I.

Introduction
A. Background of the study

The case study that is to be presented features a patient who has emphysema. Emphysema is a chronic obstructive pulmonary disease (COPD). It is often caused by exposure to toxic chemicals, including long-term exposure to tobacco smoke or cigarette smoking. The lungs become damaged because of reactions to irritants entering the airways and alveoli. Cigarette smoking is the major cause of emphysema, accounting for more than 80 percent of all cases. Emphysema occurs most often in people older than age 40 who have smoked for many years. Long-term exposure to secondhand smoke may also play a role. Smoking stresses the natural antioxidant defense system of the lung, allowing free radicals to damage tissue down to the cellular level. When cigarette smoke is inhaled, 80 to 90 per cent remains in the lungs and causes irritation, increased mucus production and damage to the deep parts of the lungs. Eventually mucus and tar clog up the air tubes, causing chronic bronchitis and emphysema. Among other causes of emphysema are industrial pollutants, aerosol sprays, non-tobacco smoke, internal-combustion engine exhaust, and physiological atrophy associated with old age (senile emphysema). It was verbalized by the wife of the patient that he used to work at the farm in Morong. this could be one factor that caused the patient’s disease. Emphysema is characterized by loss of elasticity (increased pulmonary compliance) of the lung tissue caused by destruction of structures feeding the alveoli, owing to the action of alpha 1 antitrypsin deficiency. This causes the small airways to collapse during forced exhalation, as alveolar collapsibility has decreased. As a result, airflow is impeded and air becomes trapped in the lungs, in the same way as other obstructive lung diseases. Symptoms include shortness of breath on exertion, and an expanded chest. However, the constriction of air passages isn't always immediately deadly, and treatment is available. Emphysema is often the result of smoke that has triggered the immune system to produce more harmful enzymes. Although these harmful enzymes are normally prevented from causing any significant damage by a protective protein, smoking reduces the protein’s protective effect. Even if someone has plenty of the protein in their system, smoking generates certain substances that keep the protective protein from doing its job. We as nurses are involved in learning what type of nursing interventions we are to apply to this type of patient. Beyond understanding the relevant health issue, this case study will also explore other factors that can enhance our knowledge in the field of our nursing practice. This is also the primary reason why we choose this case study because we know that it is highly beneficial aside from it being considered distinctive or unique. Included with the case study are the discussions of the anatomical parts, through physical assessment of the patient, laboratory results and their corresponding findings, a reapplied framework theory by Florence Nightingale. Added to this we also have a corresponding plan for 1

the patients discharge arrangement and finally a discussion of the patient’s daily activities and nursing care plans. B.

Objectives
General objectives

After exposure in the medical ward of Queen Mary Hospital the promotion of health and the prevention of illness should have been applied through the use of effective nursing care. Wellness should be met through the implementations that have been done with regards to the application of the nursing process. That is after developing and implementing an intervention, and monitoring the impact of that intervention to the patient. This is to know whether the treatments given to him were effective or not. Specific Objectives Our objective is to develop our skills in identifying and assessing the health problems, how to utilize and render quality health service in the care of an individual who has emphysema. Other objectives would include the establishment of rapport for the patient to fully cooperate with his treatment and so as to assess him with his health related problem.

C. Significance of the study
The importance of this study is that the case on this subject and especially in this area is still very rare.

D. Scope and limitation
The whole study is all about emphysema, its risk factors and progress, how it affects daily living, and how it is treated and managed. Our study is limited only to our patient who has the said disease, his manifestations and how it was managed up to now.

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E. Theoretical framework
m Ore ’s

• • •

Theory of Self Care Each person has a need for self care in order to maintain optimal health and wellness. Each person possesses the ability and responsibility to care for themselves and dependants. Theory is separated into three conceptual theories which include: self care, self care deficit and nursing system. Theory of Self Care Self care is the ability to perform activities and meet personal needs with the goal of maintaining health and wellness of mind, body and spirit. Self care is a learned behaviour influenced by the metaparadigm of person, environment, health and nursing. Three components: universal self care needs, developmental self care needs, and health deviation. 3

• • •

II. Nursing Assessment
A. Personal Data
Name: Mr. LP Address: G. Robles Maybangkal Street, Morong, Rizal Age: 61 years old Birth date: March 30, 1948 Religion: Roman Catholic Civil Status: Married Nationality: Filipino Occupation: Former Farmer Admitted on: June 21, 2009 Time: 9:10 p.m. Admitting Diagnosis: COPD in exacerbation, Plural Effusion, Pneumonia, t/c Electrolyte imbalance o Chief Complaint: D.O.B. (Difficulty of Breathing) o o o o o o o o o o o

B. History of Past illness
Patient has undergone, thoracentesis last June 15 at Queen Mary Help of Christians hospital prior to that admission he was diagnose with plural effusion, thoracentesis was perform and after 5 days of admission he was discharge home.

C. History of Present Illness
After the patient was discharge home around 8:50pm (June 15, 2009) after 3 days at home he experienced DOB and he was rush to the hospital accompanied by his wife and cousins. -COPD -Questionable Pneumonia -Electrolyte Imbalance

D. Family History
According to patients wife they can not recall any illness in the family of his husband except from asthma.

E. Patient’s Concept of Health Illness and Hospitalization
He didn’t expect that this would happen to him, doctors doesn’t have any idea of the source of his illness but the patient says, that it might be from the work, he thought that it would just be a 4

simple cough due to tiring day but it lasted for about a month and he needs to be admitted and undergone some procedures.

F. Physical Examination/Assessment
Area 1. Hair Normal Finding - black, evenly distributed and covers the whole scalp, thick, shiny, free from split ends - white, clean, free from masses, lumps, scars, dandruff and lesions - Oblong or oval. Symmetrical. Facial expression that is dependent on the mood or true feelings, smooth and free from wrinkles, no involuntary muscles involved - parallel and evenly placed, symmetrical, non-protruding, both eyes are black and clear - midline, symmetrical and patent clear pinkish with few cilia (-) congestion - pinkish, symmetrical, tip margin well define, smooth and moist - 32 permanent teeth, well aligned, free from carries or filing. Actual Finding I. Head - black slightly grayish , thick. Analysis -Aging

2. Scalp

- without dandruff

- normal

3. Face

- With wrinkles, symmetrical. With expression of pain and anxiety

- patient is still worried about his condition and appearance

4. Eyes

- symmetrical, black in color and can still read with out glasses - symmetrical with NGT

- normal

5. Nose

- patient has undergone surgery

6. Lips

- crack and dry lips

7. Teeth and Gums

- with out dentures, gums are normal in color

- patient wasn’t able to eat and drink that much due to his tracheotomy - patient was instructed to gargle bactidol

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8. Speech

-No hoarseness and well – modulated. Can able to say two words with meaning

Can not speak, makes some moderate noise, can communicate with sign language or by writing. -Normal Findings except, Enable to hear whisper spoken 2 feet away.

Tracheostomy can block the vocal cords that’s why patient wasn’t able to make any sounds

9. Ears

-Parallel, symmetrical, proportional to the size of the head, bean shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area, clean, firm cartilage. Ear canals are pinkish with scant amount of cerumen and a few cilia. Able to hear whisper spoken 2 feet away. -No halitosis, foul odor, fruity and sweet. -No inflammation, no difficulty in swallowing and no productive cough.

-Aging

10. Breath

- With minimal halitosis - No inflammation, Presences of cough with greenish yellow phlegm and experiencing difficulty in swallowing - Presences of palpable lumps, sensation of pain when trying to speak.

- Halitosis may be due to poor dental hygiene -excessive mucus production in his lower lung due to impaired defense mechanisms caused by prolonged years of smoking. - Lymph nodes are present after surgery, patient’s feels pain in the neck due to body weakness in the area of tracheostomy.

11. Throat

12. Neck

- Proportional to the size of body and head, symmetrical and straight. NO palpable lumps, masses, or areas of tenderness

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1. Breathing

II. Thorax - Normal breath - Abnormal sounds are Respiration 40bpm, bronchovesicular, a difficulty in medium pitched breathing. sound or medium Experiencing cough intensity, heard after nebulization. posyeriorly between the scapulae. The sound have blowing quality with the inspiratory phase equal to the expiratory phase and Vesicular sounds which heard over the lung periphery. It created by air moving through the small airways. They are soft, breezy and low pitched and the inspiratory phase is about three times longer than the expiratory phase. Respiration rate ranges from 16 – 20 in normal adult. - flat chest, tender: brownish in color. - a tube is inserted in the fifth intercostals space, mid-axillary line. - Unblemished skin, uniform color, symmetric movement cause by respiration , soft, no tenderness, no lumps or masses,

- Excessive phlegm production blocks his thorax and this may cause difficulty in breathing.

2. chest

- to remove fluid from the intrathoracic space - normal

3. Abdominal Exam

- Color is uniform, symmetrical movement caused by respiration. Soft abdomen, no tenderness, no lumps, or masses, no organomegaly

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III. Limbs 1. Extremeties - no areas of tenderness, muscle appear with good muscle tone - with IV catheter on his right arm and a red spots in the site of the IV catheter. - red spots may cause itchiness in the site of IV and also this may cause infection or phlebitis. - poor circulation

2. Nails

- transparent, smooth and cover with pink nail beds and translucent -No discharges or bleeding, no difficulty in urinating. - Can be able to responds from any questions and can still be familiar to his environment

- pale nail beds and peripheral last for 4seconds -There are no discharges or any bleeding. - He can answer/respond to us a little bit slowly.

IV. Genitalia

-Patients urinate on the bed pan

V. Mental State

- Slightly anxious about his condition, and tries to think about what when wrong before he experience his illness. - Patient has a drainage tube at his chest and undergone tracheostomy, patients experiencing body weakness can not move properly

VI. Hygiene and comfort

- Full bath and able to practice simple hygiene and care for himself.

- Patients depends on significant others in eating, taking a bath (TSB) and other chores that involves wide movement.

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Usual Pattern of daily living/ Gordon’s Health Assessment
F.

Pattern
1. Health PerceptionHealth Management

Before After Interpretation Hospitalization Hospitalization
Patient X makes sure to consult his doctor with regards to his condition, he goes for checkups because he knows that there is something wrong with him. He maintains a healthy body. He easily gets bored when he is not doing anything. He has started smoking (Marlboro Green) since he was 36 years old up to present. He is not allergic to any food or drug. His family does not have any history of hypertension, heart disease, cancer, asthma, diabetes or even tuberculosis. Patient X’s life before his pre confinement stage was normal, he can eat whatever he wants. He eats fruits like apples and bananas, fish and Patient X considers himself not healthy due to his present condition. He was diagnosed with "COPD” and he had undergone tracheostomy. He is expecting to recover from his present condition with the help of the health care providers attending to his needs. All of the medications prescribed to patient X are available. Patient X cannot function normally like before because of his confinement and because of his condition. His body image changed due to his disease and surgical procedure that he has undergone.

Analysis
A tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheotomy tube or trachea tube. This surgical procedure helps the client with his breathing problem.

2.Nutritional Metabolic Management

During hospitalization, the patient is on a DAT diet (Diet as tolerated). He eats lugaw, goto, crushed biscuits. He said he has poor appetite or he

Patient X’s nutritional and metabolic status has been changed due to his confinement and his medical health

An individual’s health status greatly affects eating habits and nutritional status (Fundamentals of Nursing by Kozier p. 1178) The patient was brought to the hospital because of ruptured 9

also vegetables most of the time. He rarely eats meats. 3.Eliminatio n Pattern Bowel Patient X defecates 1-2 times a day without Experiencing discomforts, usually in the morning and afternoon. Stool is brown in color and is wellformed. Bladder Patient X voids usually 6-8 times a day. Urine is yellow in color. No pain when voiding. In the morning, Patient X’s daily include farming in their land fields. In the afternoon after lunch, Patient X likes to watch T.V.

easily loses his appetite.

condition. His confinement status is totally affected. Bowel There was a change in the frequency, consistency and amount of stool. Bladder There was a change in the frequency, and amount.

globe right eye due to accident and burn of facial area including the neck. An illness greatly affects elimination status due to immobility.

Bowel Patient defecates once a day but not everyday. He defecates in the bed pan. Stool is soft, is minimal in amount and is brown in color. Bladder Patient voids in the bed pan without pain and discomfort. Urinates about 3-5 times a day.

4. Activity, Leisure and Recreation Pattern

Patient X’s activities in the hospitals are ambulation, deep breathing exercise, taking a bath or personal hygiene.

5. Sleep and Rest Pattern

Patient X before hospitalization already has difficulty in sleeping. He says he will fall asleep but will eventually wake up again and will not be able to

Patient X verbalizes that he has difficulty with sleeping and that he sleeps for short periods of time about: (3-4 hours) due to pain and the environment

During Patient X’s confinement in the hospital, there is limitation in his activities of daily living and a disruption in his leisure and recreation pattern. Patient X's sleep and rest pattern has not changed much before and after admission to the hospital. Pain also contributes a big factor for

Pain causes discomfort and may disrupt the patient’s daily activities.

“Illness that causes pain or physical distress can result in sleep problems. People who are ill require more sleep than normal and the normal rhythm and 10

return back to sleeping. He sleeps for A short period of time about 4 hours a day.

that he is in. He does not feel comfortable.

disturbances of his sleeping pattern.

6. CognitivePerceptual Pattern

Patient is an elementary graduate. He is a farmer. He can read and write. He can speak and be understood by others.

7. SelfPerceptionSelf-Concept Pattern

Because of Patient X’s present condition, he has difficulty in breathing. Patient is able to read and write at present. He cannot speak much because of his tracheostomy tube, he communicates through hand gestures but most data that we received came from his wife. Patient X is a He does not friendly person; he consider himself loves to socialize as a holistic with his friends in person. He has their many regrets in neighborhood. He his life like his considered himself smoking habits as a holistic before. He thinks human being as that he can't long as his function well than complete, healthy before. and his family are always there for him. He wants to have good health and live his life to the fullest.

There was a change in cognitive and perceptual pattern in terms of speaking due to his tracheostomy.

wakefulness is often disturbed.” (Fundamentals of Nursing, 7th ed by Barbara Kozier, et al, p. 1117). There is disruption of the sleep wake cycle because of the patient’s disease. Tracheostomy can block the vocal cords that’s why patient wasn’t able to make any sounds

There is a change in his self esteem.

“Events or situations may change the level of self concept over time. Illness and trauma can also affect the self concept.”

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8. Role Relationship

Patient can speak and understand English, Tagalog. He can clearly express himself. He has 8 siblings and they are all close to each other. Patient is very active and usually socializes with his neighbors. Patient and his wife perform this when he is still healthy. When he is anxious, patient wants to be alone. He does not show his emotions. When he is stressed, he prefers to rest. When it comes to problem, he lets himself think immediately for a solution.

Patient X's family still supports him despite of the change in his role due to his illness.

He cannot perform his previous activities or even support his family but still, despite of that, his wife is still there beside him taking care of him and loves him. Patient does not want to talk about it. Even though it’s hard for the patient to cope, is wife is there beside him to support him and give him strength and hope.

Illness can cause changes in one’s role.

9. SexualityReproductive Pattern 10. Coping and Stress Tolerance

The patient does not perform any sexual activity.

Illness can cause loss of interest in sexual activities. According to Folkman and Lazaruz, coping is “the cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person”(Fundamental s Of Nursing by Kozier P. 1020).

11. ValuesBelief Pattern

The recent hospitalization was a shocking experience for patient X, there has been many changes that has occurred which made it difficult for him to adjust. He cannot communicate effectively due to the procedures on his neck which is open to direct airway through an incision in the trachea. Patient X is a According to the Roman Catholic. patient, there are According to the no practices that client, he goes to affect his mass every sunday hospitalization. He with his family. follows therapeutic regimen and has

After what Due to illness, it happened, patient makes the patient is now seeking become closer to God. for medical assistance. Religious effort is still a part of patient’s life. 12

strong faith in God accounts for his fast progress.

III. ANATOMY
The Respiratory System

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Parts of the Respiratory System Structurally, the respiratory system consists of two parts: 1. Upper Respiratory Tract 2. Lower Respiratory Tract Functionally, the respiratory system consists of two parts: 1. The conducting portion 2. The respiratory portion Respiratory Tract The respiratory tract is the path of air from the nose to the lungs. It is divided into two sections: Upper Respiratory Tract Lower Respiratory Tract

Upper respiratory tract 1. Nose 2. Pharynx (throat) 3. Associated structures Lower Respiratory Tract 1. Larynx (voice box) 2. Trachea (windpipe) 3. Bronchi 4. Lungs

IV. PHYSIOLOGY
Upper respiratory tract
Nose The nose, whether “pug” or “ski-jump” in shape, is the only externally visible part of the respiratory system. During breathing, air enters the nose by passing through the external nares, or 14

nostrils. The interior of the nose consists of the nasal cavity, divided by a midline nasal mucoseptum. The olfactory receptors for the sense of smell are located in the mucosa in the slit like superior part of the nasal cavity, just beneath the ethmoid bone. Pharynx The pharynx is a muscular passageway about 13 cm long that vaguely resembles a short length of red garden hose. Commonly called the throat, the pharynx serves as a common passageway for food and air. Air enters the superior potion, the nasopharynx, from the nasal cavity and then descends through the oropharynx and laryngopharynx to enter the larynx-below.

Lower Respiratory Tract
Larynx The larynx, routes air and food into the proper channels and plays a role in speech. The largest of the hyaline cartilages is the shield shape thyroid cartilage, which protrudes anteriorly and is commonly called the Adams’s apple. Trachea Air entering the trachea or windpipe from the larynx travels down its length (10-12 cm, or about 4 inches) to the level of the fifth thoracic vertebra, which is approximately midchest. The trachea is lined with a ciliated mucosa. Primary Bronchi The division of the trachea forms the right and left primary bronchi. The right primary bronchus is wider, shorter, and straighter than the left. By the time incoming air reaches the bronchi, it is warm, cleansed of most impurities, and well humidified. Lungs The paired lungs are fairly large organs. They occupy the entire thoracic cavity except for the most central area, the mediastinum, which houses the heart, the great blood vessels, bronchi, esophagus, and other organs. The surface of each lung is covered with a visceral serosa called the pulmonary,or visceral, pleura, and the walls if the thoracic cavity is lined by the parietal pleura. Alveoli (site of gas exchange) An alveolus (plural: alveoli, from Latin alveus, "little cavity"), is an anatomical structure that has the form of a hollow cavity. In the lung, the pulmonary alveoli are spherical outcroppings of the respiratory bronchioles and are the primary sites of gas exchange with the blood. The lungs contain about 300 million alveoli, representing a total surface area of 70-90 square metres, each wrapped in a fine mesh of capillaries. It has a radii of about 0.1 mm and wall thicknesses of about 0.2 µm. It consists of an epithelial layer and extracellular matrix surrounded by capillaries. In some alveolar walls there are pores between alveoli. There are three major alveolar cell types in the alveolar wall (pneumocytes): Type I cells that form the structure of an 15

alveolar wall. Type II cells that secrete surfactant to lower the surface tension of water and allows the membrane to separate thereby increasing the capability to exchange gases. Type III cells that destroy foreign material, such as bacteria. The alveoli have an innate tendency to collapse (atelectasis) because of their spherical shape, small size, and surface tension due to water vapor. Phospholipids, which are called surfactants, and pores help to equalize pressures and prevent collapse. Pulmonary gas exchange Pulmonary gas exchange is driven by passive diffusion and thus does not require energy for exchange. Substances move down a concentration gradient. Oxygen moves from the alveoli (high oxygen concentration) to the blood (lower oxygen concentration, due to the continuous consumption of oxygen in the body). Conversely, carbon dioxide is produced by metabolism and has a higher concentration in the blood than in the air. Oxygen in the lungs first diffuses through the alveolar wall and dissolves in the fluid phase of blood. The amount of oxygen dissolved in the fluid phase is governed by Henry's Law. Oxygen dissolved in the blood may diffuse into red blood cells and bind to hemoglobin. Binding of oxygen to hemoglobin allows a greater amount of oxygen to be transported in the blood. Although carbon dioxide and oxygen are the most important molecules exchanged, other gases are also transported between the alveoli and blood. The amount of a gas that is exchanged depends on the water solubility of the gas the affinity of the gas for hemoglobin. Water vapor is also excreted through the lungs, due to humidification of inspired air by the lung tissues. Red blood cells transit the alveolar capillaries in about 3/4 of a second. Most gases (including carbon dioxide and nitrous oxide) reach equilibrium with the blood before the red blood cells leave the alveolar capillaries. Gases that reach equilibrium before the blood leaves the alveolar capillaries are perfusion limited, since the amount of the gas exchanged depends solely on the volumetric flow rate of blood past the alveoli. However, carbon monoxide is stored in such high concentrations in the blood, due to its strong binding to hemoglobin that equilibrium is not reached before the blood leaves the alveolar capillary. Thus, the concentration of carbon monoxide in the arterial system can be used to assess the resistance of the alveolar walls to gas diffusion. Transport of carbon monoxide is thus termed diffusion limited. Oxygen is normally perfusion limited, but in disease conditions it can be diffusion limited.

V. Laboratory Examination
Microbiology
Specimen: Pleural Fluid Result: No Pathogenic Organism isolated after 3 days Of intebation. Dr. Noel C. Santos MD 16

Date: 6-19-09

FPSP

Chemistry Test
Na 142.6 (137-145mmol) Mg .90 (.66-.95mmol/L) BUN 6.5 (3.2-7.1mmol/L) Creatinine 93 (71-133mmol/L) SGPT(ALT) 45 (13-61mmol/L) SGOT 19 (14-50mmol/L) K 3.62 (3.5-5.1mmol/L) Total CHON 62 (63-82G/L) Albumin 31 (35-50 G/L) Globulin 31 A/G Ratio 1.0

Date: 6-22-09

Histopathology
-Negative for Malignancy, Pleural Fluid ,Cytology

Date: 6-22-09

-Gross/Microscopic descriptions submitted for cytology is a 1L & 40ml dirty yellow fluid. -Micro show reactive mesothelial cells, lymphocytes, occasional polys. No malignant cell seen. Mennen A. Alsol M.D. Pathologist

Hematology
Hgb - 157 Hematocrit - 0.48 WBC - 15.8 Segmenters - 0.90 Lymphocyctes - 0.07 Monocytes - 0.03 (120-150g/L) (0.37-0.47) (5.0-10.0x10/L) (0.42-0.75) (0.20-0.51) (0.02-0.09)

Date: 6-23-09

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Interpretation: Polycythemia with infection related to pleural effusion

Protime
Control = 10.2 sec. Pt = 7.8 sec. IVR = 0.80 %activity = 131%

Date: 6-23-09

Serology & Immunology
Test: Prostate specific antigen Specimen: Serum Result: 1.30 mg/ml Normal Values: Less than 4.0mg/ml Pls. Note: Colerate clinically Noel C. Santos MD FPSP

Date: 6-23-09

ECG
Rhythm: Sinus QRS axis 70 Rate: Auricular 120/min. Ventricular: 120/min. PR interval 0.16 sec. QRS interval 0.10 sec. QT interval 0.36 sec.

Date: 6-26-09

Interpretation: Sinus tachycardia Left atrial enlargement, persistent fever, diffuse nonspecific Twave changes.

Urinalysis
Color: Yellow Transparency: Turbid Reaction: 5.0 Specific Gravity: 1.015 Sugar: negative Protein: positive Puss: 4.5/hpf RBC: Few

Date: 06-28-09

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Epithelial: Few Urates: Few Mucus threads: Few Dr. Mennen Alsol MD

Histopathology
Specimen: Vocal cord masses

Date: 6-29-09

Pathologic Dx -Squamous papillomas showing chronic non-specific inflammation, Right and Left vocal cords. Gross/micro description -Specimen consist of grayish white tissue fragments measuring as labeled A. 1x0.6cm and B. 1.1x0.5cm Entire specimen submitted. Microsecretions A and B disclosed tissues lined by thickened stratified squamous epithelium set in a fibrovascular stroma with Coci of chronic inflammation. There is no evidence of malignancy.

ECG
QRS – 75 Rhythm: Sinus Rate Auricular: 110/min. Ventricular: 110/min. PR Interval: 0.16/sec. QRS: 0.09/sec. QT int. 0.36/sec.

Date: 6-30-09

Interpretation: Sinus tachycardia. Incomplete Right bundle branch block And persistent fever. Dr. Ma. Imelda L. Balajadia Cardiologist

Chest AP Sitting

Date: 6-30-09

-Follow-up Chest Film 6-30-09 when compared to previous film dated 6-17-09 showed increase in previously noted PE in both hemithoraces suggest clinical cerrelation and follow-up. Dr. Rufely S. Laron MD FRAMS

Sonographic

Date: 7-1-09
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Chest Ultrasound -Pleural Effusion is present in both Right and Left hemithoraces w/ estimated volume of 1,182 ml & 519 ml respectively. No No loculation or cenoolidation seen. Ma. Clarita D. Espanol MD, FPCR Radiologist

Hematology
Hgb - 128 Hematocrit - 0.39 WBC - 11.5 Segmenters - 0.91 Lymphocytes - 0.06 Monocytes - 0.03 (120-150 gm/L) (0.37-0.47) (5.0-10.0x10/L) (.42-.75) (.20-.51) (.02-.09)

Date: 7-3-09

Interpretation: Prior to his last hematology result the patient has infection related to presence of water in his lungs(Pleural effusion). Dr. Anne Paulette C. San Antonio MD

Hematology
Hgb - 128 Hematocrit - 0.39 WBC - 11.5 Segmenters - 0.91 Lymphocytes - 0.06 Monocytes - 0.03 (120-150 gm/L) (0.37-0.47) (5.0-10.0x10/L) (.42-.75) (.20-.51) (.02-.09)

Date: 7-4-09

Interpretation: Prior to his last hematology result the patient has infection related to presence of water in his lungs(Pleural effusion). Dr. Anne Paulette C. San Antonio MD

Chest Ap Sitting

Date: 7-4-09

-Follow-up chest film when compared w/ the one done on June 30, 2009 show decrease in the amount of pleural effusion, bilaterally. There is a rightsided chest tube in place w/ its tip at the level of the 8th posterior rib. Tracheostomy tube is again seen in place. There is minimal subcutaneous in the right chest wall.

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Chest Ap Sitting

Date: 7-7-09

-Follow-up chest film 7-7-09 when compared to previous film dated 7-4-09 shows resolutions of previously noted right sided pleural effusion. However, no significant interval change in previously noted left sided pleural effusion other finding remain unchanged. Suggest clinical correlation & follow-up.

ECG
Rhythm: Sinus QRS Axis: 88 Rate: Auricular 110/min. Ventricular 110/min PR interval: 0.16 sec. QRS interval: 0.10 sec. QT interval: 0.32 sec> Interpretation: Sinus Tachycardia

Date: 7-7-09

VI. DRUG STUDY
NAME OF DRUGS Atrovent >anticholinergic, bronchodilator ACTION Chemically related to atropine, it antagonizes the effect of acetylcholine. It causes a local and site specific bronchodilatation by preventing the increase in INDICATION Acute exacerbations of COPD. Used in junction with Badrenergic stimulant for acute asthmatic attacks. NSG.CONSIDERATION Teach patient and/or family: >that the drug may induce visual disturbances, sleepiness, or dizziness, and to use care when performing tasks that require mental alertness. 21

>1 neb + 2cc NSS QID

intracellular cyclic guanosine monophosphate w/c is produce by the interaction of acetylcholine with the muscarinic receptors of the bronchial smooth muscles. Pharmacokenetics Absorption: Minimal Distribution: none Metabolism: liver (small Amount of absorption) Excretion: kidneys absorbed amount Half life: 2hrs. Pharmocodynamics Inhalation Onset: 5-15 mins. Peak: 1-2hrs. Duration: 3-6hrs.

>to increase fluid intake, as drug causes dry mouth, throat irritation, and a bad taste of the mouth.

NAME OF DRUGS ACTION Glucocorticoid w/ the high topical anti inflammatory potency. It has a strong Flixotide affinity for and agonist activity at human >anti inflammatory glococorticoid receptors. >1/2 neb + 1cc NSS Pharmacokenetics q12 Absorption: limited, (bioavailability <2%)

INDICATION Prophylactic management in mild, moderate and severe asthma.

NSG.CONSIDERATION >Monitor for possible drug induced adverse reactions: Dryness of mouth, and throat; hoarseness; paradoxical bronchospasm. > assess for pulmonary and cardiac status. >assess the pt. and families knowledge on drugs therapy. 22

distribution: minutes traces metabolism: liver excretion liver halflife: 8 hrs Pharmacodynamics Onset unknown peak: 1-2 hrs duration: unknown.

NAME OF DRUGS

ACTION Immediately and completely Prednisone converted to active prednisolone in the >adrenocorticosteroids liver. The anti, synthetic. inflammatory effects >10 mg 1 tab TID may be due to inhibition of prostaglandin synthesis. Pharmacokinetics: Absorption: well Distribution: wide Metabolism: liver Excretion: kidney Half life: 18-36hrs

INDICATION Allergic and inflammation conditions, in bronchial asthma

NSG.CONSIDERATION >obtain baseline wt. blood pressure and electrolyte level and monitor periodically during therapy. >assess for “k” depletion. Fatigue, nausea, vomiting, depression, polyuria, weakness, edema, hypertension. >monitor for possible induce reactions: CNS: insomnia CV: heart failure or HPN. GI: peptic ulcerations musculoskeletal: muscle weakness.

NAME OF DRUGS Nitroglycerine >coronary vasodilator >5mg OD

ACTION Decreases pre-load and after-load w/c thus decreases left ventricular end diastolic pressure and systemic vascular resistant: dilates coronary arteries and improve

INDICATION Treatment of acute angina.

NSG.CONSIDERATION Teach patient and/or family: >to apply only as directed >to remember to remove old pad >to rotate sites of application >not to disturb or open patch >Evaluate therapeutics effectiveness cardiac status and adverse response: e.g. hypotension, arrhythmias, GI 23

blood flow through coronary vasculature, dilates arterial, venous beds systemically. Pharmacokinetics Absorption: well absorbed (PO buccal and SL) Distribution: unknown Metabolism: liver extensively Excretion: kidney Half life: 1-4mins. Pharmacodynamics Onset: 30 mins. Peak: unknown Duration: 2-12 hrs1

disturbance.

NAME OF DRUGS ACTION Norvasc > >5mg 1tab q4 until febrile Inhibits influx of calcium ion across cell membranes to produce relaxation of coronary vascular smooth muscle

INDICATION Treatment: hypertension, chronic stable angina; vasospastic angina.

NSG.CONSIDERATION >assess for cardiorespirartory status: angina pain, B/P, pulse, respiration, ECG. >assess hydration and fluid volume status, input and output ratio, extended neck vein, lung crackles, 24

dilatation of coronary artery, decrease peripheral vascular resistance of smooth muscle decrease b/p and increases myocardial O2 delivery in patient’s w/ vasospatic angina. pharmacokinetics Absorption: well absorbed up to 90% Distribution: 95% bound in plasma protein crosses placenta Metabolism: extensively in liver Excretion: kidneys Half life: 30-50hrs. increases in elderly hepatic disease. pharmacodynamics Onset: unknown Peak: 6-10hrs Duration: 24 hrs

adequate pulses and skin turgor.

VII.

Discharge Planning

Medication
The patient has home medication to continue the following instructions: Atravent 1 Neb + 2cc NSS every 4 hours for Nebulization Cefadox 200mg 1 tablet twice a day for complete 10 days 25

• •

• • • •

Vastarel MR 35mg twice a day 1 tablet Mepirocin Ointment apply to Tracheal Stoma twice a day Prednisone 5mg ½ tablet for twice a day in 2 days then 5mg ½ tablet for once a day in 2 days then disc Ansimar 400mg 1 tablet for twice a day

Exercise
• • • • • • Mild exercise can increased oxygen utilization and re-train muscle to help improve the tissue. Encouraged the patient to pursed-lip breathing to prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance. Instructed the patient to Inhale through the nose while slowly counting to 3 then blow it slowly and evenly against pursed lips while tightening the abdominal muscles. Pursing the lips increases intratracheal pressure; exhaling through the mouth offers less resistance to expired air. Turn side by side to prevent bedsore. Instructs the patient to flexion and extension or rotate his foot.

Treatment
• • • Nebulization Tracheal Suction Oxygen Therapy

Health Teaching
• • • Placed in a semi-Fowler’s position to facilitate ventilation, promote drainage and prevent strain on the suture lines. Instruct the family to encourage breathing exercise to promote lung expansions. The member of the family keeps paper and pencil or a Magic Slate within the patient’s reach at all times to ensure a means of communication. 26

Instruct the family to avoid air pollutants such as smoke, dust or aerosol sprays which may initiate brochospasm.

Nebulizer Therapy • Instructed the patient to breath through the mouth, taking slow, deep breaths and then to hold for a few seconds then breathing out. At end of inspiration to increase intrapleural pressure and reopen collapsed alveoli. • Instructed the family to avoid replacing the nebulizer cup and the tube to the dust and smoke area, away from open window. • Avoid putting the equipments in the dishwasher area. • Instructed the family to wash the mouthpiece in a warm water and mild detergent. They can also use vinegar solution by soaking for 30 minutes then rinse through water, allow drying with a paper towel and put it in a zipper plastic bag. Tracheal Suctioning • Instructed the patient to perform hand hygiene and use glove before performing to prevent contamination and spread of. • Do not suction for longer than 10 seconds to prevent suctioning air in the lungs. Oxygen Therapy • Instructed the patient to keep oxygen tank at least15 feet away from matches, candles, gas stove or other source of flame. Also keep away from TV, radio, and other appliances at least 5 feet.

Out-Patient Follow-up
• • • Instruct the patient to follow-up check up on July 23, 2009 at room 106B at 4 pm. Instruct family to return to their attending physician for scheduled check-up and consultation. Advise family to report to the physicians any complaints.

Diet
Diet as Tolerated but be careful and be selective to the foods. • Encourage the patient to increase fluid intake to keep the mucus thin and help clear airway. • Eat meals when their energy levels are at their highest which is usually in the morning. 27

• • • •

Eat slowly and chewed food thoroughly to avoid becoming breathless while eating and to prevent choking. Limit salty food, consuming too much can cause the body to retain water and make breathing become difficulty. Eat food with balance nutritious food. Eat food with contains Vitamin C for development and maintenance of the blood vessels and scar tissues.

Spiritual
• • • Encourage the family to pray together. Encouraged the patient to think positive to all happen to his life. Instructed the family to build up his spiritual fighting to help himself treating.

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