World Citi Colleges 960 Aurora Blvd.

Quezon City Case Presentation In NCM 103

Pleural Effusion
Submitted by:
Alenzuela, Dianne Aloy, Marlyn Bacera, Arfel Boncato, Ronnie jay Reyes, Daniel Reyes, Ella Salazar, James Sañosa, Jasmine Saquitan, RJ Saring, Marie Sherman, Myrna Solatre, Carlo Tabieros, Kristine Joy Taclas, Josid Tobari, Diane Ungos, Abby

Submitted to: Mr. Dominic Bautista Ms. Myla Lim Mr. Sherwin Villegas Date of Submission: Aug. 7, 2010

I.

Introduction

This is the case of C.J 17 y/o male patient who was admitted at WCMC on July 26, 2010 at 12:15am due to chief complain of DOB. His final diagnosis is Pleural Effusion probable secondary to PTB stage 3. Pleural Effusion, a collection of fluid in the pleural space, rarely a primary disease process; it is usually secondary to other disease. Normally, the pleural space contains a small amount of fluid (5-15mL), which acts as a lubricant that follows the pleural surfaces to move without friction. Pleural effusion maybe complication of heart failure, tuberculosis, pneumonia, pulmonary infections (particularly viral infections), nephrotic syndrome, connective tissue disease, pulmonary embolus, and neoplastic tumors. The most common malignancy associated with a pleural effusion is bronchogenic carcinoma. Usually the patient is acutely ill and has signs and symptoms similar to those of an acute respiratory infection or pneumonia (fever, night sweats, pleural pain, cough, dyspnea, anorexia, weight loss). If the patient is immunocompromise, the symptoms may be vague. If the patient has received anti-microbial therapy, the clinical manifestations maybe less obvious. The severity of symptoms is determined by the size of the effusion the speed of its formation, and the underlying lung disease. A large pleural effusion causes dyspnea (SOB) .The diagnosis is established by chest CT. Usually a diagnostic thoracentesis is performed, often under ultrasound guidance. Anatomy of Pleura • Pleural fluid •Normally present between the parietal and the visceral pleura. • Acts as a lubricant and • Allows the visceral pleura covering the lung to slide along the parietal pleura lining the thoracic cavity during respiratory movements. Physiology of Pleural Fluid • It is believed that the fluid that normally enters the pleural space originates in the capillaries in the parietal pleura •Human beings

•Amount of pleural fluid formed daily in a 50-kg individual = approximately 15 mL • The mean lymphatic flow from one pleural space = 0.40 mL/kg/hour • Pleural fluid accumulates when the rate of pleural fluid formation exceeds the rate of pleural fluid absorption. •Normally, there should be a small amount (0.01 mL/kg/hour) of fluid constantly enters the pleural space from the capillaries in the parietal pleura. Almost all of this fluid is removed by the lymphatics in the parietal pleura, which have a capacity to remove at least 0.20 mL/kg/hour. • Note that the capacity of the lymphatics to remove fluid exceeds the normal rate of fluid formation by a factor of 20. In 2000, tuberculosis was the sixth leading cause of morbidity and mortality in the Philippines. The burden of the disease is made more serious by the fact that the country has the 8th highest TB incidence in the world and the 3rd in the Western Pacific Region in 2003. The control of TB, an airborne infection, is achieved mainly by rendering infectious smear-positive cases noninfectious soon after diagnosis is made and by curing as many TB cases identified. These measures reduce disease transmission and minimize the physiological and socio-economic impact of TB on the patient, his family and community. Only Vietnam, among the countries with high TB prevalence, has attained the global target of 85 percent cure rate and 70 percent case detection rate(WHO 2002). The Philippines has already achieved the 85 percent cure rate target but the case detection rate is still at 61 percent. This means that the country is on the verge of achieving the 70/85 global target for tuberculosis.

II.

Objectives

General: After the completion of the case presentation, the student will be able to: Further their knowledge about respiratory system and pleural effusion. Specific: After the completion of the case presentation, the student will be able to: • • Determine the health profile of the patient using the nursing assessment guide. Discuss the anatomy and physiology of the respiratory disease system that is directly affected in a Pleural Effusion and relates the concept to the actual situation of the patient. Discuss comprehensively the pathophysiology of Pleural Effusion. Relate the diagnostic findings to the pathophysiology of the disease process. Discuss the effect of the therapeutic regimen used. Relate the nursing care plan to the needs and problem of the patient. Discuss comprehensively the nursing care plan. Determine the prognosis of the patient.

• • • • • •

III.

Theoretical Framework

Virginia Henderson
Nursing Virginia Henderson viewed the patient as an individual requiring help toward achieving independence. She states that “The unique function of the nurse is to assist individual, sick or well, in the performance of those activities contributing to health or its recovery (or peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge and to do this in such a way to help him gain independence as rapidly as possible.”

Eliminate body wastes. Sleep and rest. 4. Environment Again.” Person Henderson viewed the patient as an individual who requires assistance to achieve health and independence or peaceful death. – The patient is usually sleeping during his hospitalization period the goal of the health care provider is to give as much comfort as possible to the patient while sick. The nurse’s responsibility is to correct this problem to provide comfort to the patient. she equated health with independence. – There is presence of malnutrition because of sudden weight loss due to having PTB. Select suitable clothes--dress and undress. Our concern is to regain patient’s desirable body weight.Health Virginia Henderson did not state her own definition of health.In our patient’s case there is presence of difficulty of breathing due to plural effusion the main goal is to secure patient’s breathing. The mind and body are inseparable. 6. 1961. which defined environment as “the aggregate of all the external conditions and influences affecting the life and development of organism. The patient and his or her family are viewed as a unit. Health care provider should advise patient to wear the suitable clothing as needed. – There is presence or impaired gas exchange in the patient. – The patient is now bed ridden due to his illness and can’t even go to the bathroom by him self. 5. 3. The 14 Basic Human Needs 1. Breathe normally. Henderson did not give her own definition of environment.. she used Webster’s New Collegiate Dictionary. Eat and drink adequately. 2. – Give proper clothing to help in breathing and comfort. But in her writing. Instead. . Move and maintain desirable postures. The health care provider’s responsibility is to take care and give as much care as possible to the patient to give the best care while in recovery.

Work in such a way that there is a sense of accomplishment. – Respecting the patient’s spirituality is an important factor in good relationship between health care provider and patient. Nursing Assessment A. – The health care provider’s responsibility is to constantly check the VS of the patient to check if there are abnormalities or significant changes noted and to give proper action as soon as possible. recovering or well. 11. .Discover. needs. or satisfy the curiosity that leads to normal development and health and use the available health facilities. Learn . Personal Data Name: C. Communicate with others in expressing emotions. IV. Establishing rapport is a good way of better relationship as patient nurse interaction.Proper communication is a good way to show care.J. Maintain body temperature within normal range by adjusting clothing and modifying the environment. 9. Keep the body clean and well groomed and protect the integument. fears or opinions. 10. – Make sure to finish what you start. 13. – Make sure that the patient as well as the people surrounding him is safe the health care provider’s job is to ensure the safety of the patient and the people around him such as advising relatives or visitors to wear mask for precaution and as for the patient putting side rails to avoid falling in from bed. 8. 12.7. Play or participate in various forms of recreation.. 14. Avoid dangers in the environment and avoid injuring others. – It is important to maintain the hygiene of the patient to avoid any complication such as infection and to give comfort while sick. Worship according to one's faith.

But the grandfather on his father side died due to Cardiac Arrest. History of Present illness: 2 days prior to admission the patient complains chest pain and difficulty of breathing especially at night. Family history: Both of the patient’s parents have no history of illness. Also. 2010 Adm. Time: 12:15 am Chief complaint: DOB – Difficulty of Breathing Clinical Impression:Pleural effusion probable secondary to PTB stage 3. He also complains stomach ache. 2010 he was admitted to St. His grandmother on his father side has a history of Hypertension.Age: Birthday: 17 years old February 12. The doctor gave medication of Myrin P forte & Iberet ordered to take for a month. When he takes a rest. Then few hours prior to admission the patient DOB. Date: July 26. D. B. fever and accompanying pain in his right lower quadrant. He was then immediately rushed to WCMC on June 27. Past Health history: June 17. 1993 Nationality: Filipino Gender: Civil Status: Address: Male Single Marikina City Occupation: HRM 2nd year Student Adm. because the doctor’s finding was pleural effusion. 2010 C.Victoria Hospital in Marikina City and was confined for 1 week. Chief Complaint is fever. Social History: . it lessens the pain. his grandfather and grandmother on his mother side has a history of Hypertension E.

PHYSICAL ASSESSMENT Day 1 HAIR Black. straight. he is exhausted due to lack of sleep and pain EYES The outer cantus of the patient eyes were symmetrical to the pinna of his ears. TEETH . His usual daily activity is playing basketball 3 times a day. Ear wax observed when exposed to pen light. The eyebrows were thin but evenly distributed and have short eyelashes. and black equally rounded pupils. Constriction were observed when light stimulation done at varying distance. NOSE The patient has pointed nose. with dry mucus membranes. He also spends a lot of time in front of the computer. shiny and short SCALP White. MOUTH He is able to open and close with ease.The patient is 17 years old. Patient’s was observed to have white sclera. He’s taking up Hotel Restaurant Management 2nd year student. During high school he was a varsity in basketball on his school. The earliest time he finish his stuff is 12 midnight & most late is 2am. He is able to hear from both ears because he was able to respond to the questions that was asked to him. oily w/ presence of dandruff FACE Symmetrical facial movement. thin. EARS Tip of the ear is aligned with the outer canthus of the eye. He also wants to hang out with his friends. pale conjunctivas.

NECK The patient’s neck has fair skin complexion and muscle tone was fairly good and able to move his head. The patient has an IV fluid of 5% Dextrose in water 250 ml on his right hand. ABDOMEN The patient has undergone appendectomy on his RLQ. . Patient’s both arms are edematous and palms were dry and warm to touch. Has fair complexion but pale. But there’s a presence of wounds & lesions. The patient has test tube drainage for his pleural effusion. No masses palpated along lymph nodes. fair skin in color and smooth with respiratory rate of 28 bpm. CHEST Chest is symmetrical during respiration. Capillary refill was within 3 seconds. He is wearing a binder.He has a complete white tooth w/ no dentures and any dental carries. Patient’s legs and feet is edematous were dry and warm to touch. UPPER EXTREMETIES The patient is having difficulty in lifting his left arm due to the presence of edema. The carotid pulse is palpable. TONGUE The patient has moist with white patches over the tongue. Capillary refill was within 3 seconds. LIPS Dry and pale in color. LOWER EXTREMETIES The patient’s right and left lower extremities are fair in complexion.

EYES The outer cantus of the patient eyes were symmetrical to the pinna of his ears. MOUTH The patient is able to open and close with ease. TONGUE The patient has moist with white patches over the tongue. he is more exhausted. Patient’s was observed to have white sclera. oily w/ presence of dandruff FACE Symmetrical facial movement. NOSE The patient has pointed nose. pale conjunctivas. The eyebrows were thin but evenly distributed and have short eyelashes. Constriction and dilation were observed when light stimulation done at varying distance. LIPS Dry and pale in color. shiny and short SCALP White. thin. TEETH He has a complete white tooth w/ no dentures and any dental carries. with dry mucus membranes EARS Tip of the ear is aligned with the outer canthus of the eye. smooth scalp. He is able to hear from both ears. and black equally rounded pupils. NECK . straight.Day 2 HAIR Black. Ear wax observed when exposed to pen light. He is sleeping during assessment because of Demerol administration to ease his pain on his RLQ.

P: 90bpm. UPPER EXTREMETIES The patient is having difficulty in lifting his left arm due to the edema. Capillary refill was within 3 seconds. BP: 110/80 U: 2 S: 1 V. 4pm (August 05. The patient has test tube drainage for his pleural effusion. Capillary refill was within 3 seconds. Has fair complexion but pale. 8pm: 37. P: 100bpm. ABDOMEN Undergo appendectomy on his RLQ.9'C. BP: 110/80 U: 2. R: 28bpm. No masses palpated along lymph nodes. warm to touch with dry. R: 28bpm. He is wearing a binder.The patient’s neck has fair skin complexion and muscle tone was fairly good and able to move his head. BP: 110/80 Day 1. The carotid pulse is palpable.1'C.6'C. P: 98bpm. Usual pattern of ADL (GORDON’S) . LOWER EXTREMETIES The patient’s right and left lower extremities fair complexion. Patient’s both arms are edematous and palms were dry. S: 1 Day 2. R: 25bpm. R: 28bpm. 10): T: 37. 10): T: 36'C. Patient’s legs and feet is edematous were dry and warm to touch. But there’s a presence of wounds & lesions. 4pm (August 06. P: 70bpm. Vital Signs Day 1. 8pm: 37. CHEST Chest is symmetrical during respiration. fair skin in color and smooth with respiratory rate of 28 bpm. The patient has an IV fluid of 5% Dextrose in water 250 ml on his right hand. BP: 120/80 Day 2.

AREA BEFORE HOSPITALIZATION The pt had an active lifestyle when he was still well. Able to do his task as a student. able to able to perceive was asleep perceive stimuli. He socializes with his friends at school. His classmates from FEU also visited him. DURING HOSPITALIZATIO N (DAY1) He socializes with the nurses and the doctors. 1. Able to move his The patient is in The patient is body with ease. Emotional He was contented He was sad when with his life as a he was alone but student. At home. strict bed rest. Sensory perception His sensory were all The patient was The patient working. The patient was asleep throughout the day. He was accompanied by one of his parents. Able to answer the questions when asked to. He plays basketball as his form of exercise. in strict bed 5. DURING HOSPITALIZA TION (DAY2) The patient was asleep throughout the day. The patient was asleep throughout the day. date and reality. throughout the day but wakes up when feels the pain on his RLQ. 3. Social history 2. 4. Mental Conscious and aware of time. classmates and friends visited him. he was playing computer games such as dota from 7:00 pm until dawn Conscious and aware of time. stimuli. date and reality. Motor Capabilitie . he cheers up when his relatives.

RLQ. RR: 4pm: 25 bpm 8pm: 28 bpm 7. He urinates and Urine: 2 defecates regularly.1’C Temp:4pm: 37. He only fried chicken.6’C 8pm: 37. Body temperatu re Temp: 4pm: 36’C 8pm: 37. throughout the evening when day. Stool: 1 Urine: 2 Stool: 1 10. 12. Stat Good skin turgor Incision on the Incision on the e of skin and warm feeling. Nutritional He eats all the foods He is in soft diet. Wounds . Wounds and RLQ. there’s a class on the ff morning. He is in soft he likes especially He only eats diet. Respirator y RR: 4pm: 28 bpm 8pm: 27 bpm rest. Elimi nation 11. Circulatory PR: 4pm: 70bpm 8pm: 100bpm PR: 98bpm 4pm: 8pm: 90bpm BP: 4pm: 110/80mmHg BP: 4pm: 120/80 8pm: 110/80mmHg 8pm:110/80 mmHg 8.s 6.9’C 9. He “lugaw” eats “lugaw” just eats vegetables when his mother forced him to. Stat e of physical rest & comfort He usually sleeps He sleeps anytime He sleeps around 10 in the of the day.

on the and lesions on the neck. When engaged in strenuous activities. but can be consciously stimulated or inhibited as in holding your breath. the rate and depth of breathing increases in order to handle the increased concentrations of carbon dioxide in the blood. This system is responsible for the mechanical process called breathing. It is this part of the body that houses our sense of smell.and appendice s lesions neck. ANATOMY AND PHYSIOLOGY The respiratory system is an intricate arrangement of spaces and passageways that conduct air from outside the body into the lungs and finally into the blood as well as expelling waste gasses. Breathing is typically an involuntary process. Upper Respiratory System Nostrils/Nasal Cavities During inhalation. . the air is heated and moisturized before it is brought further into the body. air enters the nostrils and passes into the nasal cavities where foreign bodies are removed. VI.

Bronchioles The bronchi subdivide creating a network of smaller branches. the acid-base balance of the body is maintained as part of homeostasis. becoming progressively smaller as they branch through the lung tissue. If proper ventilation is not maintained two opposing conditions could occur: 1) respiratory acidosis. and 2) respiratory alkalosis. which in reality is the thyroid gland and houses the vocal cords. until they reach the tiny air sacks of the lungs called the alveoli. Gas Exchange The major function of the respiratory system is gas exchange. It is the location of the Adam's apple. The lungs are made up of extremely thin and delicate tissues. with the smallest one being the bronchioles. It is at the alveoli that gasses enter and leave the blood stream. At the lungs. Trachea The trachea or windpipe is a tube that extends from the lower edge of the larynx to the upper part of the chest and conducts air between the larynx and the lungs. and waste gasses are returned for elimination. Avleoli The alveoli are tiny air sacks that are enveloped in a network of capillaries.Pharynx The pharynx. There are more than one million bronchioles in each lung. or throat carries foods and liquids into the digestive tract and also carries air into the respiratory tract. Lungs The lungs are the organ in which the exchange of gasses takes place. As gas exchange occurs. Larynx The larynx or voice box is located between the pharynx and trachea. Lower Respiratory System Bronchi The trachea divides into two parts called the bronchi. the bronchi subdivides. a life threatening condition. which enter the lungs. . It is here that the air we breathe is diffused into the blood.

Pleural fluid analysis Clinical Manifestations: Pati ent DOB Tachypnea Chest pain Diagnostic Evaluation: .CXR – pleural effusion in left hemithorax .Large effusion: SOB to acute respiratory distress . Size of effusion & the time course of development determine the severity.Chest CT scan .Small – Moderate: Dyspnea may not be present .CXR (lateral decubitis) . .Thoracentesis .VII.Pleural Biopsy . This type of effusion occurs secondary to other conditions.Dullness/Flatness to percussion over Diagnostic Evaluation: .Ultrasound -Thoracentesis . Pathophysiology Risk factors: Presence of Pulmonary Tuberculosis Organ Affected: LUNGS Disease Process: An exudative effusion results from increased capillary permeability characteristic of the inflammatory reaction. BOO K Clinical Manifestations: Some symptoms are caused by the underlying disease.

pain • Anemia • Shock • Some degrees of Pulmonary disease • Some degrees of Congestive heart failure • Myocardial infarction • Hypokalemia (decreased potassium) • Gastric suctioning or vomiting • Antacid administration • Aspirin intoxication Decrease: • Strenuous physical exercise • Obesity • Starvation • Diarrhea .Chest tube and water-seal drainage.45 Significance Increase: • Hyperventilation • Anxiety.Thoracentesis .Surgical pleurectomy .35-7.Medical Management: .388 Normal values 7.Meds: ethambutol.Chest tube and water-seal drainage . left side .Educate pt and family about management of drainage system with outpatient therapy Medical Management: .Chemical pleurodesis . 2010 Laboratory exams pH Results 7. levofloxacin Laboratory Exam Results: ARTERIAL BLOOD GAS Date ordered July 27.Thoracentesis . corticosteroid (Prednisone).

3 80-100mmHg Increase: • Increased oxygen levels in the inhaled air • Polycythemia Decreased • Decreased oxygen levels in the inhaled air • Anemia • Heart decompensation • Chronic obstructive pulmonary disease • Restrictive pulmonary .1 35-45mmHg Ventilatory failure • More severe degrees of Pulmonary Disease • More severe degrees of Congestive Heart Failure • Pulmonary edema • Cardiac arrest • Renal failure • Lactic acidosis • Ketoacidosis in diabetes Increase: • Pulmonary edema • Obstructive lung disease Decrease: • Hyperventilation • Hypoxia • Anxiety • Pregnancy • Pulmonary Embolism • PO2 94.PCO2 40.

6 22-26 mEq/L Decreased HCO3 • Metabolic Acidosis Increased HCO3 • BE 1. • Upper or middle airway obstruction exists (such as during an acute asthmatic attack) • Significant O2 saturation 97.1% 95-100% .3 +/. such as at increased altitudes.2 mEq/L Metabolic Alkalosis More Negative Values of Base Excess may Indicate: • Lactic Acidosis • Ketoacidosis • Ingestion of acids • Cardiopulmonary collapse • Shock More Positive Values of Base Excess may Indicate: • Loss of buffer base • Hemorrhage • Diarrhea • Ingestion of alkali Oxygen Saturation will fall if: • Inspired oxygen levels are diminished.• disease Hypoventilation HCO3 23.

Oxygen Saturation will rise if: • Deep or rapid breathing occurs • Inspired oxygen levels are increased. and liver disease.00-35. interfering with the free flow of oxygen across the alveolar membrane.alveolar lung disease exists.00 U/L Significance Increasedmyocardial infarction. but increased is more marked in ALT(SGPT) 17.3 Normal values 0. BLOOD CHEMISTRY Date ordered July 27. skeletal muscle disease. such as breathing from a 100% oxygen source PO2 (A-a) 55. Same conditions as AST(SGOT).1 It is an important factor affecting the amount of oxygen that is bound to hemoglobin.00-45 U/L .9 0. 2010 Laboratory exams AST(SGOT) Results 25.

fever.liver disease than AST(SGOT) Creatinine 64. Decrease – diarrhea.50-5. adrenocortical insuffiency. chronic renal failure. 2010 Laboratory exams WBC results 11.4 ↓ 72.7 ↓ 135. Sodium 132. acidosis.00-10.00-148.7 ↑ Normal values 4.00-127. carcinoma of liver.50 mmol/L COMPLETE BLOOD COUNT Date ordered August 5. cushing’s diease. anterior .58 3.00 mmol/L Increaseduseful in detecting gross changes in water and salt balanced Potassium 3.00 10^9/L Significant Increasedneurosyphilis.00 umol/L Increasemascular dystrophy. Increasedhemolysis. corpus luteum cysts.

00 fl .50-6. and with excessive fluid intake. hereditary anemia.00 g/L HCT 0.01↓ 4.50 10^12/L Decreasediron deficiency. catabolic methabolism. decrease in microcytic anemia HGB 109↓ 130.00-100. Increase in macrocytic anemias.54 MCV 89 80. toxic metals. Decrease in severe anemias. chronic disease. RBC 4.00-170. encephalitis lethargic. acute massive blood loss.poliomyelitis.36↓ 0. b12 or/ and folic acid deficiency. free radical pathology. severe of prolonged hemorrhage. pregnancy. anemia in pregnancy. B6. Decreased in various anemias.40-0. vit.

00-360.00-350.00 pg Increase in macrocytic anemias.19↓ 0.00 g/L Decreased in severe hypocromic anemia. Increase with infectious mononucleosis . the MCHC is elevated but not in pernicious anemia PLT Increased 150.25-0.50 . decrease in microcytic anemia MCHC 306↓ 320.MCH 27. Increased and decreased is same with MCV two exceptions in spherocytosis. myeloproliferat ive disease.00-32. rheumatoid arthritis. about 50% of patients with unexpected increase of platelet count will be found to have a malignancy. viral and Lymphocytes 0. and postoperativerl y.00 10^9/L Increased in malignancy.2 27.

decreased with aplastic anemia.50-0. bone marrow suppression. collagen Neutrophils 0. leukemia. Monocytes 0. malignant disease. parasitic disease. necrosis.00-0.01↓ 0. Increase in allergy.10 Increase with viral infections. trauma or surgery. RA. parasitic disease. immunodeficie ncy including AIDS. HIV infection.02-0. primary bone marrow disease. decrease with viral infections.80 0. hepatitis. decreased with use of corticosteroids.some bacterial infections.80 Eosinophils 0. collagen and hemolytic disorder. Increase with acute infection. SLE.05 .

disease.00-170. Decreased in various anemias. pregnancy.00 g/L .00 10^9/L Significance Increasedneurosyphilis. toxic metals. catabolic methabolism.58↓ 4. encephalitis lethargic. free radical pathology. decrease with stress. epinephrine.00-10. 2010 Laboratory exams WBC results 18. severe of prolonged RBC 3. anterior poliomyelitis.50 10^12/L HGB 103↓ 130. thyroxin COMPLETE BLOOD COUNT Date ordered August 1. subacute infections.50-6. hereditary anemia. b12 or/ and folic acid deficiency. chronic disease. Decreasediron deficiency. B6.3↑ Normal values 4. use of some medications(A CTH. vit.

hemorrhage.00 pg Increase in macrocytic anemias. decrease in microcytic anemia MCHC 320.32↓ 0.00-100. acute massive blood loss.00-32.00 fl .40-0. and with excessive fluid intake. the MCHC is elevated but not in pernicious anemia MCV 80. anemia in pregnancy.00-360. Increased and decreased is same with MCV two exceptions in spherocytosis. decrease in microcytic anemia MCH 27.54 Decrease in severe anemias.00 g/L Decreased in severe hypocromic anemia. HCT 0. Increase in macrocytic anemias.

06↓ 0.00-350.PLT Increased 150.02-0. decreased with use of corticosteroids. parasitic disease. immunodeficie ncy including AIDS. viral and some bacterial infections.50-0.10 Neutrophils 0.00 10^9/L Increased in malignancy.94 ↑ 0. SLE. about 50% of patients with unexpected increase of platelet count will be found to have a malignancy. decreased with aplastic anemia.80 . RA. and postoperativerl y. Increase with infectious mononucleosis . hepatitis. collagen and hemolytic disorder.25-0. rheumatoid arthritis. myeloproliferat ive disease. HIV infection. Increase with Lymphocytes 0.50 Monocytes 0. Increase with viral infections.

thyroxin COMPLETE BLOOD COUNT Date ordered July 27. decrease with viral infections. epinephrine. bone marrow suppression. decrease with stress. Eosinophils 0. anterior poliomyelitis. malignant disease. primary bone marrow disease. necrosis. subacute infections.05 Increase in allergy. trauma or surgery.2↑ Normal values 4.00-10. leukemia. encephalitis lethargic. 2010 Laboratory exams WBC results 15.acute infection. parasitic disease. use of some medications(A CTH.00 10^9/L Significant Increasedneurosyphilis.00-0. collagen disease. .

00 g/L HCT 0. acute massive blood loss. . Increase in macrocytic anemias.54 MCV 80. and with excessive fluid intake.00 pg Increase in macrocytic anemias. anemia in pregnancy. free radical pathology.00-170. hereditary anemia.00-32.37↓ 0.50-6.58↓ 4. Decreased in various anemias. Decrease in severe anemias. b12 or/ and folic acid deficiency. vit. chronic disease.50 10^12/L Decreasediron deficiency.RBC 3. pregnancy.40-0. toxic metals.00-100. decrease in microcytic anemia HGB 108↓ 130.00 fl MCH 27. B6. catabolic methabolism. severe of prolonged hemorrhage.

rheumatoid arthritis.25-0. Increase with infectious mononucleosis .00-360.00-350. hepatitis.00 10^9/L Increased in malignancy. viral and some bacterial infections. Lymphocytes 0. Increased and decreased is same with MCV two exceptions in spherocytosis. and postoperativerl y. the MCHC is elevated but not in pernicious anemia PLT 502 150.00 g/L Decreased in severe hypocromic anemia. myeloproliferat ive disease. about 50% of patients with unexpected increase of platelet count will be found to have a malignancy.decrease in microcytic anemia MCHC 320.50 .05↓ 0.

leukemia. HIV infection. collagen and hemolytic disorder. necrosis.92 ↑ 0. Increase in allergy. RA. SLE. decreased with use of corticosteroids. subacute infections. parasitic disease. Increase with acute infection. collagen disease. bone marrow suppression.50-0. Neutrophils 0.00-0. parasitic disease. trauma or surgery.02-0.05 .10 Increase with viral infections. immunodeficie ncy including AIDS. Monocytes 0. malignant disease.80 Eosinophils 0.decreased with aplastic anemia. decrease with viral infections. primary bone marrow disease.

epinephrine. thyroxin . use of some medications(A CTH.decrease with stress.

a kidney disorder. They may be caused by bone marrow disorders such as multiple myeloma.00 G/L 1.5 Normal values 66.0030. or a disorder in which protein is not digested or absorbed properly. Low levels may be seen in severe malnutrition an d with conditions that cause malabsorption. 2010 Laboratory exams Total Protein Results 65.0083. INCREASE High total protein levels may be seen with chronic inflammati on or infections such as viral hepatitis or HIV.Total Protein and A/G Date ordered July 27. such as Celiac disease or inflammator y bowel disease (IBD).00 G/L Albumin's role in the body is to maintain osmotic pressures and to also transport hydrophobic substances Globulin A/G ratio 40.50-2. Albumin 24.0052.50 A high A/G ratio suggests underproduction of immunoglobulins as may be seen in some genetic deficiencies and in some leukemias A low A/G ratio may reflect overproduction of globulins. such as seen in multiple .60 ↓ 15.9 ↑ 0.00 G/L Significance DECREASE Low total protein levels can suggest a liver disorder.6 ↓ 35.

100% Non-creanated- Gram Stain Result (July 27.yellow/turbid Appearance after centrifugation.yellow/ clear Total Volume: 3mL RBC Count: 1950 cells/ cu.mm WBC Count: 2250 cells/ cu.Body Fluid Cell Count (July 27.0.200 Differential Count: Neutrophils.mm Total Cell Count: 4. 2010) Recheck chest x-ray after 2 days show diminution in the pleural effusion in the left hemithorax A T-Tube is seen in situ .51 RBC Morphology: Creanated RBC. 2010) Appearance before centrifugation. 2010) Polymorphonuclear cells= Few No microorganisms seen Chest X-ray(July 30.49 Lymphocytes: 0.

and BN: Omeprazole intestines. As part of a class of drugs known as proton pump inhibitors (PPIs). Medication Action Indication Nursing Intervention Monitor patients hypersensitivity to omeprazole and its components Dosage: 40mg Frequency: . it works by decreasing the amount of acid that is produced in your stomach. Drug Study Date Ordere d July 28. stomach.201 0 GN: To treat several conditions related to the esophagus.VIII.

GN: Digoxin Lanoxin is used to treat congestive Lanoxin is also used to slow the heart Before giving the drug ask the . skin and skin structure. lower respiratory tract) Monitor bleeding manifestations or significant leukopenia following prolonged administration have occurred in some patients receiving blactam antibiotics. Bacterial infections in neutropenic children in combination with an aminoglycoside. TAZOCIN is indicated for the treatment of polymicrobic infections including those where grampositive and gramnegative aerobic and/or anaerobic organisms are suspected (intraabdominal.OD Route: IV July 28.2g TAZOCIN is for treatment of the following systemic and/or local bacterial infections in which susceptible organisms have been detected or are suspected: Children Frequency: Q8 Route: IV Appendicitis complicated by rupture with peritonitis and/or abscess formation in children aged 2 12 years. including piperacillin July 28. 2010 GN: Piperacillin BN:Tazocin Dosage: 2.

and hypertension . hyperpyrexia. post-op gas pain. convulsions. Gastritis & duodenitis accompanied by flatulence. patient about allergic reactions to digoxin Frequency: OD Route: August 06. tachycardia.201 0 GN: Meperidine BN:Demerol Dosage: Demerol is used for the relief of moderate to severe pain. heartburn and gastric hyperacidity. Antacid therapy in gastric and duodenal ulcer.2010 BN:Lanoxin heart failure Dosage: 25mg rate in patients with chronic atrial fibrillation. a heart rhythm disorder of the atria (the upper chambers of the heart that allow blood to flow into the heart). gastritis.201 0 Maalox Suspenscio n Dosage: 30cc Maalox is a balanced mixture of 2 antacids: Aluminum hydroxide is a slow-acting antacid and magnesium hydroxide is fast acting. The principal actions of therapeutic value in Demerol are analgesia and sedation. most commonly in obstetrics and post-operative conditions. Make sure patient has food intake 20 minutes – 1 hour before taking maalox Frequency: Stat August 06. Demerol is a narcotic analgesic with effects similar to Monitor patient include hyperexcitability.

Frequency: Q12 Medication Generic Name: ethambutol Brand Name: Myrin P Forte 3tab AC breakfast OD Action Inhibits the growth or other myobacteria. THERAPEUTIC EFFECTS: Tuberculostatic effects against susceptible organisms. Reassess patient’s level of pain. Route: IV Frequency: Now August 04. abdomen and brain caused by susceptible anaerobic bacteria. PHARMACOLOGIC Indication Active tuberculosis or other mycobacterial disease (with at least one other drug) Nursing Consideration . pelvis. Safety and effectiveness in pediatric patients have not been established. except for the treatment of amoebiasis.Assess lung sounds and . .25mg morphine.Mycobacterial studies and susceptibility tests should be performed before and periodically during therapy to detect possible resistance.201 0 GN: Metronidaz ole Metronidazole is an antibiotic effective against anaerobic bacteria and certain parasites BN: Flagyl Dosage: 1gm/ tab Metronidazole is used alone or in combination with other antibiotics in treating abscesses in the liver.

nausea. location. hepatic impairment or renal disease. May cause prolonged bleeding time that may persist for 24-48 hr following discontinuation of therapy. paresthesia. pleural effusion). producing peripherally mediated analgesia. Increases renal excretion of water. Also has antipyretic and antiinflammatory properties. Generic Name: furosemide Brand Name: N/A 40mg/IV STAT Generic Name: ketorolac Brand Name: Ketoradol 30mg/IV q6 Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Monitor frequency of prescription refills to determine compliance in patient treated for hypertension. and confusion. THERAPEUTIC EFFECTS: Diuresis and subsequent mobilization of excess fluid (edema. May cause . Assess patients receiving digoxin for anorexia.ACTION: antituberculars character and the amount of sputum periodically during therapy. Patients taking digoxin are at risk of digoxin toxicity because of the potassiumdepleting effect of diuretics. PHARMACOLOGIC ACTION: loop diuretics. Hypertension. magnesium. Edema due to heart failure. Decrease blood pressure. - - Monitor blood pressure and pulse before and during administration. Short-term management of pain (no to exceed 5 days total for all routes combined) - - - Assess pain (note type. Inhibits prostaglandin synthesis. vomiting. potassium. sodium. and intensity) prior to and 1-2 hr following administration. THERAPEUTIC EFFECTS: Decreased pain. muscle cramps. Effectiveness persists in impaired renal function. and calcium. chloride.

Generic Name: Management of - Assess ROM. - - increased BUN. location. or dyspnea. . restlessness). Assess patient for signs of adrenal insufficiency (hypotension. Assess blood pressure and respiratory rate before and periodically during administration. nausea. Inhibits reuptake of serotonin and nonepinephrine in the CNS. or potassium concentrations. confusion. rales/crackles. serum creatinine. steady weight gain. weakness.Generic Name: tramadol Brand Name: Tramadin 100mg/IV q8 PHARMACOLOGIC EFFECT: pyrroziline carboxylic acid. and intensity of pain before and 2-3hr (peak) after administration. THERAPEUTIC EFFECTS: Decreased pain. Monitor intake and output ratios and daily weights. Observes patient for peripheral edem. Suppresses immune system by reducing lymphatic activity. Notify health care professional if these occur. weight loss. THERAPEUTIC EFFECT: Suppression of inflammation and modification of the normal immune response. Respiratory depression has not occurred with recommended doses. - - Generic Name: corticosteroids Brand Name: Prednisone 20mg/tab 1tab BID Decreases inflammation by reversing increased cell capillary permeability and inhibiting migration of polymorphonucle ar leukocytes. Binds action to mu-opioid receptors. anorexia. PHARMACOLOGIC ACTION: analgesics (centrally acting) Moderate to moderately severe pain. lethargy. vomiting. Assess type. PHARMACOLOGIC EFFECT: corticosteroids (systemic) Inhibits the It is prescribed in the treatment of severe inflammation and for immunosuppressi on.

THERAPEUTIC EFFECT: Reduction of nausea and vomiting. Assess patient for sign of urinary retention periodically during therapy. antiinflammatory. PHARMACOLOGIC ACTION: anticholinergics acute pain including primary dysmenorrhea. THERAPEUTIC EFFECTS: Decreased pain and inflammation caused by arthritis or spondylitis. and antipyretic properties. This enzyme is required for the synthesis of prostaglandins. Generic Name: scopolamine Brand Name: Buscopan 1amp STAT Preoperatively to produce amnesia and to decrease salivation and excessive respiratory secretion. Preoperative amnesia and decreased secretions. Assess patient for pain prior to administration. Patients with these allergies should not receive celecobix. producing delirium if used without morphine and meperidine. Monitor heart rate periodically during parenteral therapy. aspirins. which may be responsible for motion sickness. Inhibits the muscarine activity of acetylcholine. Scopolamine may act as a stimulant in the presence of pain. Has analgesic. Corrects the imbalance of acetylcholine and norepinephrine in the CNS. and pain in affected joints before and periodically throughout therapy. or NSAIDs. - degree swelling.celocoxib Brand Name: Celebrex 400mg/tab 1tab OD enzyme COX-2. Assess patient for allergy to sulfonamides. - - - .

urinalysis. WBC. cloudy or foul-smelling urine) prior to and during therapy. PHARMACOLOGIC ACTION: fluoroquinolones Treatment of bacterial infections such as respiratory tract infection.Generic Name: levofloxacin Brand Name: Levox 750mg/tab 1tab OD Inhibit the bacterial DNA synthesis by inhibiting DNA gyrase. Generic Name: trimetazidine Brand Name: Vastarel Mr 35mg /tab 1tab BID Reduces the metabolic damage caused during ischemia. . THERAPEUTIC EFFECTS: Death of susceptible bacteria. sputum. appearance of wounds. - - Assess for infection (vital signs. First dose may be given before receiving results. urine. Obtaining specimens for culture and sensitivity before initiating therapy. by acting on a critical step in cardiac metabolism: fatty acid β-oxidation. and stool. frequency and urgency of urination.

For the pharmacological management of the patient’s condition • Encourage adequate rest periods between activities R. To obtain appropriate baseline data coping behaviors and methods to • Provide relaxing improve environment breathing pattern.2 hours of nursing intervention the patient has demonstrate improve breathing pattern because he was able to answer the questions that was being asked to him. To promote adequate rest periods to limit fatigue • Assist client in the use of relaxation technique R. to limit fatigue . To provide relief of causative factors • Administer prescribed medications as ordered Evaluation After 1.IX. R. and dyspnea R. Pallor skin Orthopnea Nursing Diagnosis: Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea. Nursing Management Assessment Subjective: • Dyspnea Objectives: The patient manifested the following: • • Tachypnea RR of 28 The patient may manifest the following: • • Planning Nursing Intervention After 1-2 hours of nursing • Monitor and record interventions the vital signs patient will demonstrate R.

Encourage use of relaxation techniques such as focused breathing. R: Presence of known/unknown complication/s may make the pain more severe than anticipated. providing a quite environment R: to promote non pharmacological pain management. Pain Scale: 9/10 Objective: (+) abdominal guarding (+) facial grimace (+) crying during onset of pain Restlessness RR. Provide comfort measures such as touch therapy. . Intervention Independent Nursing Action: Note location of surgical procedures. Planning After 1-2 hours of nursing intervention the patient will verbalize that pain scale of 9/10 will reduce to 5/10.Acute Pain Assessment Subjective: “Masakit na masakit po iyong inoperahan.28 PR.” as verbalized by the patient. imaging and listening to music.98 Nursing Diagnoses: Acute pain related to surgical procedure. repositioning. patient verbalized that pain scale of 9/10 was reduced to 5/10. lalo na pagumuubo ako. Collaborative: Administer analgesics as prescribed to Evalutaion After 1-2 hours of nursing interventions. R: To distract attention and reduce tension.

maximum dosage as needed.5 Diagnosis: Imbalanced Nutrition: Less than body requirements related to absence of physical conditions that would explain Planning After 1-2 hours of nursing the patient and his relatives will be able to verbalize and demonstrate ways of nutritional status.5 Underweight: <18. Conduct a nutritional assessment R: It is critical that the health care provider openly discuss and have an understanding of the complex food and weight- Evaluation After 1-2 hours of nursing the patient and his relatives has able to verbalize and demonstrate ways of nutritional status. Imbalanced Nutrition: Less than body requirements Assessment Subjective Objective: Weight before hospitalization: 50 kg Height: 165 cm BMI: 18.4 Weight: 45 kg Height: 165 cm BMI= 16. R: To maintain acceptable level of pain.food and fluid intake and weight control . food and fluid intake and weight control Intervention Record the patient’s weight and height on intake. maintaining standard conditions R: This ensures accurate record of weight changes. Weigh regularly.

and endocrine system functioning. Assess cardiovascular.e. hematological. Record intake and output for the hospitalized patient. metabolic.weight loss or prevent weight gain. R: These data help determine the patient’s actual caloric intake and eating behaviors. gastric. daily food plans that track eating trends along with emotional states and triggering events). R: Assessment provides data on the severity of malnutrition. Monitor intake (i.. renal. . related behaviors of the patient so that appropriate supports can be integrated into the treatment plan.

Activity Intolerance Assessment Planning Intervention Evaluation .

Body weakness Limited range of motion. Provide the patient with a calm and quiet environment R: To provide relaxation *Promote comfort measures and provide for relief of pain. R: Symptoms may be result of/or contribute to intolerance of activity. R: to determine current status and needs associated with participation in needed or desired activities The patient shall have used identified techniques to improve activity intolerance - Nursing Diagnosis: Activity intolerance related to insufficient oxygen. Risk for Infection . generalized weakness and complete bed rest.Subjective: “nahihirapan ako gumalaw dahil masakit ang tagiliran ko”as verbalized by the patient. pain. Unable to get up to go to the bathroom After 1-2 hours of nursing interventions. the patient will use identified techniques to improve activity intolerance Independent: *Note client reports of weakness. R: to enhance ability to participate in activities. fatigue. Objectives: . *Plan for maximal activity within the client’s activity.

Absence of fluctuations and excessive bubbling may indicate leaks Monitor and record amount and characteristics of drainage R: Increase amount s of drainage may signal worsening condition Provide regular wound dressing and tube care R: To promote comfort and hygiene.Assessment Subjective none Objective *T.36. To prevent growth of microorganisms in dressings.73bpm *R. Elevation in rates may signal infection Assess insertion site for signs of infection R: To check for skin integrity and identify need for further management Assess patency and intactness of water sealed bottle R: Any obstructions and kink may delay flow. proper wound care and water-sealed drainage bottle .90/70 mmHg *S/P CTT Insertion *With CTT connected to one way water sealed bottle *With dry and intact dressing on operative/insertio n site Diagnosis: Risk for infection related to tissue trauma secondary to surgical procedure ( CTT and appendectomy) Planning After 2-3 hours of nursing intervention the patient and his relatives will be able to verbalize and demonstrate ways in preventing infection specifically proper hand washing. To prevent growth of microorganisms in linens and robes Evaluation After 2-3 hours of nursing intervention the patient and his relatives has able to verbalize and demonstrate ways in preventing infection specifically proper hand washing.5 *P. tube Change linens and pt’s robes R: To promote comfort and hygiene.27bpm *BP. proper wound care and water-sealed drainage bottle Intervention Independent Monitor vital signs and records R: To provide baseline data for comparison.

Patient should also be advised to “take it easy” to do activates that their body can handle. Evaluation I.Tazocin . Treatment: Educate the patient how to properly take the medications and explain the action of it and the considerations to be taken during medication intake.Flagyl -Myrin -Vastarel -Furosemide -Ketoradol -Tramadin -Prednisone -Celebrex -Buscopan Exercise: Avoid strenuous activities. such as heavy lifting and any other extreme sports or activities that may trigger an increase in heart rate. . These include: .Maalox Suspension .Lanoxin . After recovery if the patient discharged the patient should start with short slow walks for about 10-15 minutes and with time gradually increase the duration and intensity of the walk. Evaluation Medication: Continue prescribed medications for PULMONARY TUBERCULOSOS.Demerol . and be aware of their complications.X.Omeprazol .

To avoid any further complications with the patient’s condition. Stick to a soft diet to ease the digestion process. Like brushing teeth to avoid any further infections. After having been admitted at WCMC. able to move on his own and even smiling while talking even though he is suffering from pain. Prognosis The client’s prognosis is not that good though he is showing some progress like being able to communicate well to the relatives and nurses. Avoid foods that will cause constipation and strain during bowel movements. Out Patient: Remind patient about upcoming check ups needed to increase the patients health. the patient is more comfortable and showed an increase in sense of energy and communication. Also advice patient about any further appointments that need to be made. .Hygiene: Educate patient on the proper self hygiene techniques to prevent any further complications. Diet: low sodium and low fat diet. Spiritualism – joining to some activities like bible studies and attending events to further develop the client’s condition after being discharged from the hospital. Educate the patient about physical limitations and the time needed to make a full recovery before resuming normal activates before hospitalization.

Sign up to vote on this title
UsefulNot useful