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UNIVERSITY OF MAKATICollege of Allied Health StudiesJ.P. Rizal Extension, West Rembo, Makati CitySpontaneous Pneumothorax

In Partial Fulfillment of the Requirements inMedical and Surgical Nursing I

Presented by:

Aloba, Kenosis P.De Asis, KennethGenerao, GinalynLupango, JessaOlino, Rustia CarenOliveros, Juan MiguelOrillaneda, JeanPasco, John CarloSale, Rhechell C.Sulangi, AngelaIntroductionINTRODUCTION

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

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

Pneumothorax(pl.pneumothoraces) is an abnormal collection of air or gas in thepleural spacethat separates thelungfrom the chest wall, and that may interfere with normalbreathing. It occurs when the parietal or visceral pleura are breached and the pleural space is exposed to positive atmospheric pressure.

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

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

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

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

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

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

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

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

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

Number of incidences:

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

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

Specific objective:

Student-centered:

To conduct a research regarding the patients condition.To discuss the underlying problem of our chosen case and give a clear view of it.To be able to provide a comprehensive nursing history to identify the cause of Spontaneous PneumothoraxTo enhance our nursing skills in identifying and classifying signs and symptoms of the patient with Spontaneous Pneumothorax.To hone us to become competitive nurses in the future.To be able to execute the effective nursing interventions that may help promote the well being of the patient and decrease risk for further complications.To assess the patients response to the treatment and evaluate the effectiveness of the nursing care given.To review the Anatomy and Physiology of the system related to the disease.To be aware of the pathophysiology of the disease.

Client-centered:

The patient will become aware of his existing condition and the different treatment modalities that are available to him.For the client to realize factors that contributes to his disease and how he can modify these factors.For the client to assist himself during discharge by health teaching contributed by the nurse.For the client to turn towards the preventive behavior to avoid recurrence of the present condition in the future.

Health HistoryPatients ProfileName:Mr. E. T. L.Sex: MaleAge:36 years old.Civil Status:MarriedNationality:FilipinoBirth date: August 26, 1975 Birth Place:Valenzuela CityAddress: Guadalupe, MakatiReligion:Roman CatholicEducational Attainment:High School GraduateOccupation:Bag seller at the Guadalupe market

Patients ProfileDate and time of admission:May 6, 2012 8:15 AMMode of admission:General wardAdmitting Diagnosis:Spontaneous PneumothoraxPreoperative Diagnosis:Massive Pneumothorax Left Secondary to Ruptured Bleb vs IdiopathicOperation Performed:E Chest Tube Thoracostomy, LeftPostoperative Diagnosis:Massive Pneumothorax, Left, Secondary to Ruptured Bleb vs Idiopathic

Informant:Patient

Percentage Reliability:90%

Chief ComplaintDalawang linggo na akong nahihirapang huminga,

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

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

There was persistence of symptoms. No improvement or progression was statedHistory of Present Illness2 days Prior to Admission, the client went to an OPD at Polymedic Clinic for consult and was advised for admission. The client decided to stay at home against medical advice.

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

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

Past Medical HistoryThe client stated that he had received complete immunization during childhood. He was also never admitted to any hospitals in the past. He has no known allergies. The client also has no history of injuries or falls. He has no history of any type of pneumothorax. He goes to clinics for a check-up whenever he is feeling unwell. No recent travel was also made.

DATEDIAGNOSISHOSPITALINTERVENTIONMEDICATIONS5 yrs oldBronchial AsthmaNoneSelf medicationSalbutamol2005Goiter due to HyperthyroidismManila Doctors HospitalUnmanagedWas only compliant with medications from yr 2005-2008.UnrecalledFamily Medical History

Family Medical HistoryInterpretation: The father and grandfather of Mr. E. T. L. died of emphysema. That means that he is at risk of developing emphysema. His uncle on the father side and younger sister are asthmatic. His mother and aunt are hypertensive and diabetic. His uncle on the mother side is also known to be diabetic. The eldest sister was also diagnosed of goiterPersonal and Social HistoryThe client and his wife are bag sellers for 3 years with their own stall at the Guadalupe Market. Their gross income is 20,000/month. He is a high school graduate at Bangkal High School in Makati City.

The client lives in his own house, together with his wife and mother. His house is a bungalow style with two bedrooms. He stated that their environment is clean and has enough space for all of them. They didnt have any children.

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

Physical AssessmentPhysical AssessmentDATE AND TIME: May 7, 20129:00am 11:00am

General appearance:(+) facial grimace Conscious and coherent Thin body figure Cooperative and responds appropriately to every question asked at moderate pace and as long as he can tolerate.Anthropometric measures: Height: 172.72 cm Weight: 54.4kg BMI *18.2 (Normal values are 18.5-25)Vital signs:Temperature: 37.3 CRespiratory rate: 27 cpmPulse rate: 105 bpmBlood pressure: 130/80 mmHg

ORGAN/BODY PARTSMETHODS USEDFINDINGSSIGNIFICANCESkinInspectionPalpation*Hematomas on antecubital and radial surface on both arms(-) cyanosisDark complexionIntact skinGood skin turgor*Hematomas are due to blood samples takenHeadInspectionNormocephalic(-) Head injury (-) Tenderness(-) LesionsNormalHairInspection(-) hair parasites(-) dandruffsHair is evenly distributedNormalFaceInspectionNormal facial movementsNormalEyesInspectionPERRLA:Pupils are equal and round, left eye 3 mm reactive to light and right eye 3 mm reactive to light, good accommodation noted.*slightly protruding eyes*Dark circles around the eyes* Eye protrusion is one of the signs of hyperthyroidism*Possible sleep deprivationORGAN/BODY PARTSMETHODS USEDFINDINGSSIGNIFICANCEEarsInspectionWatch tick testPalpationBilaterally equal in size (-) lesions (-) discharge(-) redness(-) bleedingAble to hear sounds on both earsPinna is firm, non tender and no painNormalNose:InspectionSymmetric and straight(-) discharges(-) nasal flaringWith O2 administered at 4L/min via nasal cannulaNormalO2 Therapy is used to benefit patient by increasing the supply of O2 to the lungs and thereby increasing the availability of O2 to the body tissuesMouth:Inspection*(+) dental carries*Absence of teeth on upper mandibleUniform and pinkish tongue with no lesion, Moist pink buccal mucosaThere could be difficulty in mastication.Neck:InspectionPalpationSymmetric and head centered(+) swollen lymph nodes(+) Lump on the neckThere could be presence of infectionThere is thyroid enlargementORGAN/BODY PARTSMETHODS USEDFINDINGSSIGNIFICANCEUpper ExtremitiesInspectionPalpationWith IV contraption on R metacarpal infusing PNSS 1L x 40cc/min*20.5cm mid-upper arm circumferenceEqual pulses (+) tachycardia*Normal value of MIUC in adult males is 23cm. This shows decreased amounts of fat and muscle mass in the armsNails:InspectionPalpation(-) Pail(-) IndentationsCapillary refill less than 3 secondsNormalThorax and lungs:InspectionAuscultationPercussionPalpationWith CTT one-way drainage system inserted on the 5th ICS, LMA lineRR = 27cpm(+) difficulty of breathing(+) dry cough(+)chest wall retraction(+) use of accessory musclesDiminished breath sounds and pleural rub on left lungHyper resonance on left lungTactile fremitus decreased on left lung*To remove air in the pleural space*Patient is having problems with oxygenation*Air in the pleural space dampens the transmission of sounds and vibration.HeartInspectionAuscultation(-) visible pulsationNo heart murmurs auscultated over aortic, pulmonic, tricuspid and mitral area.Normal heart rate and regular rhythmHR = 105bpm(+)TachycardiaHeart compensates to increase oxygenationORGAN/BODY PARTSMETHODS USEDFINDINGSSIGNIFICANCEAbdomenInspectionAuscultationPalpation(-)swelling(+) bowel sounds(-) palpable masses and no tenderness.NormalGenito-urinaryInspectionNo swelling, no lesions notedNormalLower ExtremitiesInspectionPalpationLegs bilaterally symmetric, no ulcerations noted.*(+) limited ROM*(+) body malaiseEqual pulses (+) tachycardia*Due to weaknessNails:InspectionPalpation(-) Pail(-) IndentationsCapillary refill less than 3 secondsNormalReview of SystemsSYSTEMCUESINTERPRETATIONSIGNIFICANCEGeneralMedyo nanghihina pa ako.(+) body malaiseBody weakness is attributed to the present conditionSkin/Integumentary SystemMay konting sakit sa mga parte na pinagkuhaan ng dugo(+) TendernessTenderness is due to puncture of skin from obtaining blood specimen.EENTEarsEyesThroatPantay ang pandinig ko.Parehas malinaw ang paningin ko.Nahihirapan akong lumunok,Is able to hear on both earsIs able to see on both eyesDifficulty in swallowingNormal NormalBrought about by thyroid enlargementSYSTEMCUESINTERPRETATIONSIGNIFICANCERespiratory SystemHirap akong huminga.Masakit yung sa gilid ng dibdib ko, parang tinutusok tusok.DOBPain on the Left lateral chestP Exacerbates when coughing and moving.Q- Stabbing painS- 6/10R Radiates to the left shoulderT 5-10 secDue to escape of oxygen into the pleural space.Cardiovascular SystemMay oras na mataas ang bp ko.BPBP is due to increased force of cardiac contractility and the bodys attempt to increase tissue perfusion and oxygenationGastrointestinal System Hindi naman ako nagtataeNagsuka ako kanina dahil sa sama ng pakiramdam ko.(-) DiarrheaVomitingAttributed to present conditionSYSTEMCUESINTERPRETATIONSIGNIFICANCEGenitourinary SystemRegular ang ihi ko, normal ang color at hindi rin masakit umihi.Wala akong mga almoranasNormalMusculoskeletal SystemMadali akong mapagod.(+) muscle weaknessLimited ROMWeakness is attributed to present condition and limited ROM NeurologicDi naman ako ulyanin.Is able to communicateNormalGordons Functional Health PatternBefore hospitalizationDuring hospitalizationHealth perception and Health Management patternClient seeks medical consultation every time he feels that there is something abnormal with his health. He normally takes over the counter drugs when he experiences a cough or cold. Client is adherent to the treatment regimenNutritional and metabolic patternHe is fond of eating salty and fatty foods.He eats what the dietary department serves. On low salt and low fat diet.Elimination patternHe defecates at least 2 times a day and urinates at least 6 times a day.Client uses a urinal to urinate. He has not made any bowel movement since hospitalization.Activity-exercise patternHe plays badminton every day.Is unable to ambulate due to presence of CTT.Sleep-rest patternHas lack of sleep.Has more difficulty of sleeping.Before hospitalizationDuring hospitalizationCognitive perpetual patternThe client can hear clearly. Cognitive and alert.The client can hear clearly. PERRLA. Self-perception and self concept patternConfident and he has a good outlook on the way things are happening.The client still has a positive outlook.Role relationshipIs satisfied with family, work, and socialrelationshipsHe cannot perform his roles as of the moment.VicesDrinks alcohol occasionally and smokes half a pack of cigarettes per day. Is unable to do vices in the hospital settingSexual patternIs satisfied with sexual relationshipNoneCoping/ Stress ToleranceClient manages stress listening to music Client handles stress of condition by practicing a regular breathing pattern.Value BeliefClient prays often for good health.Client often reads the bible.Medical and Nursing DiagnosisMedical Diagnosis:Spontaneous Pneumothorax

Nursing Diagnosis:Ineffective breathing pattern related to decreased lung expansion.Impaired gas exchange related to decreased lung expansion secondary to air accumulation in the pleural space.Acute Pain related to impaired pleural integrityDisturbed sleep pattern related to interruptions from therapeutic regimen, monitoring and other generated awakening and excessive stimulation.Activity intolerance r/t muscle weakness and fatigueRisk for trauma related to dependence on chest tube drainage system.Risk for falls related to generalized weakness.Risk for deficient fluid volume related to treatment regimen.Risk for constipation related to changes in level of activity.Risk for prone behavior related to lack of knowledge about the disease.

Laboratory ExamsHematology May 6, 2012ComponentResultNormal ValueInterpretationAnalysisHemoglobin Hematocrit WBC count RBC count 16.8

0.52

15.9

5.814-18 g/L

0.40-0.54

4-11 x10 g/L

5.0-6.4Normal

Normal

Increased

NormalInsight: Usually, elevated WBC is an indicator of infection. But in some cases with inflammation or trauma such as spontaneous pneumothorax, it may also lead to increase WBC even without infection.ComponentResultNormal ValueInterpretationAnalysisDifferential count:Eosinophils Neutrophils Segments

Lymphocytes Monocytes 0.01

0.71

0.16

0.4

0.02-0.04

0.50-0.70

0.20-0.40

0.02-0.05

Decreased

Increased

Decreased

Increased

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

Neutrophil is bodys primary defense against bacterial infection and physiologic stress. neutrophils may indicate presence of infection

Low lymphocyte counts may occur in normal individuals. . A low value doesnt necessarily mean a decrease in protection against viruses.ComponentResultNormal ValueInterpretationAnalysis Platelet count PT % activity INR

Activated PTT202

16.3 secs

57.0% 1.52

48.0 secs150-450 x10 g/L

10.4-14.05

73-127%0.88-1.21

30.4-41.2Normal

Slow

DecreasedIncreased

SlowThe prothrombin time can be prolonged as a result of deficiencies in vitamin K, warfarin therapy, malabsorption In addition, poor factor VII synthesis (due to liver disease) or increased consumption (in disseminated intravascular coagulation) may prolong the PT.In chronic liver disorders, an increasing INR indicates progression to liver failure. The INR does not increase in mild hepatocellular dysfunction and is often normal in cirrhosis.Probable coagulation factor deficiency (e.g. hemophilia).Nursing implications: Assess for fatigue, dietary deficiencies and V/S. Assess fluid balance and respiratory status.

Clinical Chemistry May 7, 2012 2:50pmComponentResultNormal ValueInterpretationAnalysisSodium Potassium Chloride Calcium, IonizedCalcium, TotalMagnesiumPhosphorus 134 mmol/L

4.3 mmol/L

97 mmol/L1.08 mmol/L1.88 mmol/L0.63 mmol/L1.68 mmol/L135 148 mmol/L

3.5 4.5 mmol/L

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

Normal

DecreasedDecreasedDecreasedDecreasedIncreasedContributory factor to lethargy and muscle weakness

Due to potassium deficiencyReason of prolonged QT interval in the ECG and PT Tends to cause low serum calcium concentrationComponentResultNormal ValueInterpretationAnalysisGlucose (fasting) Cholesterol TriglyceridesHDL -cholesterolLDL cholesterol6.84 mmol/L

2.73 mmol/L

0.83 mmol/L0.51 mmol/L1.66 mmol/L4.1 - 5.5 mmol/L

5.2 mmol/L

0.0 2.3 mmol/L0.9 1.45 mmol/L0.0 2.59 mmol/LIncreased

Normal

NormalDecreasedNormalMay predispose the client to DM

May predispose the client to development of CADComponentResultNormal ValueInterpretationAnalysisBlood Urea Nitrogen

Serum creatinine

3.9 mmol/L

60 mmol/L2.1-7.1 mmol/

45-104 mmol/LNormal

NormalBUN is affected by hydration, hepatic metabolism of protein and reduced GFRBUN indicates kidney damage, GFR

serum Crea indicates nephron damage, GFRBlood Chemistry May 7, 2012Nursing implications: Assess kidney function and check Input and Output.* Mr. E. T. L. as indicated in his blood chemistry is having a normal renal function.Stool Exam May 6, 2012Macroscopic Examination:Color:Consistency:Gross Evidence of:>WBC>RBC Remarks:Light BrownSoft

0-3/HPF0-2/HPF

No intestinal Parasites seenUrinalysis May 6, 2012ComponentResultInterpretationMACROSCOPIC EXAM:Color Transparency

SugarProtein

pHS.G. MICROSCOPIC EXAM:WBCRBCEpithelial CellsCrystalsBacteria Dark Yellow

Slightly Hazy

N (-)+2

6.01.025

0-2/ HPF1-3/ HPFFEWAmorphous Urates / Phosphates: OccasionalFEW Dehydration is the most common condition that can produce yellow urine. Normal urine is transparent. Normal turbid urine includes precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria.

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

NormalNormal Renal epithelial cells normally appear in the urine in small numbers.NormalNormalChest X-ray May 6, 2012TYPE: In-patient Examination:

Remarks: Department of Medicine General Ward

Chest

-Follow up chest x-ray after a few hours shows complete re-expansion of the left lung with no evidence of pneumothorax-Left sided CTT seen in place.Electrocardiogram Test (ECG) May 6, 2012ABNORMAL FINDINGSINTERPRETATIONPoor R progression

ST-T abnormality (Ant, Lat)

Negative T (Inf)

Right axis deviation

QT prolongation

Clockwise rotation

Atrial FibrillationNoise or baseline drift is present ( V1, V6)Increase the magnitude of the voltage in the leads from V1 to V4Ventricular conduction abnormalities and rhythms originating in the ventricles.Represents ventricular repolarization rhythms originating in the ventricles.congenital heart condition wherein the electrical conduction of the heart is greater than +105 degrees. Between +90 degrees and +180 degrees the condition may be termed Indeterminate Deviation or more often Extreme Right Axis Deviation.factor for sudden cardiac death, Since medications can promote or exacerbate the condition, detection of QT interval prolongation is important for clinical decision support.intraventricular conduction abnormalities secondary to myocardial degeneration.cardiac arrhythmia or irregular heart beat. The ventricles contract irregularly, leading to a rapid and irregular heartbeat.Electrocardiogram Test (ECG) May 6, 2012Nursing Implications: Explain the purpose of the test and explain that there will be no pain from the test.Explain the procedure of the test. The test may be performed when the patient is fully awake, drowsy, undergoing stimuli, asleep, during sleep deprivation, under sedation, or other situations.Prepare the patient: Restrict only sedatives and/or stimulants such as caffeine, alcohol, etc. prior to the test. Patient Teaching: Be sure to include family in the teaching process. The machine may look frightening to the patient. Reassure the patient that he will not get a shock from the machine, especially if this is the first time this patient will have this test. Patients have other misconceptions and fears about the test.Report to the physician if the patient is taking any medications. Some drugs (legal or otherwise) may affect the results of the test. Report if the patient is unusually anxious or upset before the test.The patient will be carefully observed during the test. Ask the patient to relax and lay still during the test. Usually, normal activity may resume after the test. Liver Enzymes May 7, 2012 11:06pmComponentS.I. ResultNormal ValueInterpretationAST (SGOT)

ALT (SGPT) 41u/L

37u/L15-37 u/L

30-65 u/LIncreased

Normal AST is normally found in red blood cells, liver, heart muscle tissue, pancreas, and kidneys. AST may involve prolonged intake of several medication, alcoholism, or due to hyperthyroidismArterial Blood Gases (ABG) May 8, 2012Arterial Blood Gas 05-08-12 3:40PMComponentResultNormal ValueInterpretationPH : pCO2: pO2HCO3: B.ESat O2 Total CO2: 7.45530.2 mm/Hg97.5 mm/Hg22.9 mmol/L1.9 mmol/L97.8 %21.7 mmol/L7.350-7.45035.00-45.0080.00-100.00NormalDecreasedNormalNormalNormalCourse in the WardMay 7, 20126am-2pm ShiftTimeDataActionResponse6:00 am-received pt. in high fowlers position, conscious and coherent- with O2 support via nasal cannula at 4LPM- With IV contraption on R metacarpal infusing PNSS 1L x 40cc/min-with CTT to thoraco bottle on L lower lateral chest wall at 300 water peak level. Initial H2O in CTT: 200-maintain pt. in high fowlers position.-maintain o2 support via nasal cannula at 4lpm-monitored IV rate-monitored placement and patency of CTT6:30 am Paputol-putol yung tulog ko dito kasi maingay at maya-maya ginigising ako.>Dark circles around the eyes> Weakness and restlessness.>Naps whenever possible>Yawning>Assessed sleep pattern disturbances associated with the environment.>Observed and obtain feedbacks regarding on the usual sleeping pattern, bedtime routine and the usual number of hours of sleep and rest.>Did as much care as possible without waking up the client and do as much care as possible while the client is still awake.>Explained necessity of disturbances for monitoring Vital Signs and care when hospitalized.7:00 am-v/s taken and recorded-chest tube tubings, dressing and patency was checked-medication given: methimazole 20mg1tab PO after breakfast-Temp : 36.8c RR: 27 cpm PR: 105 bpm BP: 130/80 mmHg-chest tube are patent, tubings are hang in straight line from mattress to the drainage bottle7:14am-clinical chemistry done-chest tube tubings, dressing and patency was checked-Chest tube is patent, tubings are hanged in a straight line from mattress to the drainage bottle7: 30amNahihirapan akong humingaParang hinihingal ako.RR 27cpm>(+) facial grimace>(+) difficulty of breathing>(+) dry cough>(+)chest wall retraction>(+) use of accessory muscles>(+) shallow breathing>Diminished breath sounds.>Auscultated breath sounds>evaluated respiratory function. >Maintained the clients position (High Fowlers)>Encouraged client to do deep breathing exercises and effective coughing.>Monitored bottle for fluctuation>Maintained O2 therapy @ 4lpm>Administered Salbutamol + Ipratropium through nebulization8:00 amMonitored BP before and after meds.-meds given:Furosemide 20mg1tab PO/ODx 3 daysEnalapril 5mg 1tab PO/OD-Daily O2 Saturation and CBG takenBP within normal ranges.-O2 sat. 96%-CBG: 109 mg/ dL 8:30 amMas nakakahinga na ko ng maayos.RR- 20cpm-Client has established an effective respiratory pattern-Client has shown improved ventilation9:00 amMasakit yung sa gilid ng dibdib ko, parang tinutusok tusok.(+) facial grimace(+) guarding at the affected area- Pain on the Left lateral chestP Exacerbates when coughing and moving.Q- Stabbing painS- 6/10R Radiates to the left shoulderT 5-10 secnanghihina ako, hinahapo pa ako tuwing bumabangon ako.>(+) fatigue--assessed pt.-v/s taken & recorded-medication given:Tramadol 50mg TIV>Evaluated medications the client is taking to see if they could be causing activity intolerance.>Assessed nutritional needs associated with activity intolerance.>Monitored vitals before and after any activity, noting any abnormal changes.> Assessed for pain before activity.> Instructed client in energy-conserving techniques (e.g. carrying out activities at a slower pace).9:30ammga 3 nalang ang score kumpara kanina.-client verbalized a decrease in the level of pain from 6/10 to 3/1010:00am-bed side care done-health teaching on chest tube drainage system provided-pt. verbalized understanding on chest tube system precaution12:00 nn- v/s taken and recorded-input & output measured-meds given: Ceftriaxone 2g TIV (loading dose)-encouraged ambulation- Temp: 36.9c RR = 20 breaths per minute RR: 23 cpm PR: 103 bpm BP: 130/70 mmHg- Input Oral: 500 cc IV: 80cc Total: 580 cc- urine output: 430 cc-Chest tube drainage output: 40ccTotal: 470cc-BM: 02:00 pm-Endorsed patient to the next shiftMay 8, 20126am-2pm ShiftTimeDataActionResponse6:00 am-received pt. sitting on bed, conscious and responsive-continuous with O2 support via nasal cannula at 4LPM- With IV contraption on R metacarpal infusing PNSS 1L x KVO-with CTT to thoraco bottle on L lower lateral chest wall at 300water peak level. Initial H2O in CTT: 200-maintained pt. on sitting position-maintained o2 therapy-monitored IV rate-maintained patency of CTT-pt. verbalized increased comfort6:30ammas okay tulog ko kumapara kahapon.>Patient displayed improvements in sleeping pattern.7:00 am-v/s taken and recorded- medication given: methimazole 20mg 1tab PO afterbreakfast-Temp : 36.9 c RR: 23cpm PR: 100bpm BP: 130/80 mmHg8:00 am-Monitored BP before and after meds- meds given:Furosemide 20mg 1tab PO/ODx 3days Enalapril 5mg 1tab PO/OD-meds given: Ceftriaxone 500mg q 8 hoursBP: 110/70mmHg9:00 amFrom time to time may inaabot ako sa mesa.Makukulit mga kamag-anak ko dito sa pwesto ko.>CTT bottle not secured under the bed.-Daily O2 Saturation and CBG taken>Instructed to refrain from lying or pulling on tubing.>Monitored changes and situations like change in sound of bubbling, sudden air hunger and chest pain, and disconnection of equipment.-O2 sat. 97% -CBG: 116 mg/ dL 10:00amMadalas wala dito ang asawa pag natutulog ako.>With left side rails down while client is in semi-fowlers position.>Caregiver is absent.>Limited ROM >(+) Body weakness>Ensured patients safety by raising the side rails>Advised client not to rise abruptly from a supine position>Provided emotional support to client10:30amMay dugong nalabas sa tubo.Madalas akong naihi.>Noted signs and symptoms of dehydration such as dry mucous membranes, and thirst.>Measured intake and output accurately. 12:00 nn- v/s taken and recorded-input & output measured-meds given: Ceftriaxone 500mg q 8 hours- Temp: 36.9c RR = 20 breaths per minute RR: 23 cpm PR: 99 bpm BP: 120/80 mmHg- Input Oral: 300 cc IV: 320cc Total: 620 cc- urine output: 480 cc CTT output: 30ccTotal: 510cc-BM: 02:00 pm-Endorsed patient to the next shift-The client was free from injury and falls throughout the 8 hour nursing shift.Anatomy and PhysiologyANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

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

A. Nasal PassagesThe nose, the uppermost portion of the humanrespiratory system, is a hollow airpassage that functions in breathing andin the sense of smell. While transporting air to the pharynx, the nasal passage is vital because it playstwocriticalroles:theyfiltertheairtoremovepotentially disease-causing particles; and they moisten and warm the air to protect the structures in the respiratory system.B. PharynxAir leaves the nasal passages and flows to the pharynx, a short, funnel-shaped tube about 13 cm (5 in) long that transports air to the larynx. Like the nasal passages, thepharynx is lined with a protective mucous membrane and ciliated cells that remove impurities from the air.When theadenoidsare swollen, theyblock the flow of air from the nasal passages to the pharynx, and a person must breathe through the mouth.

C. LarynxAir moves from the pharynx to the larynx, a structure about 5 cm (2 in) long located approximately in the middle of the neck. Several layers of cartilage, a tough and flexible tissue, comprise most of the larynx. While the primary role of the larynx is to transport air to the trachea, it also serves other functions. It plays a primary role in producing sound; it prevents food and fluid from entering the air passage to cause choking; and its mucous membranes and cilia-bearing cells help filter air.

D. Trachea, Bronchi, and BronchiolesAir passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6in) long located just below the larynx. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy cartilage rings hold the trachea open, enabling air to pass freely at all times. The open part of the C-shaped cartilage lies at the back of the trachea, and the ends of the C are connected by muscle tissue. The base of the trachea is located a little below where the neck meets the trunk ofthe body. Here the trachea branches into two tubes, the left and right bronchi, which deliverair tothe leftand right lungs,respectively. Within thelungs,the bronchi branch into smaller tubes called bronchioles. The trachea, bronchi, and the first few bronchioles contribute to the cleansing function of the respiratory system, for they, too, are lined with mucous membranes and ciliated cells that move mucus upward to the pharynx.

E. AlveoliThe bronchioles divide many more times in the lungs to create an impressive tree with smaller and smaller branches, some no larger than 0.5 mm (0.02 in) in diameter. These branches dead-end into tiny air sacs called alveoli. The alveoli deliver oxygen to the circulatory system and remove carbon dioxide. Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli and remove foreign substances that have not been filtered out earlier. The macrophages are the last line ofdefenseoftherespiratorysystem;theirpresencehelpsensurethatthealveoliareprotected from infection so that they can carry out their vital role.

Differential DiagnosisSIGNS AND SYMPTOMSPNEUMOTHORAXPLEURAL EFFUSIONPULMONARY EDEMAProductive coughAbsentPresentPresentAbsent or diminished breath sounds on the affected sideEvidentEvidentNot evident TachypneaPresentPresentPresentDyspneaPresentPresentPresentDifficulty of breathingPresentPresentPresentAbsent or diminished tactile fremitus on the affected sideEvidentEvidentNot evidentDullness on the affected side when percussedAbsentPresentAbsentAsymmetrical chest expansionEvidentEvidentNot evidentSharp chest pain exacerbated when coughingPresentPresentAbsentOrthopneaPresentPresentPresentLateral CXR: Opaque densities on the lower lobe, blunting of the costophrenic angleAbsentPresentAbsentPosteroanterior CXR:Air in the pneumo region shown is much darker than the air within the actual lung in the affected partThere is an area of whiteness in the affected areaKerley lines: thin linear pulmonary opacities:Pathophysiology

Nursing Care PlanAssessmentDiagnosisInferencePlanningNursing InterventionRationaleEvaluationS: Nahihirapan akong humingaO:> conscious and coherent> V/S: RR 27cpm>(+) facial grimace>(+) difficulty of breathing>(+) dry cough>(+)chest wall retraction>(+) use of accessory muscles>Diminished breath sounds.>With under water seal Chest tube on the Left lung, 5th ICS, LMA line.Ineffective breathing pattern related to decreased lung expansion.Air accumulation in the pleural space

Increase pressure around the lungs

Decreased lung expansion

Inspiration/expiration doesnt provide adequate ventilation

Ineffective breathing patternAfter 1 hour of nursing intervention, the Client will establish an effective respiratory pattern with a normal respiratory rate of 16-20cpm.Independent:Auscultated breath sounds and evaluate respiratory function, noting rapid/shallow respirations, dyspnea,reports of air hunger, development of cyanosis, changes in v/sMaintained the clients position (High Fowlers)Monitored bottle for fluctuationMonitored Chest tube drainage output.Positioned chest tube drainage below the bed.Dependent:Maintained O2 therapy @ 4lpmAdministered Salbutamol + Ipratropium .Collaborative:Monitored Chest x-raysIndependent:Regularly scheduled evaluation provides a baseline to evaluate resolution of pneumothorax .Respiratory distress and changes in v/s occur as a result of physiologic distress and pain, or may indicate development of shock due to hypoxia/ hemorrhage.Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion. To check for chest tube patency.To determine if patient is bleeding from a vessel that was not cauterized during closure of chest or a ruptured graft.To avoid kinking, damaging and any instances that will affect the drainage system.Dependent:Oxygenation provides more o2 supply.This medication dilates the bronchi and creates a better airway.Collaborative: To monitor the progress of resolving pneumothorax and re-expansion of lungs.After 1 hour of nursing intervention, the Client has established an effective respiratory pattern as evidenced by respiratory rate of 20cpm.AssessmentDiagnosisInferencePlanningNursing InterventionRationaleEvaluationS:Parang hinihingal ako.O:conscious and coherent> V/S: RR 27cpm PR 105bpm>(+) difficulty of breathing>(+) dry cough>(+)chest wall retraction>(+) use of accessory muscles>Diminished breath sounds.>With under water seal Chest tube on the Left lung, 5th ICS, LMA line.Impaired Gas exchange related to decreased lung expansion secondary to air accumulation in the pleural space.Air accumulation in the pleural space

Increase pressure around the lungs

Decreased lung expansion

Decreased surface area for oxygen and carbon dioxide to exchange

Impaired Gas ExchangeAfter 1 hour of nursing intervention, the Client will have improved ventilation and adequate oxygenation as evidenced by respiratory rate of 16-20.Independent:Maintained airway clearances clean and patent.Monitored ABG resultsMaintained clients High Fowlers position.Have patient practice pursed lip breathing.Encouraged client to stop smokingDependent:1. Administered O2 at 4 LpmCollaborative:Monitored ABG and Chest X-ray results.Independent:Clearing airways of secretions improves ventilationperfusion relationship.ABG results provide integral information to determine deficits in capacity and effect of oxygen delivery.To facilitate chest expansionPromotes alveolar openTo decrease risk and prevent further decline in lung functionDependent:To provide O2 to the clients body and balance ABG.Collaborative:To monitor the progress of the clients conditionAfter 1 hour of nursing intervention, the Client has improved ventilation and adequate oxygenation as evidenced by 20cpm.AssessmentDiagnosisInferencePlanningNursing InterventionRationaleS:Masakit ang dibdib ko, parang tinutusok tusok.O:> conscious and coherent> V/S: RR 27cpm>(+) facial grimace>Guarding at the affected area>Pain at the Left thoracic region. P Exacerbates when coughing and moving.Q- Stabbing painS- 6/10R Radiates to the left shoulderT 5-10 secAcute Pain related to impaired pleural integrityTissue damage

Peripheral neurotransmitters released

Free nerve endings (nociceptors) triggered

Signals travel to spinal cord

Signals rerouted to appropriate area of brain

Brain interprets quality and intensity of pain presentAfter 30 minutes of nursing intervention, the client will verbalize a decrease of level of pain from a score of 6/10 to a 3/10Independent:Monitored pain. Let the client describe the pain he feels.Assisted client on splinting the painful area when coughing and deep breathing.Provided a calm, quiet environment.Monitored vital signs.Monitored the sleeprest pattern.Stabilized chest tube.Explained and demonstrated the proper breathing exercise to the ptexplained and demonstrated cutaneous stimulation to the ptExplained the ways and benefits of diversional activities to alleviate the pain of the ptDependent:Administer Tramadol 50mg TIVIndependent:Pain is subjective in nature, and only the patient can fully describe it.Splinting the affected area may lessen the pain that the client feels.Promotes action and effect of medication by providing decreased stimuli. To detect changes that might indicate pain or a complication of pain.Fatigue may contribute to an increased pain response, or pain can contribute to interrupted sleep.To reduce pull or drag on latex connector tubing which could add up to the pain.Enhances sense of control and may improve coping abilities.Reduces muscle tension and anxiety associated with pain.Enhances sense of well-being and helps forget the thought of pain.Dependent:Analgesics given TIV reach the pain centers immediately, providing more effective relief with small doses of medication.Assessment:Nursing diagnosis:Inference:Planning:Intervention:Rationale:Evaluation:Subjective:Paputol-putol yung tulog ko dito kasi maingay at maya-maya ginigising ako.Objective:>Dark circles around the eyes> Weakness and restlessness.>Taking nap when there is a chance or if there is a free time.>YawningDisturbed Sleep Pattern related to interruptions for therapeutics, monitoring and other generated awakening and excessive stimulation (noise and lighting).External noises and interruptions

Excessive environmental stimulation

Disruption of relaxation

Reduced initiation of the body to induce sleep

Patient is unable to obtain adequate sleep

Disturbed sleep patternAfter 1 day of nursing intervention the patient will display improvements in sleeping pattern. Independent:1. Assess sleep pattern disturbances that are associated with the environment.2. Observe and obtain feedbacks regarding on the usual sleeping pattern, bedtime routine and the usual number of hours of sleep and rest.3. Do as much care as possible without waking up the client and do as much care as possible while the client is still awake.4. Explain necessity of disturbances for monitoring Vital Signs and care when hospitalized.5. Provide information about relaxation techniques (such as instrumental music and meditation).Dependent:1. Administer sedatives as indicatedIndependent:1. High percentage of sleep disturbances can affect the recovery of the patient. 2. To determine usual sleeping pattern and to compare if there are any improvements on the sleeping pattern of the patient. 3. To avoid disturbances during sleep, and also to maximize the sleep and rest of the client.4. For the patient to have an understanding of the importance of care being done to her and to minimize the complaints.5. For the client to condition his body for sleeping.Dependent:1. Timely medication can enhance rest or sleep.After 1 day of nursing intervention the patient was able to display improvements in sleeping pattern.AssessmentNursing diagnosisInferencePlanningInterventionRationaleEvaluationSubjective:nanghihina ako, hinahapo pa ako tuwing bumabangon ako.Objective:>RR- 27cpm>Weak in appearance>(+) fatigue>thin in appearance>(+) DOBActivity intolerance r/t generalized weakness and fatigueGeneralized weakness

Insufficient physical or psychological energy to endure or perform desired activities

Activity intoleranceAfter 4 hours of nursing intervention, the patient will be able to identify techniques in enhancing activity tolerance.Independent: 1. Evaluated medications the client is taking to see if they could be causing activity intolerance.2. Assessed nutritional needs associated with activity intolerance.3. Monitored vitals before and after any activity, noting any abnormal changes.4. Assessed for pain before activity.5. Instructed client in energy-conserving techniques (e.g. carrying out activities at a slower pace).Collaborative:1. Administer analgesics as indicatedIndependent:1. Medications such as beta-blockers, lipid- lowering agents, which can damage muscle tissue, and some antihypertensive can result in decreased functioning.2. The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers.3. This can be caused by a temporary insufficiency of blood supply4. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.5. Energy-saving technique reduces the energy expenditure, thereby assisting in equalization of oxygen supply and demand.Collaborative:1. Relief of pain can help increase tolerance to activitiesAfter 4 hours of nursing intervention, the patient was be able to identify techniques in enhancing activity toleranceAssessmentDiagnosisInferencePlanningNursing InterventionRationaleEvaluationS:From time to time may inaabot ako sa mesa.Makukulit mga kamag-anak ko dito sa pwesto ko.O:> With under water seal Chest tube on the Left lung, 5th ICS, LMA line.>CTT bottle is not secured under the bed>Patient is restlessRisk for Trauma related to dependence on Chest tube Drainage systemChest tube insertion

Chest tube Drainage system dependence

CTT bottle is not secured under the bed

Visitors constantly moving around the bed

Risk for TraumaClient will be free from trauma throughout the 8 hour nursing shiftIndependent:Instruct client to refrain from lying or pulling on tubing.Monitor changes and situations like change in sound of bubbling, sudden air hunger and chest pain, and disconnection of equipment.Provide safe transportation when client is sent off unit for diagnostic purposes.Anchor thoracic catheter to chest wall and provide extra length of tubing before turning or moving client.Monitor thoracic insertion site, noting condition of skin and presence and characteristics of drainage from around the catheter. Change and reapply sterile occlusive dressing as needed.Observe for signs of respiratory distress if thoracic catheter is disconnected/ dislodged.Independent:Reduces risk of obstructing drainage or inadvertently disconnecting the tubing. Timely intervention may prevent serious complications.Promotes continuation of optimal evacuation of fluid or air during transport.Prevents thoracic catheter dislodgment or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing.Provides for early recognition and treatment of developing skin or tissue erosion or infection.6. Pneumothorax may recur/ worsen, compromising respiratory function and requiring emergency interventionClient was free from trauma throughout the 8 hour nursing shiftAssessmentNursing diagnosisInferencePlanningInterventionRationaleEvaluationSubjective:Madalas wala dito ang asawa pag natutulog ako.Objective:>With left side rails down while client is in semi-fowlers position.>Caregiver is absent.>Limited ROM >(+) Body weaknessRisk for falls related to generalized weakness Body weakness

Decreased muscle strength

Lowered side rails

Patient is left unattended by the significant other

Risk for fallsWithin the 8 hour nursing shift, the client will be free from falls Independent:1. Assessed patients general condition2. Ensured patients safety by raising the side rails3. Monitored vital signs4. Advised client not to rise abruptly from a supine position5. Provided emotional support to client6. Created an individualized exercise program for the clientCollaborative:Consult with dietician for proper diet and nutritionIndependent:1. To determine the patients status2. To keep the patient from falling of f the bed when moving3. To obtain baseline data4. Abrupt change of position can lead to orthostatic hypotension5. To decrease anxiety.6. Engaging in regular exercise and activity will strengthen muscles, improve balance, and increase bone density.Collaborative:1. Proper nutrition and diet promotes body strength and bone density.Within the 8 hour nursing shift, the client was free from fallsAssessmentDiagnosisInferencePlanningNursing InterventionRationaleEvaluationS: May dugong nalabas sa tubo.Madalas akong naihi.O:>Conscious and coherent> With under water seal Chest tube on the Left lung, 5th ICS, LMA line.> With ongoing IVF, PNSS 1L x 40cc/ min attached to patients right metacarpal vein.> Client is also under medication of Furosemide 20mg, 1 tab OD x 3 days Risk for deficient fluid volume related to treatment regimenTreatment regimen(chest tube drainage system and Furosemide medication)

Collection of blood and air from the chest tube. Furosemide creates diuresis

Decreased fluid in the body

Risk for deficient fluid volumeThroughout the 8 hour nursing intervention, the client will be able to maintain a near balance between intake and output.Independent:1. Measure I&O accurately. Weight daily. Calculate insensible fluid losses.2. Encourage fluid intake. Provide allowed fluids throughout 24 hour period.3. Monitor BP, noting postural changes and heart rate4. Note signs and symptoms of dehydration such as dry mucous membranes, thirst, dulled sensorium and peripheral vasoconstriction5. Control environmental temperature, limit bed linens as indicated.Collaborative:1. monitor labs studies such as sodiumIndependent:1. Helps estimate fluid replacement needs.2. To replace lost fluids.3. orthostatic hypotension and tachycardia suggest hypovolemia4. For immediate prevention of severe dehydration.5. may reduce diaphoresis which contributes to overall fluid losses.Collaborative:1. To gain a more accurate assessment of the patients conditionThroughout the 8 hour nursing intervention, the client was able to maintain a near balance between intake and outputAssessmentNursing diagnosisInferencePlanningInterventionRationaleEvaluationSubjective:Di ako masyado nakakagalaw-galaw.Objective:>Client is conscious and coherent>Limited ROM >(+) Body malaiseRisk for constipation related to changes in level of activity Body weakness and lack of privacy

Decrease in level of activity

Decreased stimulation of the smooth muscles of the G.I tract.

Decrease in peristalsis

Risk for constipationAfter 1 hour of nursing intervention, the Client will verbalize understanding of ways in improving bowel elimination patterns an effective respiratory pattern. Independent:1. Ascertained usual bowel pattern and aids used. Compare with current routine.2. Provided diet high in fiber bulk in the form of whole-grain cereals, breads, and fresh fruits.3. Encouraged increased fluid intake.4. Institute an individualized program of exercise, rest, and diet.5. Provided emotional support to clientDependent:Administered medications as indicated (e.g. bulk providers and stool softeners)Independent:1. Determines extent of problem and indicates types of interventions appropriate.2. Improves stool consistency, promotes evacuation3. Promotes normal stool consistency.4. Increase in activities and movement increases peristalsis.5. Decreases feelings of embarrassment and frustration.Dependent:1. Promotes regularity by increasing bulk or improving consistency. After 1 hour of nursing intervention, the Client has verbalized understanding of ways in improving bowel elimination patterns an effective respiratory patternAssessmentNursing diagnosisInferencePlanningInterventionRationaleEvaluationSUBJECTIVE:Mahirap tumigil sa pagyoyosi eh.OBJECTIVE:>Request forInformation about the disease process.>Inaccurate follow through of instructions.> Demonstrates nonacceptance of health status change.Risk forProne healthbehaviorrelated tolack ofknowledgeabout thediseaseLack of knowledge about the disease process

Reduced motivation to modify lifestyle

Reduced interest in self-care

Risk for prone health behaviorAfter 4 hoursof nursinginterventions,the patient will demonstrate increase in interest and participation in self-care INDEPENDENT:1. Established rapport2. Assessed patients general condition.3. Assisted the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol, smoking, and drinking.4. Reinforced the importance of adhering to treatment regimen and keeping follow up appointments.5. Identify with the client past and present significant support systems (family, church, groups and organizations).6. Identify possible cultural beliefs / values influencing clients response to change.7. Acknowledge clients efforts to adjust: You have done your best.Collaborative:1. Refer to spiritual adviser in necessaryINDEPENDENT:1. To prevent patient anxiety and establish cooperation2. To determine patients status.3. These risk factors have been shown to contribute to the development of several types of diseases.4. Provides basis for understanding of the condition. Lack of cooperation may lead to failure of therapy.5. Identifies helpful resources that may be needed in current situation.6. Different cultures deal with change of health issues.7. Avoids feelings of blame / guilt and defensive response.Collaborative:1. For the client to be given spiritual counseling.After 4 hoursof nursinginterventions,the patient will demonstrate increase in interest and participation in self-careDrug StudyDRUG NAMECLASSIFICATIONMECHANISM OF ACTIONINDICATIONDOSAGE/ROUTE/FREQUENCYNURSING CONSIDERATIONSEVALUATIONBRAND NAME:ReglanGENERIC:MetoclopramideAntiemetic, Dopaminergic blocker, GI stimulantStimulates motility of upper GI tract without stimulating gastric, biliary or pancreatic secretions.Sensitizes tissues to action of acetylcholineRelaxes pyloric sphincter, which when combined with effects of motilityAccelerates gastric emptying and intestinal transit; little effect on gallbladder or colon motilityIncreases esophageal sphincter pressure, has sedative propertiesInduces release of prolactin.-Relief of symptoms of acute and recurrent gastroparesis.-Stimulation of gastric emptying and intestinal transit of barium.10 mg/ TIV/ now then PRN for nausea & vomiting.-Assess for allergy to metoclopramide, GI hemorrhage, mechanical obstruction or perforation, epilepsy.-Assess the patients orientation, reflexes, VS, bowel sounds, normal output, EEG.-Monitor BP carefully during IV administration.-Monitor for extrapyramidal reactions, and notify physician if they occur.-Report involuntary movement of the face, eyes, limbs, severe depression & severe diarrhea.-The patients VS were monitored, in normal ranges during IV administration.-Nausea and vomiting was prevented.DRUG NAMECLASSIFICATIONMECHANISM OF ACTIONINDICATIONDOSAGE/ROUTE/FREQUENCYNURSING CONSIDERATIONSEVALUATIONBRAND NAME:Propyl-ThyracilGENERIC:PropylthiouracilAntithyroid drugInhibits the synthesis of thyroid hormones

Partially inhibits the peripheral conversion of T4 to T3 the more potent form of thyroid hormone.Hyperthyroidism 50 mg / 1 tab per orem/ q6-Asses for allergy to antithyroid drugs.-Assess the patients skin color, lesions, pigmentations, orientation, reflexes.-Administer drug in three equally divided doses at 8 hour intervals, schedule to maintain patients sleep pattern.-Arrange for regular, periodic blood tests to monitor bone marrow depression and bleeding tendencies.-Report fever, sore throat, unusual bleeding or bruising. Headache & general malaise.-The clients thyroid hormones are within normal levels.DRUG NAMECLASSIFICATIONMECHANISM OF ACTIONINDICATIONDOSAGE/ROUTE/FREQUENCYNURSING CONSIDERATIONSEVALUATIONBRAND NAME:VasotecGENERIC:EnalaprilACE inhibitor, AntihypertensiveRenin released into circulation

Acts on a plasma precursor to produce angiotensin IConverted by ACE to angiotensin IIIncreases BP.Blocks the conversion of angiotensin I to angiotensin II

Decreases BP and aldosterone secretion, slightly increases serum K+ levels and causing Na+ and fluid loss. Treatment of hypertension5 mg/ 1 tab Per Orem/ OD-Assess for allergy to enalapril, impaired renal function, salt or volume depletion.-Assess patients skin color, lesions, turgor, orientation, reflexes, peripheral sensations, VS, mucous membranes, bowel sounds and liver evaluation.-Monitor patient on diuretic therapy for excessive hypotension after the first few doses of enalapril.-Monitor patient closely in any situation that may lead to a drop in BP secondary to reduced fluid volume (excessive perspiration, and dehydration, vomiting and diarrhea).-Patient was monitored closely for any situation that might lead to a drop in BP.-Patients blood pressure is within normal ranges.DRUG NAMECLASSIFICATIONMECHANISM OF ACTIONINDICATIONDOSAGE/ROUTE/FREQUENCYNURSING CONSIDERATIONSEVALUATIONBRAND NAME:Apo-FurosemideGENERIC:FurosemideLoop diuretic Action at the proximal and distal tubules and ascending limb of the loop of Henle Inhibition of reabsorption of sodium and chloride

Leads to a sodium-rich diuresis.For mild to moderate hypertension20 mg/ 1 tab Per Orem/ OD x 3 days-Assess allergy to medication.-Assess the patients skin color, lesions.-Reduce dosage if given with antihypertensive drugs , readjust dosage gradually as BP responds.-Give early in the day so that increased urination will not disturb sleep.-Avoid IV use if oral use is at all possible.-Measure and record weight to monitor fluid changes.-Arrange to monitor serum electrolytes, hydration, liver and renal function.-Arrange for potassium rich diet or supplemental potassium as needed.-Patients sleep pattern was not disturbed.-Patients blood pressure is within normal ranges.DRUG NAMECLASSIFICATIONMECHANISM OF ACTIONINDICATIONDOSAGE/ROUTE/FREQUENCYNURSING CONSIDERATIONSEVALUATIONBRAND NAME:InnoPran XLGENERIC:PropranololAntianginal, antiarrhythmic. Antihypertensive, Beta-adrenergic blocker (non selective)Completely blocks beta-adrenergic receptors in the heart and juxtoglomerular apparatus Decreases the influence of sympathetic nervous system on these tissues, the excitability of the heart, cardiac workload and O2 consumption, and the release of renin and lowering BP.For adult hypertension20 mg/ 1 tab Per Orem/ q8-Assess allergy to beta-blocking agents, sinus bradycardia, second or third degree heart block, cardiogenic shock, peripheral vascular diseases.-Assess the patients weight, skin color, lesions, edema, reflexes.-Provide continuous cardiac and regular BP monitoring with IV form.-Give oral drug with food to facilitate absorption.-Report difficulty of breathing, night cough, swelling of extremities, slow pulse, confusion, depression, rash fever, sore throat.Patients cardiac status and BP were maintained within the normal range.DRUG NAMECLASSIFICATIONMECHANISM OF ACTIONINDICATIONDOSAGE/ROUTE/FREQUENCYNURSING CONSIDERATIONSEVALUATIONBRAND NAME:TapazoleGENERIC:MethimazoleAntithyroid drugInhibits the synthesis of thyroid hormone.Treatment of hyperthyroidism.Methimazole 20mg 1 tab Per Orem after breakfast Methimazole 5mg/ tab 2 Per Orem tab after dinner -Assess allergy to antithyroid products.-Assess for skin color, lesions, pigmentation, orientation. Reflexes.-Give drug in three equally divided doses at 8-hr interval.-Establish a schedule that fits the patients routine.-Advise the patient that taking this drug could increase the risk of bleeding problems.-Report fever, sore throat, unusual bleeding or bruising, headache and general malaise.-Obtain regular, periodic blood tests to monitor bone marrow depression and bleeding tendencies.-Thyroid storm was prevented.-Patient did not develop any allergies to the medicationDRUG NAMECLASSIFICATIONMECHANISM OF ACTIONINDICATIONDOSAGE/ROUTE/FREQUENCYNURSING CONSIDERATIONSEVALUATIONBRAND NAME:RocephinGENERIC:CeftriaxoneAntibiotic, Cephalosporin (third generation)Binds to receptors of bacterial cells

Inhibits synthesis of bacterial cell wall

Causes cell deathLower respirations infections2g/ TIV/ OD (loading dose)500mg for consecutive doses TIV q8 -Assess for hepatic and renal impairment.-Assess the skin status, renal function tests, culture of affected area, sensitivity tests.-Advice the patient that he may experience stomach upset and diarrhea.-Report severe diarrhea, difficulty breathing, unusual tiredness or fatigue, pain at the injection site.-Discontinue if hypersensitivity occurs.Patient was monitored closely for stomach upset and diarrhea.DRUG NAMECLASSIFICATIONMECHANISM OF ACTIONINDICATIONDOSAGE/ROUTE/FREQUENCYNURSING CONSIDERATIONSEVALUATIONBRAND NAME:TitradoseGENERIC:Isosorbide DinitrateVasodilatorRelaxes vascular smooth muscle with a resultant decrease in venous return

Decrease in arterial BP Reduces left ventricular workload Decreases myocardial oxygen consumptionTreatment and prevention of angina pectoris/ chest pain5mg/tab/ 1 tab OD for chest pain-Assess for any allergy to nitrates, severe anemia, GI hypermobility.-Assess for skin color, lesions, orientation, reflexes.-Monitor effectiveness of drug in relieving angina.-Headaches tend to decrease in intensity and frequency with continued therapy but may require administration of analgesic and reduction in dosage.-Make position changes slowly, particularly from recumbent to upright posture, and dangle feet and ankles before walking.-Keep a record of angina attacks and the number of sublingual tablets required to provide relief.Patient was monitored closely and chest pain was relieved.DRUG NAMECLASSIFICATIONMECHANISM OF ACTIONINDICATIONDOSAGE/ROUTE/FREQUENCYNURSING CONSIDERATIONSEVALUATIONBRAND NAME:DuoNebGENERIC:Salbutamol + IpatropiumAntiasthmatic & COPD preparationsIPATROPIUM:Anticholinergic agent inhibits vagally-mediated reflexes by antagonizing the action of acetylcholine. Prevents the increase in intracellular concentration of cyclic guanosine monophosphate w/c are brought about by interaction of acetylcholine with the muscarinic receptors on bronchial smooth muscle.SALBUTAMOL:Direct acting Beta2-adrenergic agent. Acts on the airway smooth muscle resulting in bronchodilation.Provides inhalation for DOB.1 nebule Q6 PRN for DOB-Monitor respiratory status; Auscultate lungs before and after inhalation.-Report treatment failure (exacerbation of respiratory symptoms) to physician.-Do not allow the solution to enter the eyes.-Allow 30-60 seconds between puffs for optimum results.-Advice patient to wait for 5 mins between this and other inhaled medications.-Let the patient rinse mouth after medication puffs to reduce bitter taste.Patients DOB was managed and relieved.DRUG NAMEClassificationActionIndicationDosage/Route/FrequencyNursing ConsiderationsEVALUATIONBrand Name:TramadineGeneric Name:TramadolAnalgesics (opioid)Inhibits reuptake of norepinephrine, serotonin and enhances serotonin release.

Inhibits reuptake of norepinephrine, serotonin and enhances serotonin release.

Decreased painIndicated for the management of moderate to moderately severe pain.50mg TIV p.r.n. q6 -Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration.-Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression-Discontinue drug and notify physician if S&S of hypersensitivity occur.-Assess bowel and bladder function; report urinary frequency or retention.-Monitor ambulation and take appropriate safety precautions.-Client has verbalized that pain was either reduced or relieved. Discharge PlanDischarge PlanMedications:Inform the client the importance of compliance with taking the medications as prescribed by the physician.Continue medications prescribed such as:Methimazole 20mg 1 tab Per Orem after breakfast Methimazole 5mg/ tab 2 Per Orem tab after dinnerPain medication should be given on discharge.Exercise:Instruct on Deep Breathing Exercise and effective coughingInstruct patient to avoid extremes exercises, which will lead him to stress; and as to avoid shortness of breath.Instruct client to perform exercise as tolerated Treatment:Instructed client to continue steam inhalation and gentle chest physiotherapy.Health Education:Self care:Encourage patient to avoid doing strenuous activitiesChest tube wound site should be monitored for infection and to ensure proper healing.Encourage patient to stop smoking and avoid excessive alcohol intakeProvide information about Pneumothorax and its signs and symptoms to avoid another occurrence in the future.Home Care: Encourage to have a regular BP check-up at the nearest barangay health stationKeep an environment free of air and noise pollution.

Discharge PlanOPD follow up:Instruct patient to return if there is chest pain or shortness of breathTeach patient when to notify the physician of complication (e.g. infections and an unhealed wound)Review all follow- up appointments with the patient, involving chest x-rays, arterial blood gas analysis, and a physical exam.Diet:Instructed client on regular fluid intake and regular dietEat foods high in protein and high in calories. Foods such as whole dairy products, nuts and peanut butter, and fatty cuts of meat can help to add needed nutrients.Eat foods with enough calcium contents such as dairy products.Avoid excessive intake of caffeine

Spirituality:Support clients religious practices.Refer client for spiritual counseling.

Thank you! :D