UNIVERSITY OF MAKATI

College of Allied Health Studies

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

Spontaneous Pneumothorax
In Partial Fulfillment of the Requirements in Medical and Surgical Nursing I
Presented by: Aloba, Kenosis P. De Asis, Kenneth Generao, Ginalyn Lupango, Jessa Olino, Rustia Caren Oliveros, Juan Miguel Orillaneda, Jean Pasco, John Carlo Sale, Rhechell C. Sulangi, Angela

Introduction

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

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

Pneumothorax (pl. pneumothoraces) is an abnormal collection of air or gas in the pleural space that separates the lung from the chest wall, and that may interfere with normal breathing. It occurs when the parietal or visceral pleura are breached and the pleural space is exposed to positive atmospheric pressure.
Normally, the pressure in the pleural space is negative. This negative pressure is required to maintain lung inflation. When either of them is breached, air enters the pleural space and the lung or a portion of it collapses. The types of pneumothorax include simple, traumatic, and tension pneumothorax.

A simple, or spontaneous, pneumothorax may occur in an apparently healthy person in the absence of trauma due to rupture of an air-filled bleb, or blister, on the surface of the lung, allowing air from the airways to enter the pleural cavity. The spontaneous pneumothorax is either a primary or a secondary pneumothorax. Primary Spontaneous Pneumothorax is the air in the pleural space without preceding trauma and without underlying clinical or radiologic evidence of lung disease.
Secondary Spontaneous Pneumothorax occurs in patients with underlying pulmonary structural pathology. Air can enter the pleural space via distended, damaged, or compromised alveoli. It may present with more serious clinical symptoms and sequel due to comorbidity. Pneumothorax can also develop as a result of underlying lung diseases, including cystic fibrosis, chronic obstructive pulmonary disease (COPD), lung cancer, asthma, and infections of the lungs.

A Traumatic Pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or from a wound in the chest wall. It may result from a blunt trauma (e.g. rib fractures), penetrating chest or abdominal trauma (e.g. stab wounds or gunshot wounds), or diaphragmatic tears. Open Pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Such injuries are called sucking chest wounds due to the rush of air producing a sucking sound. Not only does the lung collapse, but the structures of the mediastinum (heart and great vessels) also shift toward the uninjured side with each inspiration and in the opposite direction with expiration. This is called the mediastinal flutter or swing.

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

The risk factors that a person is more likely to develop pneumothorax include: sex (occurs more in males than females, 4:1 ratio), age (2040 yrs), tall and thin body built, history of smoking, change in atmospheric pressure, previous history of pneumothorax, family history, underlying chronic lung disease (e.g. emphysema, asthma, tuberculosis, pneumonia, cystic fibrosis and lung cancer), medical procedures (e.g. Thoracentesis), and mechanical ventilation.

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

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

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

Specific objective:
Student-centered:
To conduct a research regarding the 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 Pneumothorax To enhance our nursing skills in identifying and classifying signs and symptoms of the patient with Spontaneous Pneumothorax. To hone us to become competitive nurses in the future. To be able to execute the effective nursing interventions that may help promote the well being of the patient and decrease risk for further complications. To assess the patients response to the treatment and evaluate the effectiveness of the nursing care given. To review the Anatomy and Physiology of the system related to the disease. To be aware of the pathophysiology of the disease.

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

Health History

Patients Profile
Name: Mr. E. T. L. Sex: Male Age: 36 years old. Civil Status: Married Nationality: Filipino Birth date: August 26, 1975 Birth Place: Valenzuela City Address: Guadalupe, Makati Religion: Roman Catholic Educational Attainment: High School Graduate Occupation: Bag seller at the Guadalupe market

Patients Profile
Date and time of admission: May 6, 2012 8:15 AM Mode of admission: General ward Admitting Diagnosis: Spontaneous Pneumothorax Preoperative Diagnosis: Massive Pneumothorax Left Secondary to Ruptured Bleb vs Idiopathic Operation Performed: E Chest Tube Thoracostomy, Left Postoperative Diagnosis: Massive Pneumothorax, Left, Secondary to Ruptured Bleb vs Idiopathic

Informant:

Patient

Percentage Reliability: 90%

Chief Complaint
Dalawang linggo na akong nahihirapang huminga,

History of Present Illness

2 weeks Prior to Admission, the client experienced difficulty of breathing and had a fever of 38.1C. 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 stated

History of Present Illness

2 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 History

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

5 yrs old

Bronchial Asthma None

Self medication

Salbutamol

2005

Goiter due to Hyperthyroidism

Manila Doctors Hospital

Unmanaged

Was only compliant with medications from yr 20052008. Unrecalled

Family Medical History

Family Medical History

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

Personal and Social History

The 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 Assessment

Physical Assessment
DATE AND TIME: May 7, 2012 General appearance: 9:00am 11:00am (+) 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 C Respiratory rate: 27 cpm Pulse rate: 105 bpm Blood pressure: 130/80 mmHg

ORGAN/BODY PARTS

METHODS USED

Skin

Inspection Palpation

Head
Hair Face Eyes

Inspection

Inspection

FINDINGS *Hematomas on antecubital and radial surface on both arms (-) cyanosis Dark complexion Intact skin Good skin turgor Normocephalic (-) Head injury (-) Tenderness (-) Lesions (-) hair parasites (-) dandruffs Hair is evenly distributed Normal facial movements PERRLA: Pupils are equal and round, left eye 3 mm reactive to light and right eye 3 mm reactive to light, good accommodation noted. *slightly protruding eyes *Dark circles around the eyes

SIGNIFICANCE

*Hematomas are due to blood samples taken

Normal

Normal

Inspection Inspection

Normal

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

ORGAN/BODY PARTS

Ears

METHODS USED Inspection Watch tick test Palpation

FINDINGS

SIGNIFICANCE

Nose:

Inspection

Mouth:

Inspection

Neck:

Inspection Palpation

Bilaterally equal in size Normal (-) lesions (-) discharge (-) redness (-) bleeding Able to hear sounds on both ears Pinna is firm, non tender and no pain Symmetric and straight Normal (-) discharges O2 Therapy is used to (-) nasal flaring benefit patient by increasing With O2 administered at the supply of O2 to the lungs 4L/min via nasal cannula and thereby increasing the availability of O2 to the body tissues *(+) dental carries *Absence of teeth on upper There could be difficulty in mandible mastication. Uniform and pinkish tongue with no lesion, Moist pink buccal mucosa Symmetric and head centered There could be presence of (+) swollen lymph nodes infection (+) Lump on the neck There is thyroid enlargement

ORGAN/BODY PARTS Upper Extremities

METHODS USED Inspection Palpation

FINDINGS
With IV contraption on R metacarpal infusing PNSS 1L x 40cc/min *20.5cm mid-upper arm circumference Equal pulses (+) tachycardia
(-) Pail (-) Indentations Capillary refill less than 3 seconds With CTT one-way drainage system inserted on the 5th ICS, LMA line RR = 27cpm (+) difficulty of breathing (+) dry cough (+)chest wall retraction (+) use of accessory muscles Diminished breath sounds and pleural rub on left lung Hyper resonance on left lung Tactile fremitus decreased on left lung (-) visible pulsation No heart murmurs auscultated over aortic, pulmonic, tricuspid and mitral area. Normal heart rate and regular rhythm HR = 105bpm (+)Tachycardia

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

Nails: Thorax and lungs:

Inspection Palpation Inspection Auscultation Percussion Palpation

Heart

Inspection Auscultation

Heart compensates to increase oxygenation

ORGAN/BODY PARTS Abdomen

METHODS USED Inspection Auscultation Palpation Inspection Inspection Palpation

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

SIGNIFICANCE Normal

Genito-urinary Lower Extremities

No swelling, no lesions Normal noted Legs bilaterally symmetric, no *Due to weakness ulcerations noted. *(+) limited ROM *(+) body malaise Equal pulses (+) tachycardia (-) Pail (-) Indentations Capillary refill less than 3 seconds Normal

Nails:

Inspection Palpation

Review of Systems
SYSTEM
General

CUES

INTERPRETATION

SIGNIFICANCE

Medyo nanghihina pa ako.

(+) body malaise

Body weakness is attributed to the present condition Tenderness is due to puncture of skin from obtaining blood specimen.

Skin/Integumentary May konting sakit sa System mga parte na

(+) Tenderness

pinagkuhaan ng dugo
EENT Ears Eyes Throat

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

Is able to hear on both ears Normal Is able to see on both eyes Normal Difficulty in swallowing Brought about by thyroid enlargement

SYSTEM Respiratory System

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

INTERPRETATION DOB Pain on the Left lateral chest P Exacerbates when coughing and moving. Q- Stabbing pain S- 6/10 R Radiates to the left shoulder T 5-10 sec

SIGNIFICANCE Due to escape of oxygen into the pleural space.

Cardiovascular System

May oras na mataas ang bp ko.

BP

BP is due to increased force of cardiac contractility and the bodys attempt to increase tissue perfusion and oxygenation Attributed to present condition

Gastrointestinal System

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

(-) Diarrhea Vomiting

SYSTEM

CUES

INTERPRETATION

SIGNIFICANCE

Genitourinary System

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

Normal

Musculoskeletal System

Madali akong mapagod.

(+) muscle weakness Limited ROM

Weakness is attributed to present condition and limited ROM

Neurologic

Di naman ako ulyanin.

Is able to communicate

Normal

Gordons Functional Health Pattern

Before hospitalization Health perception Client seeks medical and Health consultation every time Management pattern he feels that there is something abnormal with his health. He normally takes over the counter drugs when he experiences a cough or cold. Nutritional and He is fond of eating salty metabolic pattern and fatty foods. Elimination pattern He defecates at least 2 times a day and urinates at least 6 times a day. Activity-exercise He plays badminton pattern every day. Sleep-rest pattern Has lack of sleep. During hospitalization Client is adherent to the treatment regimen

He eats what the dietary department serves. On low salt and low fat diet. Client uses a urinal to urinate. He has not made any bowel movement since hospitalization. Is unable to ambulate due to presence of CTT. Has more difficulty of sleeping.

Cognitive perpetual pattern

Self-perception and self concept pattern Role relationship

Vices

Sexual pattern Coping/ Stress Tolerance Value Belief

Before hospitalization The client can hear clearly. Cognitive and alert. Confident and he has a good outlook on the way things are happening. Is satisfied with family, work, and social relationships Drinks alcohol occasionally and smokes half a pack of cigarettes per day. Is satisfied with sexual relationship Client manages stress listening to music Client prays often for good health.

During hospitalization The client can hear clearly. PERRLA.

The client still has a positive outlook.

He cannot perform his roles as of the moment. Is unable to do vices in the hospital setting

None Client handles stress of condition by practicing a regular breathing pattern. Client often reads the bible.

Medical and Nursing Diagnosis

Medical Diagnosis:
Spontaneous Pneumothorax

Nursing Diagnosis:
1. Ineffective breathing pattern related to decreased lung expansion. 2. Impaired gas exchange related to decreased lung expansion secondary to air accumulation in the pleural space. 3. Acute Pain related to impaired pleural integrity 4. Disturbed sleep pattern related to interruptions from therapeutic regimen, monitoring and other generated awakening and excessive stimulation. 5. Activity intolerance r/t muscle weakness and fatigue 6. Risk for trauma related to dependence on chest tube drainage system. 7. Risk for falls related to generalized weakness. 8. Risk for deficient fluid volume related to treatment regimen. 9. Risk for constipation related to changes in level of activity. 10. Risk for prone behavior related to lack of knowledge about the disease.

Laboratory Exams

Hematology May 6, 2012

Component
Hemoglobin

Result
16.8

Normal Value
14-18 g/L

Interpretation
Normal

Analysis

Hematocrit

0.52

0.40-0.54

Normal

WBC count

15.9

4-11 x10 g/L

Increased

RBC count

5.8

5.0-6.4

Normal

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

Component

Result

Normal Value

Interpretation

Analysis

Differential count:
Eosinophils 0.01 0.02-0.04 Decreased Low eosinophil level is usually not a cause for concern and is actually quite common.

Neutrophils
Segments 0.71 0.50-0.70 Increased

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

Lymphocytes

0.16

0.20-0.40

Decreased

Monocytes

0.4

0.02-0.05

Increased

Low lymphocyte counts may occur in normal individuals. . A low value doesnt necessarily mean a decrease in protection against viruses.

Component

Result

Normal Value

Interpretation

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

Platelet count

202

150-450 x10 g/L

Normal

PT

16.3 secs

10.4-14.05

Slow

% activity INR

57.0% 1.52

73-127% 0.88-1.21

Decreased Increased

Activated PTT

48.0 secs

30.4-41.2

Slow

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

Clinical Chemistry May 7, 2012 2:50pm

Analysis Component Sodium Potassium Chloride Result 134 mmol/L 4.3 mmol/L 97 mmol/L Normal Value 135 148 mmol/L 3.5 4.5 mmol/L 98 107 mmol/L Interpretation Decreased
Contributory factor to lethargy and muscle weakness

Normal

Calcium, Ionized
Calcium, Total Magnesium Phosphorus

1.08 mmol/L
1.88 mmol/L 0.63 mmol/L 1.68 mmol/L

1.12-1.32 mmol/L
2.15-2.55 mmol/L 0.66-0.99 mmol/L 0.81-1.58 mmol/L

Decreased Decreased Decreased Decreased Increased

Due to potassium deficiency Reason of prolonged QT interval in the ECG and PT Tends to cause low serum calcium concentration

Component

Result

Normal Value

Interpretation

Analysis

Glucose (fasting) Cholesterol

6.84 mmol/L 2.73 mmol/L

4.1 - 5.5 mmol/L 1. 5.2 mmol/L

Increased

May predispose the client to DM

Normal

Triglycerides
HDL -cholesterol LDL cholesterol

0.83 mmol/L 0.51 mmol/L 1.66 mmol/L

0.0 2.3 mmol/L 0.9 1.45 mmol/L 0.0 2.59 mmol/L

Normal Decreased Normal

May predispose the client to development of CAD

Blood Chemistry May 7, 2012

Component Result Normal Value Interpretation Analysis

Blood Urea Nitrogen

3.9 mmol/L

2.1-7.1 mmol/

Normal

BUN is affected by hydration, hepatic metabolism of protein and reduced GFR

BUN indicates kidney damage, GFR

Serum creatinine

60 mmol/L

45-104 mmol/L

Normal

serum Crea indicates nephron damage, GFR

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

Stool Exam May 6, 2012

Macroscopic Examination: Color: Consistency: Gross Evidence of: >WBC >RBC Light Brown Soft

0-3/HPF
0-2/HPF

Remarks:
No intestinal Parasites seen

Urinalysis May 6, 2012

Component Result Interpretation

MACROSCOPIC EXAM: Color Transparency Dark Yellow 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.

Slightly Hazy

Sugar Protein

N (-) +2

Equivalent to 100mg/dl. >2+ in concentrated or dilute urine indicates significant proteinuria Normal pH Normal S.G. Normal Normal Renal epithelial cells normally appear in the urine in small numbers. Normal Normal

pH S.G. MICROSCOPIC EXAM: WBC RBC Epithelial Cells Crystals Bacteria

6.0 1.025

0-2/ HPF 1-3/ HPF FEW Amorphous Urates / Phosphates: Occasional FEW

Chest X-ray May 6, 2012

TYPE: 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, 2012

ABNORMAL FINDINGS Poor R progression ST-T abnormality (Ant, Lat) Negative T (Inf) Right axis deviation INTERPRETATION Increase the magnitude of the voltage in the leads from V1 to V4 Ventricular conduction abnormalities and rhythms originating in the ventricles. Represents ventricular repolarization rhythms originating in the ventricles. congenital heart condition wherein the electrical conduction of the heart is greater than +105 degrees. Between +90 degrees and +180 degrees the condition may be termed Indeterminate Deviation or more often Extreme Right Axis Deviation. factor for sudden cardiac death, Since medications can promote or exacerbate the condition, detection of QT interval prolongation is important for clinical decision support. intraventricular conduction abnormalities secondary to myocardial degeneration. cardiac arrhythmia or irregular heart beat. The ventricles contract irregularly, leading to a rapid and irregular heartbeat.

QT prolongation

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

Electrocardiogram Test (ECG) May 6, 2012

Nursing Implications: Explain the purpose of the test and explain that there will be no pain from the test. Explain the procedure of the test. The test may be performed when the patient is fully awake, drowsy, undergoing stimuli, asleep, during sleep deprivation, under sedation, or other situations. Prepare the patient: Restrict only sedatives and/or stimulants such as caffeine, alcohol, etc. prior to the test. Patient Teaching: Be sure to include family in the teaching process. The machine may look frightening to the patient. Reassure the patient that he will not get a shock from the machine, especially if this is the first time this patient will have this test. Patients have other misconceptions and fears about the test. Report to the physician if the patient is taking any medications. Some drugs (legal or otherwise) may affect the results of the test. Report if the patient is unusually anxious or upset before the test. The patient will be carefully observed during the test. Ask the patient to relax and lay still during the test. Usually, normal activity may resume after the test.

Liver Enzymes May 7, 2012 11:06pm

Component S.I. Result
Normal Value 15-37 u/L

Interpretation

AST (SGOT)

41u/L

Increased

ALT (SGPT)

37u/L

30-65 u/L

Normal

AST is normally found in red blood cells, liver, heart muscle tissue, pancreas, and kidneys. AST may involve prolonged intake of several medication, alcoholism, or due to hyperthyroidism

Arterial Blood Gases (ABG) May 8, 2012

Arterial Blood Gas 3:40PM
Component Result Normal Value

05-08-12

Interpretation

PH : pCO2: pO2

7.455 30.2 mm/Hg 97.5 mm/Hg

7.350-7.450 35.00-45.00 80.00-100.00

Normal Decreased Normal

HCO3:
B.E Sat O2 Total CO2:

22.9 mmol/L
1.9 mmol/L

Normal
Normal

97.8 % 21.7 mmol/L

Course in the Ward

May 7, 2012 6am-2pm Shift

Time 6:00 am Data -received pt. in high fowlers position, Action -maintain pt. in high fowlers Response

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 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

position.
-maintain o2 support via nasal cannula at 4lpm -monitored IV rate -monitored placement and patency of CTT

6:30 am

>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

-Temp : 36.8c

-chest tube tubings, dressing and

patency was checked -medication given:

RR: 27 cpm
PR: 105 bpm BP: 130/80 mmHg

methimazole 20mg 1tab PO after breakfast

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

7:14am

-clinical chemistry done -chest tube tubings, dressing and patency was checked Nahihirapan akong huminga Parang hinihingal ako. RR 27cpm >(+) facial grimace >(+) difficulty of breathing >(+) dry cough >(+)chest wall retraction >(+) use of accessory muscles >(+) shallow breathing >Diminished breath sounds. >Auscultated breath sounds >evaluated respiratory function. >Maintained the 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 nebulization Monitored BP before and after meds. -meds given: Furosemide 20mg 1tab PO/ODx 3 days Enalapril 5mg 1tab PO/OD -Daily O2 Saturation and CBG taken BP within normal ranges. -O2 sat. 96% -CBG: 109 mg/ dL -Chest tube is patent, tubings are hanged in a straight line from mattress to the drainage bottle

7: 30am

8:00 am

8:30 am

Mas nakakahinga na ko ng maayos. RR- 20cpm

-Client has established an effective respiratory pattern -Client has shown improved ventilation

9:00 am

Masakit yung sa gilid ng dibdib --assessed pt. ko, parang tinutusok tusok. -v/s taken & recorded -medication given: (+) facial grimace Tramadol 50mg TIV (+) guarding at the affected area >Evaluated medications the client is taking to see if they - Pain on the Left lateral chest could be causing activity P Exacerbates when coughing intolerance. and moving. >Assessed nutritional needs Q- Stabbing pain associated with activity intolerance. S- 6/10 >Monitored vitals before and R Radiates to the left shoulder after any activity, noting any T 5-10 sec abnormal changes. > Assessed for pain before nanghihina ako, hinahapo pa activity. ako tuwing bumabangon ako. > Instructed client in energy>(+) fatigue conserving techniques (e.g. carrying out activities at a slower pace). mga 3 nalang ang score kumpara kanina. -client verbalized a decrease in the level of pain from 6/10 to 3/10

9:30am

10:00am

-bed side care done -health teaching on chest tube drainage system provided -pt. verbalized understanding on chest tube system precaution - Temp: 36.9c RR = 20 breaths per minute RR: 23 cpm PR: 103 bpm BP: 130/70 mmHg - Input Oral: 500 cc

12:00 nn

- v/s taken and recorded -input & output measured -meds given: Ceftriaxone 2g TIV (loading dose) -encouraged ambulation

IV: 80cc

Total: 580 cc - urine output: 430 cc

-Chest tube drainage output: 40cc

Total: 470cc -BM: 0 2:00 pm -Endorsed patient to the next shift

May 8, 2012 6am-2pm Shift

Time 6:00 am Data -received pt. sitting on bed, conscious and responsive -maintained o2 therapy -continuous with O2 support via nasal cannula at 4LPM -monitored IV rate Action -maintained pt. on sitting position Response -pt. verbalized increased comfort

- With IV contraption on R metacarpal

-maintained patency of CTT

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

6:30am

mas okay tulog ko kumapara kahapon.

>Patient displayed improvements in sleeping pattern. -v/s taken and recorded -Temp : 36.9 c

7:00 am

- medication given: methimazole 20mg 1tab PO afterbreakfast

RR: 23 cpm

PR: 100bpm

BP: 130/80 mmHg

8:00 am

9:00 am From time to time may inaabot ako sa mesa. Makukulit mga kamaganak ko dito sa pwesto ko. >CTT bottle not secured under the bed. 10:00am Madalas wala dito ang asawa pag natutulog ako. >With left side rails down while client is in semifowlers position. >Caregiver is absent. >Limited ROM >(+) Body weakness

-Monitored BP before and BP: 110/70mmHg after meds - meds given: Furosemide 20mg 1tab PO/ODx 3days Enalapril 5mg 1tab PO/OD -meds given: Ceftriaxone 500mg q 8 hours -Daily O2 Saturation and -O2 sat. 97% CBG taken -CBG: 116 mg/ dL >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.

>Ensured patients safety by raising the side rails >Advised client not to rise abruptly from a supine position >Provided emotional support to client

10:30am

May dugong nalabas sa tubo. Madalas akong naihi.

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

12:00 nn

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

- Temp: 36.9c 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: 30cc Total: 510cc 2:00 pm -Endorsed patient to the next shift -BM: 0 -The client was free from injury and falls throughout the 8 hour nursing shift.

Anatomy and Physiology

ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

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

A. Nasal Passages The nose, the uppermost portion of the human respiratory system, is a hollow air passage that functions in breathing and in the sense of smell. While transporting air to the pharynx, the nasal passage is vital because it plays two critical roles: they filter the air to remove potentially disease-causing particles; and they moisten and warm the air to protect the structures in the respiratory system. B. Pharynx Air leaves the nasal passages and flows to the pharynx, a short, funnel-shaped tube about 13 cm (5 in) long that transports air to the larynx. Like the nasal passages, the pharynx is lined with a protective mucous membrane and ciliated cells that remove impurities from the air. When the adenoids are swollen, they block the flow of air from the nasal passages to the pharynx, and a person must breathe through the mouth. C. Larynx Air 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 Bronchioles Air passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6in) long located just below the larynx. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy cartilage rings hold the trachea open, enabling air to pass freely at all times. The open part of the C-shaped cartilage lies at the back of the trachea, and the ends of the C are connected by muscle tissue. The base of the trachea is located a little below where the neck meets the trunk of the body. Here the trachea branches into two tubes, the left and right bronchi, which deliver air to the left and right lungs, respectively. Within the lungs, the bronchi branch into smaller tubes called bronchioles. The trachea, bronchi, and the first few bronchioles contribute to the cleansing function of the respiratory system, for they, too, are lined with mucous membranes and ciliated cells that move mucus upward to the pharynx. E. Alveoli The bronchioles divide many more times in the lungs to create an impressive tree with smaller and smaller branches, some no larger than 0.5 mm (0.02 in) in diameter. These branches dead-end into tiny air sacs called alveoli. The alveoli deliver oxygen to the circulatory system and remove carbon dioxide. Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli and remove foreign substances that have not been filtered out earlier. The macrophages are the last line of defense of the respiratory system; their presence helps ensure that the alveoli are protec ted from infection so that they can carry out their vital role.

Differential Diagnosis

SIGNS AND SYMPTOMS Productive cough Absent or diminished breath sounds on the affected side Tachypnea Dyspnea Difficulty of breathing Absent or diminished tactile fremitus on the affected side Dullness on the affected side when percussed Asymmetrical chest expansion Sharp chest pain exacerbated when coughing

PNEUMOTHORAX Absent Evident

PLEURAL EFFUSION Present Evident

PULMONARY EDEMA Present Not evident

Present Present Present Evident

Present Present Present Evident

Present Present Present Not evident

Absent Evident Present

Present Evident Present Present Present

Absent Not evident Absent Present Absent

Orthopnea Present Lateral CXR: Opaque densities on the Absent lower lobe, blunting of the costophrenic angle Posteroanterior CXR: Air in the pneumo region shown is much darker than the air within the actual lung in the affected part

There is an area of whiteness in the affected area

Kerley lines: thin linear pulmonary opacities:

Pathophysiology

Nursing Care Plan

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

Diagnosis
Ineffective breathing pattern related to decreased lung expansion.

Inference
Air accumulation in the pleural space

Planning

Nursing Intervention
Independent: 1. Auscultated breath sounds and evaluate respiratory function, noting rapid/shallow respirations, dyspnea,reports of air hunger, development of cyanosis, changes in v/s 2. Maintained the clients position (High Fowlers) 3. Monitored bottle for fluctuation 4. Monitored Chest tube drainage output. 5. Positioned chest tube drainage below the bed. Dependent: 1. Maintained O2 therapy @ 4lpm 2. Administered Salbutamol + Ipratropium . Collaborative: 1. Monitored Chest x-rays

Rationale
Independent: 1. Regularly scheduled evaluation provides a baseline to evaluate resolution of pneumothorax .Respiratory distress and changes in v/s occur as a result of physiologic distress and pain, or may indicate development of shock due to hypoxia/ hemorrhage. 2. Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion. 3. To check for chest tube patency. 4. To determine if patient is bleeding from a vessel that was not cauterized during closure of chest or a ruptured graft. 5. To avoid kinking, damaging and any instances that will affect the drainage system. Dependent: 1. Oxygenation provides more o2 supply. 2. This medication dilates the bronchi and creates a better airway. Collaborative: 1. To monitor the progress of resolving pneumothorax and re-expansion of lungs.

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

After 1 hour of nursing intervention, the Client will Increase pressure around establish an the lungs effective respiratory pattern with a Decreased lung expansion normal respiratory rate of 16-20cpm. Inspiration/expiration doesnt provide adequate ventilation

Ineffective breathing pattern

Assessment S: 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.

Diagnosis Inference Impaired Gas Air accumulation in exchange the pleural space related to decreased Increase pressure lung around the lungs expansion secondary to air Decreased lung accumulation expansion in the pleural space. Decreased surface area for oxygen and carbon dioxide to exchange

Planning After 1 hour of nursing intervention, the Client will have improved ventilation and adequate oxygenation as evidenced by respiratory rate of 1620.

Impaired Gas Exchange

Nursing Intervention Independent: 1. Maintained airway clearances clean and patent. 2. Monitored ABG results 3. Maintained clients High Fowlers position. 4. Have patient practice pursed lip breathing. 5. Encouraged client to stop smoking Dependent: 1. Administered O2 at 4 Lpm Collaborative: 1. Monitored ABG and Chest X-ray results.

Rationale Independent: 1. Clearing airways of secretions improves ventilationperfusion relationship. 2. ABG results provide integral information to determine deficits in capacity and effect of oxygen delivery. 3. To facilitate chest expansion 4. Promotes alveolar open 5. To decrease risk and prevent further decline in lung function Dependent: 1. To provide O2 to the clients body and balance ABG. Collaborative: 1. To monitor the progress of the clients condition

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

Assessment S: 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 pain S- 6/10 R Radiates to the left shoulder T 5-10 sec

Diagnosis Acute Pain related to impaired pleural integrity

Inference Tissue damage Peripheral neurotransmitters released Free nerve endings (nociceptors) triggered Signals travel to spinal cord Signals rerouted to appropriate area of brain Brain interprets quality and intensity of pain present

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

Nursing Intervention Independent: 1. Monitored pain. Let the client describe the pain he feels. 2. Assisted client on splinting the painful area when coughing and deep breathing. 3. Provided a calm, quiet environment. 4. Monitored vital signs. 5. Monitored the sleeprest pattern. 6. Stabilized chest tube. 7. Explained and demonstrated the proper breathing exercise to the pt 8. explained and demonstrated cutaneous stimulation to the pt 9. Explained the ways and benefits of diversional activities to alleviate the pain of the pt Dependent: 1. Administer Tramadol 50mg TIV

Rationale Independent: 1. Pain is subjective in nature, and only the patient can fully describe it. 2. Splinting the affected area may lessen the pain that the client feels. 3. Promotes action and effect of medication by providing decreased stimuli. 4. To detect changes that might indicate pain or a complication of pain. 5. Fatigue may contribute to an increased pain response, or pain can contribute to interrupted sleep. 6. To reduce pull or drag on latex connector tubing which could add up to the pain. 7. Enhances sense of control and may improve coping abilities. 8. Reduces muscle tension and anxiety associated with pain. 9. Enhances sense of well-being and helps forget the thought of pain. Dependent: 1. Analgesics given TIV reach the pain centers immediately, providing more effective relief with small doses of medication.

Assessment: Subjective: Paputol-putol yung tulog ko dito kasi maingay at maya-maya ginigising ako. Objective: >Dark circles around the eyes > Weakness and restlessness. >Taking nap when there is a chance or if there is a free time. >Yawning

Nursing diagnosis: Inference: Disturbed Sleep External noises Pattern related to and interruptions interruptions for therapeutics, Excessive monitoring and environmental other generated stimulation awakening and excessive Disruption of stimulation (noise relaxation and lighting). Reduced initiation of the body to induce sleep Patient is unable to obtain adequate sleep Disturbed sleep pattern

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

Intervention: Independent: 1. Assess sleep pattern disturbances that are associated with the environment. 2. Observe and obtain feedbacks regarding on the usual sleeping pattern, bedtime routine and the usual number of hours of sleep and rest. 3. Do as much care as possible without waking up the client and do as much care as possible while the client is still awake. 4. Explain necessity of disturbances for monitoring Vital Signs and care when hospitalized. 5. Provide information about relaxation techniques (such as instrumental music and meditation). Dependent: 1. Administer sedatives as indicated

Rationale: Independent: 1. High percentage of sleep disturbances can affect the recovery of the patient. 2. To determine usual sleeping pattern and to compare if there are any improvements on the sleeping pattern of the patient. 3. To avoid disturbances during sleep, and also to maximize the sleep and rest of the client. 4. For the patient to have an understanding of the importance of care being done to her and to minimize the complaints. 5. For the client to condition his body for sleeping. Dependent: 1. Timely medication can enhance rest or sleep.

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

Assessment Subjective:

nanghihina ako, hinahapo pa ako tuwing bumabangon ako.

Objective: >RR- 27cpm >Weak in appearance >(+) fatigue >thin in appearance >(+) DOB

Nursing diagnosis Activity intolerance r/t generalized weakness and fatigue

Inference Generalized weakness Insufficient physical or psychological energy to endure or perform desired activities Activity intolerance

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

Intervention 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 energyconserving techniques (e.g. carrying out activities at a slower pace). Collaborative: 1. Administer analgesics as indicated

Rationale Independent: 1. Medications such as beta-blockers, lipidlowering agents, which can damage muscle tissue, and some antihypertensive can result in decreased functioning. 2. The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers. 3. This can be caused by a temporary insufficiency of blood supply 4. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement. 5. Energy-saving technique reduces the energy expenditure, thereby assisting in equalization of oxygen supply and demand. Collaborative: 1. Relief of pain can help increase tolerance to activities

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

Assessment S: From time to time may inaabot ako sa mesa. Makukulit mga kamag-anak ko dito sa pwesto ko. O: > With under water seal Chest tube on the Left lung, 5th ICS, LMA line. >CTT bottle is not secured under the bed >Patient is restless

Diagnosis Risk for Trauma related to dependence on Chest tube Drainage system

Inference Planning Nursing Intervention Chest tube insertion Client will be free Independent: from trauma Instruct client to refrain throughout the 8 1. Chest tube Drainage hour nursing shift from lying or pulling on system dependence tubing. 2. Monitor changes and situations like change in sound of bubbling, CTT bottle is not sudden air hunger secured under the and chest pain, and bed disconnection of equipment. 3. Provide safe Visitors constantly transportation when moving around the client is sent off unit for bed diagnostic purposes. 4. Anchor thoracic catheter to chest wall Risk for Trauma and provide extra length of tubing before turning or moving client. 5. Monitor thoracic insertion site, noting condition of skin and presence and characteristics of drainage from around the catheter. Change and reapply sterile occlusive dressing as needed. 6. Observe for signs of respiratory distress if thoracic catheter is disconnected/ dislodged.

Rationale Independent: 1. 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. Pneumothorax may recur/ worsen, compromising respiratory function and requiring emergency intervention

Evaluation

Client was free from trauma throughout the 8 hour nursing shift

2.

3.

4.

5.

6.

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Madalas wala dito ang asawa pag natutulog ako. Objective: >With left side rails down while client is in semifowlers position. >Caregiver is absent. >Limited ROM >(+) Body weakness

Risk for falls related to generalized weakness

Body weakness Within the 8 hour nursing Decreased shift, the client muscle strength will be free from falls Lowered side rails Patient is left unattended by the significant other Risk for falls

Within the 8 1. Assessed patients 1. To determine the patients hour nursing shift, the client general condition status was free from 2. Ensured patients 2. To keep the patientfrom falls safety by raising the fallingof f the bed when side rails moving 3. Monitored vital signs 3. To obtain baseline data 4. Abrupt change of position can lead to 4. Advised client not orthostatic to rise abruptly hypotension from a supine 5. To decrease anxiety. position 6. Engaging in regular 5. Provided exercise and activity emotional will strengthen support to client muscles, improve 6. Created an balance, and increase individualized bone density. exercise program Collaborative: for the client 1. Proper nutrition and Collaborative: diet promotes body 1. Consult with strength and bone dietician for density. proper diet and nutrition

Independent:

Independent:

Diagnosis S: Risk for deficient fluid volume May dugong related to nalabas sa tubo. treatment Madalas akong regimen 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

Assessment

Planning Throughout the 8 hour nursing intervention, the client will be able to maintain a near balance Collection of blood between and air from the intake and chest tube. output. Furosemide creates diuresis

Inference Treatment regimen(chest tube drainage system and Furosemide medication)

Nursing Intervention Independent: 1. Measure I&O accurately. Weight daily. Calculate insensible fluid losses.

Rationale Independent: 1. Helps estimate fluid replacement needs. 2. To replace lost fluids. 3. orthostatic hypotension and tachycardia suggest hypovolemia 4. For immediate prevention of severe dehydration.

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

3. Monitor BP, noting postural changes and heart rate

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

Decreased fluid in the body

Risk for deficient fluid volume

4. Note signs and symptoms 5. may reduce diaphoresis of dehydration such as which contributes to dry mucous membranes, overall fluid losses. thirst, dulled sensorium and peripheral Collaborative: vasoconstriction 1. To gain a more accurate 5. Control environmental assessment of the temperature, limit bed patients condition linens as indicated.
Collaborative: 1. monitor labs studies such as sodium

ASSESSMENT Subjective: Di ako masyado nakakagalawgalaw. Objective: >Client is conscious and coherent >Limited ROM >(+) Body malaise

NURSING DIAGNOSIS Risk for constipation related to changes in level of activity

INFERENCE Body weakness and lack of privacy

PLANNING

INTERVENTION

RATIONALE Independent: 1. Determines extent of problem and indicates types of interventions appropriate. 2. Improves stool consistency, promotes evacuation 3. Promotes normal stool consistency. 4. Increase in activities and movement increases peristalsis. 5. Decreases feelings of embarrassment and frustration. Dependent: 1. Promotes regularity by increasing bulk or improving consistency.

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

After 1 hour of Independent: nursing 1. Ascertained usual intervention, the bowel pattern and Client will aids used. Decrease in level verbalize Compare with of activity understanding of current routine. ways in 2. Provided diet high Decreased improving bowel in fiber bulk in the stimulation of elimination form of wholethe smooth patterns an grain cereals, muscles of the effective breads, and fresh G.I tract. respiratory fruits. pattern. 3. Encouraged Decrease in increased fluid peristalsis intake. 4. Institute an Risk for individualized constipation program of exercise, rest, and diet. 5. Provided emotional support to client Dependent: 1. Administered medications as indicated (e.g. bulk providers and stool softeners)

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Mahirap tumigil sa pagyoyosi eh. OBJECTIVE: >Request for Information about the disease process. >Inaccurate follow through of instructions. > Demonstrates nonacceptance of health status change.

Risk for Prone health behavior related to lack of knowledge about the disease

Lack of knowledge After 4 hours about the disease of nursing process interventions, the patient will Reduced demonstrate motivation to increase in interest modify lifestyle and participation in self-care Reduced interest in self-care Risk for prone health behavior

INDEPENDENT: 1. Established rapport 2. 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 necessary

INDEPENDENT: 1. To prevent patient anxiety and establish cooperation 2. 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 hours of nursing interventions, the patient will demonstrate increase in interest and participation in self-care

Drug Study

DRUG NAME

CLASSIFICATION

BRAND NAME: Reglan GENERIC: Metoclopramide

Antiemetic, Dopaminergic blocker, GI stimulant

MECHANISM OF ACTION Stimulates motility of upper GI tract without stimulating gastric, biliary or pancreatic secretions. Sensitizes tissues to action of acetylcholine Relaxes pyloric sphincter, which when combined with effects of motility Accelerates gastric emptying and intestinal transit; little effect on gallbladder or colon motility

INDICATION

DOSAGE/ROUTE/FREQUENCY

NURSING CONSIDERATIONS

EVALUATION

-Relief of 10 mg/ TIV/ now then PRN for symptoms of nausea & vomiting. acute and recurrent gastroparesis. -Stimulation of gastric emptying and intestinal transit of barium.

Increases esophageal sphincter pressure, has sedative properties

Induces release of prolactin.

-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 NAME

CLASSIFICATION

BRAND NAME: Propyl-Thyracil GENERIC: Propylthiouracil

Antithyroid drug

MECHANISM OF INDICATION ACTION Inhibits the Hyperthyroidism synthesis of thyroid hormones

DOSAGE/ROUTE/FREQUENCY

50 mg / 1 tab per orem/ q6

Partially inhibits the peripheral conversion of T4 to T3 the more potent form of thyroid hormone.

NURSING CONSIDERATIONS -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.

EVALUATION

-The clients thyroid hormones are within normal levels.

DRUG NAME

CLASSIFICATION

BRAND NAME: Vasotec GENERIC: Enalapril

ACE inhibitor, Antihypertensive

MECHANISM OF INDICATION ACTION Renin released into Treatment of circulation hypertension Acts on a plasma precursor to produce angiotensin I Converted by ACE to angiotensin II Increases BP. Blocks the conversion of angiotensin I to angiotensin II Decreases BP and aldosterone secretion, slightly increases serum K+ levels and causing Na+ and fluid loss.

DOSAGE/ROUTE/FREQUENCY

5 mg/ 1 tab Per Orem/ OD

NURSING CONSIDERATIONS -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).

EVALUATION

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

DRUG NAME BRAND NAME: Apo-Furosemide GENERIC: Furosemide

CLASSIFICATION Loop diuretic

MECHANISM OF INDICATION ACTION Action at the For mild to proximal and distal moderate tubules and hypertension ascending limb of the loop of Henle Inhibition of reabsorption of sodium and chloride Leads to a sodiumrich diuresis.

DOSAGE/ROUTE/FR NURSING EQUENCY CONSIDERATIONS -Assess allergy to 20 mg/ 1 tab Per Orem/ OD x 3 days 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.

EVALUATION -Patients sleep pattern was not disturbed. -Patients blood pressure is within normal ranges.

DRUG NAME

CLASSIFICATION

MECHANISM OF ACTION

INDICATION

DOSAGE/ROUTE/FR EQUENCY

NURSING CONSIDERATIONS

EVALUATION

BRAND NAME: InnoPran XL GENERIC: Propranolol

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

Completely For adult blocks betahypertension 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.

20 mg/ 1 tab Per Orem/ q8

-Assess allergy to betablocking 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 NAME BRAND NAME: Tapazole GENERIC: Methimazole

CLASSIFICATION Antithyroid drug

MECHANISM OF ACTION Inhibits the synthesis of thyroid hormone.

INDICATION Treatment of hyperthyroidism.

DOSAGE/ROUTE/FR EQUENCY Methimazole 20mg 1 tab Per Orem after breakfast Methimazole 5mg/ tab 2 Per Orem tab after dinner

NURSING CONSIDERATIONS -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.

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

DRUG NAME BRAND NAME: Rocephin GENERIC: Ceftriaxone

CLASSIFICATION Antibiotic, Cephalosporin (third generation)

MECHANISM OF ACTION

INDICATION

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

NURSING CONSIDERATIONS -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.

EVALUATION Patient was monitored closely for stomach upset and diarrhea.

Binds to receptors Lower of bacterial cells respirations infections

Inhibits synthesis of bacterial cell wall

Causes cell death

DRUG NAME

CLASSIFICATION

BRAND NAME: Vasodilator Titradose GENERIC: Isosorbide Dinitrate

MECHANISM OF ACTION Relaxes vascular smooth muscle with a resultant decrease in venous return Decrease in arterial BP Reduces left ventricular workload Decreases myocardial oxygen consumption

INDICATION Treatment and prevention of angina pectoris/ chest pain

DOSAGE/ROUTE/FR NURSING EQUENCY CONSIDERATIONS 5mg/tab/ 1 tab OD -Assess for any allergy to for chest pain 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.

EVALUATION Patient was monitored closely and chest pain was relieved.

DRUG NAME BRAND NAME: DuoNeb GENERIC: Salbutamol + Ipatropium

CLASSIFICATION Antiasthmatic & COPD preparations

MECHANISM OF ACTION IPATROPIUM: Anticholinergic agent inhibits vagally-mediated reflexes by antagonizing the action of acetylcholine. Prevents the increase in intracellular concentration of cyclic guanosine monophosphate w/c are brought about by interaction of acetylcholine with the muscarinic receptors on bronchial smooth muscle. SALBUTAMOL: Direct acting Beta2-adrenergic agent.

INDICATION Provides inhalation for DOB.

DOSAGE/ROUTE/FREQ NURSING CONSIDERATIONS UENCY 1 nebule Q6 PRN for -Monitor respiratory status; DOB 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.

EVALUATION Patients DOB was managed and relieved.

Acts on the airway smooth muscle resulting in bronchodilation.

DRUG NAME

CLASSIFICATION

ACTION

INDICATION

DOSAGE/ROUTE/FR EQUENCY

NURSING CONSIDERATIONS

EVALUATION

BRAND NAME: Tramadine GENERIC NAME: Tramadol

Analgesics (opioid)

Inhibits reuptake of norepinephri ne, serotonin and enhances serotonin release. Inhibits reuptake of norepinephri ne, serotonin and enhances serotonin release. Decreased pain

Indicated for the management of moderate to moderately severe pain.

50mg TIV p.r.n. q6

-Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. -Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression -Discontinue drug and notify physician if S&S of hypersensitivity occur. -Assess bowel and bladder function; report urinary frequency or retention. -Monitor ambulation and take appropriate safety precautions.

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

Discharge Plan

Discharge Plan
Medications: Inform the client the importance of compliance with taking the medications as prescribed by the physician. Continue medications prescribed such as: Methimazole 20mg 1 tab Per Orem after breakfast Methimazole 5mg/ tab 2 Per Orem tab after dinner Pain medication should be given on discharge. Exercise: Instruct on Deep Breathing Exercise and effective coughing Instruct patient to avoid extremes exercises, which will lead him to stress; and as to avoid shortness of breath. Instruct client to perform exercise as tolerated Treatment: Instructed client to continue steam inhalation and gentle chest physiotherapy. Health Education: Self care: Encourage patient to avoid doing strenuous activities Chest tube wound site should be monitored for infection and to ensure proper healing. Encourage patient to stop smoking and avoid excessive alcohol intake Provide information about Pneumothorax and its signs and symptoms to avoid another occurrence in the future. Home Care: Encourage to have a regular BP check-up at the nearest barangay health station Keep an environment free of air and noise pollution.

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

Thank you! :D