Professional Documents
Culture Documents
II. Objective:
Health teachings to the patient and giving factors at which client would
weigh in the proper choice towards healthy lifestyle.
III.Demographic Data:
Gender: Female
Status: Married
2 weeks prior to patient admission, patient experience cough productive of greenish sputum
accompanied by undocumented fever, decreasing appetite and progressive weight loss. She also had
minimal difficulty of breathing. She self medicated with a 2 does of amoccicilin 500 mg tab TID
and sabutamol neb, which provided partial relief. However few hours of patient experience
difficulty of breathing was severe unrelieved by any medication, consult and subsequent addmition.
GORDONS
.
Activity exercise pattern: (while confined)
The client stated that she has no sufficient energy to perfomerd desired activates. During
hospitalization she stated that she wants to rest all the time because she can’t be able to move
because of her CVP on her left arm. But she have had bathroom privileges after CVP line was been
removed.
Cognitive-perceptual pattern:
Patient was calm, responsive, conscious, well oriented with time and place and with normal
behavior of communication.
Patient Mahinay Jemema said that she is not so much active in his sexual patterns.
Having this condition makes her challenge, and thinks that everything will be alright, though
she remains to be calm but he is a bit worried.
Value-Belief Pattern
She is a Roman Catholic and don’t believe in superstitious beliefs. She said, “God is our
savior and he is our creator, he has a plan for me”.
PHYSICAL ASSESSMENT
ASSESSMENT FINDINGS
ASSESSMENT DATA
SKIN
Color Fair
Temperature 36 º C
Integrity Intact
Others
NAILS
Color Pinkish
Texture Smooth
Shape Concave
Others
HAIR
Color Black
Quantity Moderate
Others
HEAD
Shape Round
Size Normocephalic
Configuration Symmetrical
Headache None
ASSESSMENT DATA
EARS
Hearing Good
Tinnitus None
Vertigo No vertigo
Earaches No earaches
Infection No infection
Discharge’s No discharges
Hoarseness None
NECK
Symmetry Symmetrical
LUNG
Symmetry Symmetrical
# of breath 24cpm
AUSCULTATION:
Apical Pulse
Pulse pressure
Done
ABDOMEN:
Symmetry Symmetrical
Skin Lesion none
Tenderness none
HEAD AND NECK:
Swelling None
Scars None
Discoloration None
MUSCULOSKELETAL SYSTEM:
Posture
Pleural effusion Chest x-ray of a pleural effusion. The arrow A shows fluid layering
in the right pleural cavity. The B arrow shows the normal width of the lung in the cavity.
The pleural cavity is created between the 4th and 7th week of embryologic development and is
lined by the splanchnopleurae and somatopleurae. These embryonic components of visceral and
parietal pleurae develop different anatomic characteristics with regard to vascular, lymphatic, and
nervous supply. Both pleurae have two layers: a superficial mesothelial cell layer facing the pleural
space and an underlying connective tissue layer. Various ultrastructures of the pleura show a close
relationship to the basic functions of the pleural membranes, such as local inflammatory response
and maintenance of the pleural fluid.
The latter function is especially important in the mechanical coupling of the lung and chest wall.
The fluid in the pleural space transmits transpleural forces involved in normal respiration, and the
maintenance of the optimal volume and thickness is regulated closely. Fluid is filtered into the
pleural space according to the net hydrostaticoncotic pressure gradient. It flows downward along a
vertical pressure gradient, presumably determined by hydrostatic pressure and resistance to viscous
flow. There also may be a net movement of fluid from the costal pleura to the mediastinal and
interlobar regions. In these areas, pleural fluid is resorbed primarily through
Precipitating lymphatic stomata on
Factors:
Predisposing Factor
the parietal pleural surface.
Lifestyle, environmental
Age, gender
Hypoxia
Medical Surgical Management
Analgesics given regularly to maintain pain at tolerable level. Titrate dosages to achieve pain
control.
Surgical Intervention
Therapeutic Interventions.
• Total parenteral nutrition for malnourished patient who is unable or unwilling to eat .
• Removal of the pleural fluid (by thoracentesis or tube thoracostomy) and instillation
of sclesrosing agent to obliterate pleural space and fluid recurrence.
Nursing Management
1. Elevate the head of the bed to ease the work of breathing and to prevent fluid collection in
upper body (from superior vena cava syndrome).
2. Teach breathing retraining exercise to increase diaphragmatic excursion and reduce work of
breathing.
3. Augment the patient’s ability to cough effectively by splinting the patient’s chest manually.
4. Instruct the patient to inspire fully and cough two to three times in on breath.
6. Teach relaxation techniques to reduce anxiety associated with dyspnea. Allow the severely
dyspneic patient to sleep in reclining chair.
8. Ensure adequate protein make such as milk, eggs, oral nutritional supplements and chicken,
fowl and fish of other treatments are not tolerated – to promote healing and prevent edema.
9. Advice the patient to eat small amounts of high-calories and high protein foods frequently,
rather than three daily meals.
10. Suggest eating the major meal in the morning if rapid satiety is the problem.
11. Consider alternative pain control method’s such as biofeedback and relaxation methods, to
increase the patient’s sense of control.
DISCHARGE PLAN
M- Medication
• Medication includes Kalium Durule, NaCl, clindymizine and sabutamol neb. These
medicines are taken depending on severity and kind of pleural effusion.
E- E xercise
• Teaching breathing retaining exercise to increase diaphragmatic excursion and reduce work
of breathing.
• Augment the patient’s ability to cough effectively by splinting the patient’s chest manually.
T- Treatment
• Keep a list of your medicines: Keep a written list of the medicines you take, the amounts
and when and why you take them. Bring the list of your medicines or the pill bottles when
you see your caregivers. Do not take any medicines, over the counter drugs, vitamins, herbs
or food supplements without first talking to caregivers.
• To decrease your pain; when coughing, hold a pillow over your chest where the pain is.
• Quit smoking. Do not smoke and do not allow others to smoke around you. Smoking
increases your risk of lung infections such as pneumonia. Smoking also makes it harder for
you to get better after having a lung problem. Talk to your caregiver if you need help
quitting smoking.
• Drink enough liquids and get plenty of rest. Be sure to drink enough liquids every day. Most
people should drink at least 8(oz.) Cups of water a day. This help to keep your air passages
moist and better able to get rid of germs and other irritants. You may feel like resting more.
Slowly start to do more each day. Rest when you feel it is needed.
Exercise your lungs. The discomfort of pleural effusion may cause you to avoid breathing as
deeply as you should. Coughing and deep breathing can help prevent a new or worsening
lung infection. Take a deep breath and hold the breath as long as you can then push the air
out of your lungs with a deep, strong cough. Take 10 deep breaths in a row every hour that
you are awake. Remember to follow each deep breathe with a cough.
O- Out patient
D- Diet
• Ensure adequate protein intake such as milk, eggs, oral nutritional supplements, chicken,
and fish if other treatments not tolerated.
• Advice patient to eat small amounts of high-calorie and protein foods frequently rather than
three daily large meals.