

between activity, changing of position gradually

Instructed SO to clamp CT tube when transferring patient from bed to chair

Planned for adequate rest periods, included SO in planning of activities.

E> Goal met as evidenced by patient identified basis of fatigue and demonstrated ways to

conserve energy




I>




342




Assist with ADLs





E>Goal met AEB the SO understood the health teachings provided and proper therapeutic

regimen and CTT care.



I>








Assist with ADLs









343





improve circulation

I>











Assist with ADLs










circulation

344




I>










Assist with ADLs










345

D. EVALUATION

1. Client’s Daily Progress Chart

DAYS

Admiss

ion

Nov. 3,

2013

Nov.

4,

2013

Nov.

5,

2013

Nov.

6,

2013

Nov.

7,

2013

Nov

. 8,

201

3

Nov.

9,

2013

Nov.

10,

2013

Nov.

11,

2013

Nov.

12,

2013

Nov

. 13,

201

Nov

. 14,

201

3

Discharg

e

Nov. 15,

2013

Nursing care Plan

1. ACUTE PAIN X X X X X X X X X

2. HYPERTHERR

MIA

X X

3. INEFFECTIVE

AIRWAY

CLEARANCE

X X X X X X X X X X X X

4. INEFFECTIVE

BREATHING

PATTERN

X X X X X X X X X X

5. DECREASED

CARDIAC

OUTPUT

X X X X X X X X X X X X

6. INEFFECTIVE

TISSUE

PERFUSION

X X

7. FLUID AND

ELECTROLYTR

IMBALANCE

X X X

8. FLUID

VOLUME

X X X

346

EXCESS

9. IMPAIRED

URINARY

ELIMINATION

X X X X X X X X X X

10. IMPAIRED

SKIN

INTEGRITY

X X X X X X X X X X

11. RISK FOR

INFECTION

X X X X X X X X X X

12. CONSTIPATION X X X X X

13. IMPAIRED

PHYSICAL

MOBILITY

X X X X

14. RISK FOR

IMPAIRED GAS

EXCHANGE

X X X X X X X X X X

15. ACTIVITY

INTOLERANCE

X X

16. FATIGUE X X X

347

DIAGNOSTIC

AND

LABORATORY

DAYS

Admission

Nov. 3,

2013

Nov.

4,

2013

Nov.

5,

2013

Nov.

6,

2013

Nov.

7,

2013

Nov

. 8,

201

3

Nov.

9,

2013

Nov.

10,

2013

Nov.

11,

2013

Nov.

12,

2013

Nov

. 13,

201

Nov

. 14,

201

3

Discharg

e

Nov. 15,

2013

COMPLETE

BLOOD COUNT

X X X

Hemoglobin 128 107 112

Hematocrit 0.35% 0.31

%

0.31%

White Blood Cell

6.48 x 10 9/L

12.36

x 10 9/L

Neutrophils 0.70

0.88

Lymphocytes 0.13

0.10

Monocytes 0.04

0.02

Eosinophils 0.02

0.01

Platelet 172 x10 9/L 122

Creatinine

3.29

mg/d

l

3.61

mg/dl

2.23

mg/d

l

1.54

mg/d

l

Blood Urea

Nitrogen

46.27

mg/dl

47.39

39.38

348

mg/d

l

mg/d

l

Serum Sodium 138

meq/L

Serum Potassium

5.13

mEq/

L

5.43

mEq/

L

5.96

mEq/

L

6.03

mEq/

L

5.16

mEq

/L

4.41

mEq/

L

Electrocardiogra

phy

Sinus

Brad

ycard

ia

First

Degre

e AV

Block

Sinus

Brad

ycar

dia

Sinus

Brady

cardia

Sin

us

Bra

dyc

ardi

a

Random Blood

Sugar (RBS)

X X X X X X X X X X X

URINALYSIS

Light

yellow

Slightl

y

turbid

Acidic

Specif

ic

349

gravit

y

1.010

Sugar

Trace

Albu

min

Trace

Pus

cells

3-

5/HPF

RBC

0-

2/HPF

Epith

elial

Cells

Rare

350

IVF

DAYS

Admission

Nov. 3,

2013

Nov.

4,

2013

Nov.

5,

2013

Nov.

6,

2013

Nov.

7,

2013

Nov

. 8,

201

3

Nov.

9,

2013

Nov.

10,

2013

Nov.

11,

2013

Nov.

12,

2013

Nov

. 13,

201

Nov

. 14,

201

3

Discharg

e

Nov. 15,

2013

PNSS 1L x 80

cc/hr

X X X

PNSS 1L x 80

cc/hr

X

PNSS 1L x 100

cc/hr

X X X X X

PNSS 1L x KVO

(40 cc/hr)

X

D5LRS 1L x 80

cc/hr

X X

PLRS 1L x 100

cc/hr

X X X

PLRS 1L x 100

cc/hr

X X

351

OXYGEN

THERAPY

3 LPM via face

mask

X X X X

NEBULIZATIO

N

DAYS

Admission

Nov. 3,

2013

Nov.

4,

2013

Nov.

5,

2013

Nov.

6,

2013

Nov.

7,

2013

Nov

. 8,

201

3

Nov.

9,

2013

Nov.

10,

2013

Nov.

11,

2013

Nov.

12,

2013

Nov

. 13,

201

Nov

. 14,

201

3

Discharg

e

Nov. 15,

2013

Nebulization

with

duavent/combive

nt every 6 hours

X X X X X X X X

INSULIN DRIP

Insulin drip 100

“u” HR in 100 cc

of PNSS @ 10

“u” per hour.

X

Insulin drip 100

X

352

“u”/hr in 100cc

PNSS x 12 “u”/hr

Insulin drip 100


PNSS at 15

“u”/hr

X

Insulin Drip 100


of PNSS x 5

“u”/hr

X

Insulin drip 100

“u” HR + 100 cc

PNSS x 5 “u”/hr

X

Insulin drip 100

“u” HR + 100 cc

PNSS x 13 “u”/hr

X

Insulin drip 100


PNSS at 8 “u”/hr

X

Haesteril X

353

DOPAMINE

DRIP

DAYS

Admission

Nov. 3,

2013

Nov.

4,

2013

Nov.

5,

2013

Nov.

6,

2013

Nov.

7,

2013

Nov

. 8,

201

3

Nov.

9,

2013

Nov.

10,

2013

Nov.

11,

2013

Nov.

12,

2013

Nov

. 13,

201

Nov

. 14,

201

3

Discharg

e

Nov. 15,

2013

Dopamine Drip

5mcg/kg/min

X X

Dopamine Drip

3mcg/kg/min

X X X

DRUGS

DAYS

Admission

Nov. 3,

2013

Nov.

4,

2013

Nov.

5,

2013

Nov.

6,

2013

Nov.

7,

2013

Nov

. 8,

201

3

Nov.

9,

2013

Nov.

10,

2013

Nov.

11,

2013

Nov.

12,

2013

Nov

. 13,

201

Nov

. 14,

201

3

Discharg

e

Nov. 15,

2013

Cefepime

X X X X X X X

Cefixime X X X X

Mixtard 30 HM X X X X X X X X X X X X

Humulin R X X X X X

Tramadol

(Ultram, Tramal

Retard, Algesia)

X X X X X

354

Ketesse X

X

X

Paracetamol

(Biogesic, Aeknil) X X X X X

Pantoloc X

X X

Furosemide

(Lasix) X X X X

Nephrosteril)

X X

X

Calcium

Gluconate

X

Bisacodyl

(Dulcolax) X X

Lactulose

(Cephulac) X X X X

Neprocan

X X

X

X

Nutren DM X X

X

X

Linagliptin

(Trajenta) X X

X

X

X

355

Diet:

DAYS

Admission

Nov. 3,

2013

Nov.

4,

2013

Nov.

5,

2013

Nov.

6,

2013

Nov.

7,

2013

Nov

. 8,

201

3

Nov.

9,

2013

Nov.

10,

2013

Nov.

11,

2013

Nov.

12,

2013

Nov

. 13,

201

Nov

. 14,

201

3

Discharg

e

Nov. 15,

2013

NPO [Nothing per

orem) X

Soft Diet X X X

DM Diet X X X X X X X X

Exercises/

Activity

Bed rest X

Sit up on bed,

Dangle Legs X

Ambulate X X X X X X X X X X

356

2. DISCHARGE PLANNING

a. General Condition of Mr. Baga upon Discharge (lifted from the chart)

Mr. Baga was discharged on November 15, 2013 with a final diagnosis of

Recurrent Massive Hemoptysis secondary to TB Bronchiectasis, Fungus Ball, Left upper

lobe. Received patient on bed, awake and coherent; without contraptions noted; with

intact and dry dressing; (-) DOB and chest pain; (-) pain complaints; afebrile; with stable

V/S; awaiting clearance.

b. METHOD

Medications

Mixtard 50 units SC in AM; 25 units SC in PM

Insulin was prescribed as maintenance drug for the patient‘s DM.

Inject insulin 50 units at 8am and 25 units at 8pm subcutaneously.

Linagliptin (Trajenta) 5mg OD

Trajenta was prescribed as maintenance drug for the patient‘s DM.

Take one tablet once a day.

Cefixime 20mg 1 cap BID x 7days

Antibiotic was prescribed as to prevent infection.

Take one capsule once a day for 7 days.

Exercise:

Continue and maintain passive range of motion exercises gradually as

tolerated.

Treatment:

If symptoms of complications persistreport immediately and consult the

physician for further treatment.

357

Health teachings:

Stressed the importance of strict compliance to treatment regimen

specially medication intake and diet therapy.

Warned Mr. Baga and his significant others regarding the side effects and

adverse reaction of the medications.

Instructed Mr. Baga and his significant others to provide a stress-free

environment.

Instructed Mr. Baga to avoid engaging in strenuous activities.

Stressed the importance of regular medical check-up

Out-Patient-Department:

Mr. Baga was instructed to come back on November 25, 2013 at a tertiary

hospital in Angeles City, Pampanga with RBC and urinalysis results.

Diet:

Diet as Tolerated for continuity of usual diet (Diabetic Diet)

Sample 7 Days Diabetes Meal Plan

Day 1

BREAKFAST

1 Cup Skim Milk

1 Orange, medium

1 Cup Cheerios Cereal

MORNING SNACK

1 Cup Cantaloupe Melon

LUNCH

Grilled Shrimp Skewers

over White Bean Salad

1 Whole-Wheat Pita Bread,

small

1 Cup Skim Milk

1 Fudgsicle, no sugar added

AFTERNOON SNACK

2 Tablespoons Prepared Hummus

3 Ounces Celery Sticks

DINNER

1/2 Cup Cooked Brown Rice

North African Spiced Carrots

Tomato-Herb Marinated Flank Steak

1/2 Banana, small

http://www.eatingwell.com/recipes/grilled_shrimp_bean_salad.html

http://www.eatingwell.com/recipes/grilled_shrimp_bean_salad.html

http://www.eatingwell.com/recipes/north_african_spiced_carrots.html

http://www.eatingwell.com/recipes/tomato_herb_marinated_flank_steak.html

358

Day 2

BREAKFAST

1 Cup Skim Milk

1/2 Banana, small

1 Cup Bran Flakes Cereal MORNING SNACK

1 Fruit & Nut Granola Bar LUNCH

Chopped Greek Salad with Chicken

1 Whole-Wheat Bread

Vanilla-Orange Freezer Pops

o

AFTERNOON SNACK

6 Ounces Nonfat Vanilla or Lemon Yogurt,

Sweetened with Low-Calorie Sweetener

DINNER

1 Cup Steamed Brussels Sprouts

Grilled Shrimp Remoulade

1/2 Cup Cooked Couscous 1 Peach, medium

Day 3

BREAKFAST

1 Whole-Wheat English Muffin

1 Cup Skim Milk

1/2 Cup Blueberries

1 Teaspoon Fat Free Cream Cheese MORNING SNACK

1 Apple, small LUNCH

1 Cup Tossed Salad Mix

1 Tablespoon Fat Free Blue Cheese

Salad Dressing

Hungarian Beef Goulash

1/2 Cup Fresh Pineapple

1 Slice Reduced-Calorie Oatmeal Bran

Bread

1 Cup Skim Milk

Five-Spice Tilapia

1/2 Cup Cooked Quinoa

1 Nectarine, medium

AFTERNOON SNACK


Sweetened with Low-Calorie Sweetener DINNER

Asian Green Bean Stir-Fry

http://www.eatingwell.com/recipes/chopped_greek_salad_with_chicken.html

http://www.eatingwell.com/recipes/vanilla_orange_freezer_pops.html

http://www.eatingwell.com/recipes/grilled_shrimp_remoulade.html

http://www.eatingwell.com/recipes/hungarian_beef_goulash.html

http://www.eatingwell.com/recipes/five_spice_tilapia.html

http://www.eatingwell.com/recipes/asian_green_bean_stir_fry.html

359

Day 4

BREAKFAST

1 Cup Skim Milk

1/2 Cup Hot Oatmeal

1 Ounce Dried Fruit

1 Tablespoon Walnuts MORNING SNACK

1 Kiwi LUNCH


Manhattan Crab Chowder

1 Tablespoon Low Calorie Caesar Salad

Dressing

1 Slice Reduced-Calorie Oatmeal Bran

Bread

1 Cup Honeydew Melon

AFTERNOON SNACK

1 Cup Blackberries

1 Cup Skim Milk DINNER


Maple-Glazed Chicken Breasts

1/2 Cup Steamed Summer Squash

1/2 Cup Mango

Day 5

BREAKFAST

1 Scrambled Eggs

2 Slices Reduced-Calorie Oatmeal Bran

Bread

1/2 Cup Grapefruit

1 Cup Skim Milk MORNING SNACK

6 Ounces Nonfat Vanilla or Lemon

Yogurt, Sweetened with Low-Calorie

Sweetener LUNCH


1 Tablespoon Fat Free French Salad

Dressing

Cheese-&-Spinach-Stuffed Portobellos

1/2 Cup Unsweetened Applesauce

AFTERNOON SNACK

1/2 Plain Bagel

2 Tablespoons Prepared Hummus DINNER

1/2 Cup Cooked Quinoa

Roasted Baby Bok Choy

1 Cup Strawberries

http://www.eatingwell.com/recipes/manhattan_crab_chowder.html

http://www.eatingwell.com/recipes/maple_glazed_chicken_breasts.html

http://www.eatingwell.com/recipes/cheese_spinach_stuffed_portobellos.html

http://www.eatingwell.com/recipes/roasted_baby_bok_choy.html

360

Day 6

BREAKFAST

1 Cup Skim Milk

1 Whole-Wheat English Muffin

1 Teaspoon Creamy Peanut Butter

1 Tablespoon Sugar-Free Jam MORNING SNACK

1 Orange, medium LUNCH

Chicken Mulligatawny

1 Cup Skim Milk

1 Whole-Wheat Pita Bread, small

1 Cup Watermelon

o

AFTERNOON SNACK


Sweetened with Low-Calorie Sweetener DINNER

Singapore Chile Crab with Spinach


Rainbow Pepper Saute

1 Cup Cantaloupe Melon

Day 7

BREAKFAST

1 Cup Skim Milk

1 Plum

Quick Breakfast Taco MORNING SNACK

1 Apple, small LUNCH

1 Veggie Burger

1 Whole-Wheat Roll

Bok Choy-Apple Slaw

1 Apricot

Turkish Chicken Thighs


1 Peach, medium

o

AFTERNOON SNACK

3 Ounces Carrot Sticks

1/4 Cup Salsa DINNER

1 Cup Skim Milk


1 Tablespoon Low Calorie Caesar Salad

Dressing

http://www.eatingwell.com/recipes/chicken_mulligatawny.html

http://www.eatingwell.com/recipes/singapore_chile_crab_with_spinach.html

http://www.eatingwell.com/recipes/rainbow_pepper_saute.html

http://www.eatingwell.com/recipes/quick_breakfast_taco.html

http://www.eatingwell.com/recipes/bok_choy_apple_slaw.html

http://www.eatingwell.com/recipes/turkish_chicken_thighs.html

361

III. SUMMARY OF FINDINGS

The researchers were able to accomplish the task given to them. They were able

to established rapport and achieve trust with the patient and her significant others. They

were able to gain needed information for the completion of the study. Also, they were

able to identify the diagnosis of the patient and his complications. They were also able to

recognized and identified actual potential problem and his prognosis with day-to-day

basis. They were able to show patient‘s data with the information gathered and interpret

the data. The workload is properly distributed with the patient. The work tasks are

completed on time.

After 5 days of nurse-patient interaction, the student nurses were able to

familiarized the attitude of the patient‘s family health as well as to obtain the personal

and pertinent family health-illness history of the client and relate it to the present disease

condition. Identified the statistics and prevalence of the disease condition as well as the

latest trends in the management of the disease condition. Gathered pertinent information

about the patient regarding his personal and socio-economic histories, cultural beliefs,

environmental factors as well as his family health-illness history that may have

contributed in the development of the disease condition. Analyzed the diagnostics and

laboratory procedures performed to diagnose the condition of the patient. Identified and

prioritize appropriate nursing care plans to aid in the management of the patient‘s

condition. Provided various therapeutic nursing interventions that are suitable with the

presenting problems experienced by the patient.

After completion of this case study, the student nurses were able to discussed

Tuberculosis, Bronchiectasis and Fungus Ball, Diabetes Mellitus Type II and

Hypertension, its definition, risk factors, sign and symptoms that had contributed to the

occurrence of the disease condition. As well as to identify the apparent sign and

symptoms manifested by the patient in relation to the mentioned disease condition.

Performed a comprehensive assessment; physical, neurological and neurovascular

assessment as to general condition of the patient; as well as its effects to the significant

362

other may be it physically, socially, mentally and spiritually to confirm the diagnosis of

Pulmonary Tuberculosis, Bronchiectasis, and Fungus ball, Diabetes Mellitus Type 2,

Hypertension; or to identify other possible causes of patient‘s symptoms.

Comprehensively analyzed and interpreted the different laboratory and diagnostic

procedures in relation to the clinical manifestations of the disease condition; and the

different nursing interventions that must be done before, during and after each procedure.

Identified nursing problems and appropriate nursing care plan that involves the patient

and the significant others. Specified the various treatments modalities such as medical

management and surgical management as well as current trends in managing


Hypertension. Identified the appropriate nursing diagnosis and make corresponding

interventions and carry them out as the situation permits as to promote patient wellness.

Made daily progress chart to evaluate patient‘s response to medical management

Formulated discharge planning and care of patient at home. Formulated conclusions

based on findings and enumerate recommendations concerning the management of


Hypertension. Evaluated effectiveness of nursing care and medical interventions rendered

After 5 days of nurse-patient interaction, the patient and relative were able to

established rapport with student nurses and will trust and cooperate with them.

Understood the purpose of the student nurse purpose for acquiring related information

about the patient with regards to the condition. Determined the level of understanding

about the disease condition. Cooperate during the interview process and gathering of data

thereby sharing of information that is significant to the present condition of the patient.

Demonstrated awareness on the activities necessary to accomplish the case study.

Willingly answered the questions of the student nurses and shared relevant information

about their health belief and practices. Shared their perceptions regarding the history of

illness their family are experiencing. Imparted their views in what the possible effects of

these health problems are and what interventions can be done to solve them.

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After the completion of the case study the patient and his family were able to

enumerated the underlying cause of the disease and its occurrence. Participated in the

modality of the treatment given to the patient. Obtained pharmacological and non-

pharmacological treatment to alleviate disease condition. Acquired palliative care and

management of pain as well as reducing the occurrence of complication from disease

condition. Participated in formulating various nursing care plans with the student nurses

to improve patient‘s condition.

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IV. CONCLUSION

Tuberculosis (TB) is an infectious disease that primarily affects the lung

parenchyma. It also may be transmitted to other parts of the body, including the

meninges, kidneys, bones, and lymph nodes. The initial damage to the bronchi may result

from a number of different causes; one of these is Tuberculosis, leading to

Bronchiectasis. Bronchiectasis is a disease state defined by localized, irreversible dilation

of part of the bronchial tree caused by destruction of the muscle and elastic tissue. It is

classified as an obstructive lung disease; involved bronchi are dilated, inflamed, and

easily collapsible, resulting in airway obstruction and impaired clearance of secretions.

With such manifestations, treatment depends on the underlying cause and

manifestations. Persons with this condition should be closely monitored for signs of

progression of disease. Alteration of the environment and team effort from different

members of the health care team such as the physician, the nurse and most importantly

the family of the patient is much needed to the rapid wellness and optimum level of

functioning

The following manifestations observed by student nurses may help in deciding

whether the patient condition has a poor or good prognosis. The absence of recurrent

massive hemoptysis: As explained by Knechel (2009), hemoptysis or coughing of blood

may be caused by destruction of a patent vessel located in the wall of the cavity, rupture

of a dilated vessel in a cavity, or the formation of an aspergilloma in an old cavity. In

response of the body to these alterations in the body, hematologic studies may reveal

anemia, which causes fatigue and weakness, leukocytosis will also present as response to

the infection. The socio-economic status of Mr. Baga. His financial status helped the

patient‘s condition improved because of the surgical management, lobectomy on the left

upper lobe, which the patient complied. Medications are given and taken by the patient

during the entire length of hospitalization. Home medications, are likewise taken as

ordered after conducting home visit.

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Prolonging and improving the patient‘s quality of life through prescribed

medications, diet, activity, monitoring of health status and follow-up consultations is a

more realistic measure. Several factors may help in contributing to the enhancement of

quality of life of the patient. The support of the family, prescribed medical and nursing

management and other support-resources can be of additional help for the recovery of the

patient.

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V. RECOMMENDATIONS

After conducting the case of Mr. Baga, a patient with a diagnosis of Recurrent

Massive Hemoptysis Secondary to TB Bronchiectasis Fungus Ball, Left Upper Lobe, the

student nurses came up with the following recommendations. They are divided into:

patient-based and nursing-based recommendations.

PATIENT and FAMILY-BASED:

Lifestyle modification is very important towards control of the said disease.

Modification of Mr. Baga towards health promotion activities may help prevent

further complications associated with the condition.

Maintaining a schedule that contains adequate time for rest and sleep should be

considered. Good rest and enough sleep will enhance the patient‘s body by

reservation of energy and enhancement of muscular strength and tonicity.

Strict compliance to medical and nursing regimen is another key factor toward good

prognosis of Mr. Baga‘s health condition. Taking medications as instructed is just one

of the several roles he has to do diligently. The condition would be properly promoted

and controlled as the client seeks a quality of life that is worth living.

The family serves as the main support system of the patient physically, emotionally

and financially. The family therefore should realize the significance of its role and

must comply with the regimen prescribed for the patient. The family must be

involved with patient‘s care from the beginning. Patient and family education about

disease condition begins on admission and continues through rehabilitation. It is

necessary to share information repeatedly for the patient and family to assimilate it.

The prognosis of the patient does not only depend on his own but to the members of

the family. Health care providers should also assist the patient and family in

identifying and using support systems and appropriate coping mechanisms.

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NURSING-BASED:

The patient and family should be educated concerning the possible effects of

medications and the need to notify the physician if adverse effects develop. Mr. Baga

and family were unaware of the actions, side and adverse effects of the drugs being

given to him.

Strict monitoring and continuous assessment of patient‘s condition is a must. Physical

assessment, and early assessment of signs and symptoms is a vital way that gives

essential status of the patient.

Continuous monitoring of urine output and bladder function should be done to

properly evaluate medical and nursing interventions provided to the patient and

revision of said interventions may be implemented to improve disease condition.

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VI. LEARNING DERIVED

Tuberculosis may come without any sign and symptoms which may lead to

untreated until such disease will decrease the immune system of the body. In this

problem complication may occur such as blood loss due to hemoptysis and also the

presence of fungal ball because the lungs was not able to destroy micro-organism because

it was been damage. Recognition and treatment of these problems are major factors in the

care of person with TB.

As student nurses, we are given vast opportunities to handle different clients with

different diseases. As in our case, we were able to manage a client with peritonitis

secondary to ruptured appendicitis. Through handling this case, the researchers were able

to know the different modifiable and non-modifiable factors that may have contributed

the patient‘s condition and to the signs and symptoms related to the disease. Diagnostic

procedures were also identified as equally important in order to identify or to confirm the

disease and along with the nursing responsibilities before, during, and after the procedure

is done. The researchers also learned the importance of each medical management done

to the patient, specifically, their actions, indications, nursing implications and the client‘s

response to the management given. Nursing care plans were formulated for the care of

the patient, and for the achievement of the goals specified in the plan for the promotion of

patient‘s health. At the same time, knowledge regarding the latest trends on tuberculosis

were learned by the researchers.

All throughout the provision of care to the patient, the researchers were able to

see life in a different perspective. Rendering care to patients does not only mean going to

patient and give interventions physically. Provision of care also entails giving the patient

a caring environment and seeing the patient and his family in an emphatic and holistic

way.

It is without a doubt that nurses do not hold the patient‘s life but the researchers

believe that if nurses are equipped with sufficient knowledge and skills regarding the care

of patients with fracture, nurses surely can make a difference to the life of the patients

and to his family. ~ GROUP 14

Hard Bound

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