NOOTAN COLLEGE OF

NURSING
VISNAGER

SUB:- clinical speciality -1

( MEDICAL SURGICAL NURSING )

TOPIC:- PROCEDURE ON
“ Thoracocentesis ”

SUBMITTED TO:- SUBMITTED BY:-

Miss . Srushti contractor Patel Dharmendra .B

Assistant professor 1st year M.sc Nursing

NCN,Visnagar NCN,Visnagar
 BIODATA OF THE PATIENT

 Name of the patient – Mr. Mukesh Shah

 Age - 46 yrs.

 Date of admission – 23/03/18

 Address - Sambhaji nagar bapodi

 Marrital satus - Married

 Religion - Hindu

 Educational qualification - 12th

 Occupation - Business man

 Family income - 12000/ month

 Diagnosis – Myasthenia gravis

Present Colpalints –

Patient came with the complaints of Diplopia, Ptosis ,Weakness of the muscle of the
face and throat Generalized weakness, Dyspnea , Dysphagia

History Of Present Illness -

Patient is suffering with Diplopia, Ptosis ,Weakness of the muscle of the face and throat
Generalized weakness,Dyspnea , Dysphagia.

Allergy – no history of allergy

Habit / vices – no bices except tobacco chewing

Family History –

Sr.no. Name of the family Age/ Relation with HOF Education Remark
member sex

1 Mr. Mukesh Shah 46yrs H.O.D 12th Mr. Mukesh is suffering

with myasthenia gravis.
2 Mrs. Anjali Shah 42yrs Wife 8th

3 Mr. Pankaj Shah 22yrs Son B.sc 2nd y

4 Ms. Pinki Shah 18yrs Daughter 12th

Socio-economic status–

Economically Mr. Mukesh Shah is not stable because he has taken loan foe business from
Bank and his income is only 12000/ month.

Past medical and surgical history – no any other past medical history

Family history of illness – there is no history of major family illness except minor illness.

Menstrual history – no

Hygiene – They maintain adequate hygienic practices.

Activity / exercise – There is no importance of activity and exercise in his life

Elimination pattern – 2 times in a day

Cognitive perceptual - He is well oriented to time place and person

Value & beliefs – He beliefs in spiritual activities and celebrate most of the hindu festivals.
 PHYSICAL EXAMINATION

BASE LINE DATA –

 Weight – 72 k.g

 Height – 5’’9 inches

 Abdominal girth – 42 cms

 Temperature – 96 F

 Pulse – 86/min

 Respiration – 28/ min

GENERAL APPEARANCE –

NEUROLOGICAL –

 Orientation Patient is completely oriented to time, place and person & he is in

completely conscious state.

 Pupils – Pupils are equally reacting to light

 Size – 5mm

MUSCULOSKELETAL

 Normal range of motion - yes

 Weakness/ paralysis/ contractures - no

 Joint sweeling /pain /others -

RESPIRATORY SYSTEM –

 Pattern – there is even & normal respiratory pattern &

repiratory rate is 24/min.

 Breathing sound –is clear

 Cough – not present

GENITOR-URINARY -
  Urine last voided – 2hrs before

 Catheter present – no

 Intake & output – 1250/ 1100 ml

 Any illness related to GU system – no

SELF CARE -

 Ambulation – self

 Elimination - self

 Meals - self

 Hygiene – self

 Dressing – self

NUTRITION –

 General appearance - Well nurished

 Appetite –Patient is having anorexia & pattern ofmeal is disturbed due to the hospital
envirrment.

 Diet – Vegetarian / non veg – Both

 Meal pattern – 3 times a day

 Need assistant - no

 Total feed / day – 3 feeds

SKIN ASSESSMENT –

Patient skin is intact, healthy & no sign of developing bed sore.

CARDIOVASCULAR –

 Pulse – 86/ min

 Edema – not present

 Rhythm – regular
GASTROINTESTINAL SYSTEM –

 Oral mucosa – normal, no coated tounge

 Bowel sounds – normal

 Stool frequency – two times in a day

MYASTHENIA GRAVIS

DEFINITION –

It is an autoimmune disorder affecting the myoneural, junction is characterized by

varying degree of weakness of the voluntary muscles.

Approximately 60,000 people have myasthenia gravis in the united states.

Womens are affected more frequently than man and they tend to develop the disease at
an earlier age ( 20-40 yrs of age)

PATHOPHYSILOGY –

Chemical impulses precipitates the release of acetylcholine from vesicles on the nerve terminals
at the mayoneural junction.

- The acetylcholine attach to receptor sites on the motor endplare and stimulates muscle
contraction.

- Continues binding of the acetycholine to the receptors site is required for the muscular
contraction to be sustained.

- In myasthenia gravis, antibodies directed at the acetylcholine receptor site impair

transmission of impulses across the myoneural junction.

- Therefore fewer receptors are available for stimulation, resulting in voluntary muscle
weakness that escalates with continued activity.
CLINICAL MANIFESTATIONS –

BOOK PICTURE PATIENT PICTURE

 Diplopia  Present

 Ptosis ( dropping of the eyelids)  Present

 Weakess of the muscle of the face and throat  Present

 Generalized weakness  Present

 Dysphonia ( voice impairement)  Present

 Choking & aspiration  Not present

 Decreased vital capacity & respiratory failure  Not present

 Dyspnea  Present

 Dysphagia  Present

Assessment & diagnostic findings

BOOK PICTURE PATIENT PICTURE

 Acetylcholinesterase inhibitor test e.g  Not done

endophonium chloride

 MRI of thymus gland

 Not done
 Complete blood count
 Hb- 13.2 gm/dl

 TLC- 7400/MM3

 Serum urea – 26 mg%

 Serum creatinine – 0.9 m.g%

 ALT – 25 / IU/ L

 ALP – 34 IU /L
 Electrolytes
 Na+ - 140
 Tesilone test
 K+ - 3.8

 Not done

MANAGEMENT –
Aim –

To improve functioning and reducing and removing circulating antoboodies.

Book picture Patient picture

 Pyridosting mine bromide  Tab- Enam 10 m.g - OD

(mestinon) an anticholinersterase
 Tab – Atex 25 m.g - OD
medication is the first line of the
therapy

 If pyridostigmine does not improve  Tab – Distinon 60 m.g - QID

muscle strength and control next
agent used are the
immunosuppressive drugs, the goal  Tab – Azoran 10 m.g - BD
is resuce the production of
antibodies.
 Tab – Wyselone 10 m.g - OD
e.g prednisolone

 cytotoxic medications e.g

azathoprine inhibit the T-  Tab – Rantac 150 m.g - BD

lymphocytes and reduces the

acetycholine receptors antibody
levels.  Tab – Ecosprin 75 m.g - OD

 Cyclosporins and
cyclophosphomide may be used.

PLAMAPHORESIS

Plasmaphoresis (plasma excange) is a technique used to treat exacerbation. The patient plasma
and plasma components are removed through a centrally placed large bore double lumen
catheter. The blood cells and antibodies containing plasma are separated after which the cells
and plama substitutes are reinfused.

Plasma exchange produce a temperory reduction in the level of circulating antibodies.

PATIENT PICTURE
It is not done for my patient

SURGICAL MANAGEMENT

- Thymectomy ( Surgical removal of thymus gland) can produce

antigen specific immunosupression and result in clinical improvement.

COMPLICATIONS

Respiratory failure

Mysthenic crisis

MEDICATION

Atenolol

Drug classes

Beta1-selective adrenergic blocking agent

Antianginal

Antihypertensive

Therapeutic actions

Blocks beta-adrenergic receptors of the sympathetic nervous system in the heart and
juxtaglomerular apparatus (kidney), thus decreasing the excitability of the heart, decreasing
cardiac output and oxygen consumption, decreasing the release of renin from the kidney, and
lowering BP.

Indications

 Treatment of angina pectoris due to coronary atherosclerosis

 Hypertension, as a step 1 agent, alone or with other drugs, especially diuretics

 Treatment of MI
  Unlabeled uses: Prevention of migraine headaches; alcohol withdrawal syndrome,
treatment of ventricular and supraventricular arrhythmias

Contraindications and cautions

 Contraindicated with sinus bradycardia, second- or third-degree heart block, cardiogenic

shock, CHF, pregnancy.

 Use cautiously with renal failure, diabetes or thyrotoxicosis (atenolol can mask the usual
cardiac signs of hypoglycemia and thyrotoxicosis), lactation, respiratory disease.

Available forms

Tablets—25, 50, 100 mg; injection—5 mg/10 mL

Dosages

ADULTS

 Hypertension: Initially, 50 mg PO once a day; after 1–2 wk, dose may be increased to
100 mg/day.

 Angina pectoris: Initially, 50 mg PO daily. If optimal response is not achieved in 1 wk,
increase to 100 mg daily; up to 200 mg/day may be needed.

 Acute MI: Initially, 5 mg IV given over 5 min as soon as possible after diagnosis; follow
with IV injection of 5 mg 10 min later. Switch to 50 mg PO 10 min after the last IV dose;
follow with 50 mg PO 12 hr later. Thereafter, administer 100 mg PO daily or 50 mg PO
bid for 6–9 days or until discharge from the hospital.

PEDIATRIC PATIENTS

Safety and efficacy not established.

GERIATRIC PATIENTS OR PATIENTS WITH RENAL IMPAIRMENT

Dosage reduction is required because atenolol is excreted through the kidneys. The following dosage is
suggested:

Creatinine Clearance Half-life Maximum

(hr) Dosage
mL/min

15–35 16–27 50 mg/day

 < 15 > 27 25 mg/day

For patients on hemodialysis, give 25–50 mg after each dialysis; give only in hospital setting;
severe hypotension can occur.

IV facts

Preparation: May be diluted in dextrose injection, sodium chloride injection, or sodium chloride
and dextrose injection. Stable for 48 hr after mixing.

Infusion: Initiate treatment as soon as possible after admission to the hospital; inject 5 mg over
5 min; follow with another 5-mg IV injection 10 min later.

Adverse effects

 Allergic reactions: Pharyngitis, erythematous rash, fever, sore throat, laryngospasm,

respiratory distress

 CNS: Dizziness, vertigo, tinnitus, fatigue, emotional depression, paresthesias, sleep

disturbances, hallucinations, disorientation, memory loss, slurred speech

 CV: Bradycardia, CHF, cardiac arrhythmias, sinoatrial or AV nodal block, tachycardia,

peripheral vascular insufficiency, claudication, CVA, pulmonary edema, hypotension

 Dermatologic: Rash, pruritus, sweating, dry skin

 EENT: Eye irritation, dry eyes, conjunctivitis, blurred vision

 GI: Gastric pain, flatulence, constipation, diarrhea, nausea, vomiting, anorexia, ischemic
colitis, renal and mesenteric arterial thrombosis, retroperitoneal fibrosis, hepatomegaly,
acute pancreatitis

 GU: Impotence, decreased libido, Peyronie's disease, dysuria, nocturia, frequent urination

 Musculoskeletal: Joint pain, arthralgia, muscle cramps

 Respiratory: Bronchospasm, dyspnea, cough, bronchial obstruction, nasal stuffiness,

rhinitis, pharyngitis (less likely than with propranolol)

 Other: Decreased exercise tolerance, development of antinuclear antibodies,

hyperglycemia or hypoglycemia, elevated serum transaminase, alkaline phosphatase, and
LDH
Interactions

Drug-drug

 Increased effects with verapamil, anticholinergics, quinidine

 Increased risk of orthostatic hypotension with prazosin

 Increased risk of lidocaine toxicity with atenolol

 Possible increased BP-lowering effects with aspirin, bismuth subsalicylate, magnesium

salicylate, sulfinpyrazone, hormonal contraceptives

 Decreased antihypertensive effects with NSAIDs, clonidine

 Decreased antihypertensive and antianginal effects of atenolol with ampicillin, calcium

salts

 Possible increased hypoglycemic effect of insulin

Drug-lab test

 Possible false results with glucose or insulin tolerance tests

Nursing considerations

Assessment

 History: Sinus bradycardia, second- or third-degree heart block, cardiogenic shock, CHF,
renal failure, diabetes or thyrotoxicosis, lactation, pregnancy

 Physical: Baseline weight, skin condition, neurologic status, P, BP, ECG, respiratory
status, renal and thyroid function tests, blood and urine glucose, cholesterol, triglycerides

Interventions

 WARNING: Do not discontinue drug abruptly after long-term therapy (hypersensitivity

to catecholamines may have developed, causing exacerbation of angina, MI, and
ventricular arrhythmias). Taper drug gradually over 2 wk with monitoring.

 Consult physician about withdrawing drug if patient is to undergo surgery (withdrawal is

controversial).

NURSING RESPONSIBILITIES
  Take drug with meals if GI upset occurs.

 Do not stop taking this drug unless told to do so by a health care provider.

 Avoid driving or dangerous activities if dizziness or weakness occur.

 You may experience these side effects: Dizziness, light-headedness, loss of appetite,
nightmares, depression, sexual impotence.

 Report difficulty breathing, night cough, swelling of extremities, slow pulse, confusion,
depression, rash, fever, sore throat.

Ranitidine hydrochloride

Drug class

Histamine2 (H2) antagonist

Therapeutic actions

Competitively inhibits the action of histamine at the histamine 2 (H2) receptors of the parietal
cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is
stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin.

Indications

 Short-term treatment of active duodenal ulcer

 Maintenance therapy for duodenal ulcer at reduced dosage

 Short-term treatment of active, benign gastric ulcer

 Short-term treatment of GERD

 Pathologic hypersecretory conditions (eg, Zollinger-Ellison syndrome)

 Treatment of erosive esophagitis

 Treatment of heartburn, acid indigestion, sour stomach

Contraindications and cautions

 Contraindicated with allergy to ranitidine, lactation.

  Use cautiously with impaired renal or hepatic function, pregnancy.

Available forms

Tablets—75, 150, 300 mg; effervescent tablets and granules—25, 150 mg; syrup—15 mg/mL;
injection—1, 25 mg/mL

Dosages

ADULTS

 Active duodenal ulcer: 150 mg bid PO for 4–8 wk. Alternatively, 300 mg PO once daily hs
or 50 mg IM or IV q 6–8 hr or by intermittent IV infusion, diluted to 100 mL and infused
over 15–20 min. Do not exceed 400 mg/day.

 Maintenance therapy, duodenal ulcer: 150 mg PO hs.

 Active gastric ulcer: 150 mg bid PO or 50 mg IM or IV q 6–8 hr.

 Pathologic hypersecretory syndrome: 150 mg bid PO. Individualize dose with patient's
response. Do not exceed 6 g/day.

 GERD, esophagitis, benign gastric ulcer: 150 mg bid PO.

 Treatment of heartburn, acid indigestion: 75 mg PO as needed.

PEDIATRIC PATIENTS

Safety and efficacy not established.

GERIATRIC PATIENTS OR PATIENTS WITH IMPAIRED RENAL FUNCTION

For creatinine clearance < 50 mL/min, accumulation may occur; use lowest dose possible,
150 mg q 24 hr PO or 50 mg IM or IV q 18–24 hr. Dosing may be increased to q 12 hr if patient
tolerates it and blood levels are monitored.

Pharmacokinetics

Route Onset Peak Duration

Oral Varies 1–3 hr 8–12 hr

IM Rapid 15 min 8–12 hr

IV Immediate 5–10 min 8–12 hr

Preparation: For IV injection, dilute 50 mg in 0.9% sodium chloride injection, 5% or 10%
dextrose injection, lactated Ringer's solution, 5% sodium bicarbonate injection to a volume of 20
mL; solution is stable for 48 hr at room temperature. For intermittent IV, use as follows: Dilute
50 mg in 100 mL of 5% dextrose injection or other compatible solution

Infusion: Inject over 5 min or more; for intermittent infusion, infuse over 15–20 min;
continuous infusion, 6.25 mg/hr

Incompatibilities: Do not mix with amphotericin B

Adverse effects

 CNS: Headache, malaise, dizziness, somnolence, insomnia, vertigo

 CV: Tachycardia, bradycardia, PVCs (rapid IV administration)

 Dermatologic: Rash, alopecia

 GI: Constipation, diarrhea, nausea, vomiting, abdominal pain, hepatitis, increased ALT
levels

 GU: Gynecomastia, impotence or decreased libido

 Hematologic: Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia

 Local: Pain at IM site, local burning or itching at IV site

 Other: Arthralgias

Interactions

Drug-drug

 Increased effects of warfarin, TCAs; monitor patient closely and adjust dosage as needed

Nursing considerations

Assessment

 History: Allergy to ranitidine, impaired renal or hepatic function, lactation, pregnancy

 Physical: Skin lesions; orientation, affect; pulse, baseline ECG; liver evaluation,
abdominal examination, normal output; CBC, LFTs, renal function tests

Interventions
  Administer oral drug with meals and hs.

 Decrease doses in renal and liver failure.

 Provide concurrent antacid therapy to relieve pain.

 Administer IM dose undiluted, deep into large muscle group.

 Arrange for regular follow-up, including blood tests, to evaluate effects.

PATIENT TEACHING

 Take drug with meals and at bedtime. Therapy may continue for 4–6 weeks or longer.

 If you also are on an antacid, take it exactly as prescribed, being careful of the times of
administration.

 Have regular medical follow-up care to evaluate your response.

 You may experience these side effects: Constipation or diarrhea (request aid from your
health care provider); nausea, vomiting (take drug with meals); enlargement of breasts,
impotence or decreased libido (reversible); headache (adjust lights and temperature and
avoid noise).

 Report sore throat, fever, unusual bruising or bleeding, tarry stools, confusion,
hallucinations, dizziness, severe headache, muscle or joint pain.

Aspirin

Drug classes

 Antipyretic

 Analgesic (nonopioid)

 Anti-inflammatory

 Antirheumatic

 Antiplatelet

 Salicylate
  NSAID

Therapeutic actions

Analgesic and antirheumatic effects are attributable to aspirin's ability to inhibit the synthesis of
prostaglandins, important mediators of inflammation. Antipyretic effects are not fully
understood, but aspirin probably acts in the thermoregulatory center of the hypothalamus to
block effects of endogenous pyrogen by inhibiting synthesis of the prostaglandin intermediary.
Inhibition of platelet aggregation is attributable to the inhibition of platelet synthesis of
thromboxane A2, a potent vasoconstrictor and inducer of platelet aggregation. This effect occurs
at low doses and lasts for the life of the platelet (8 days). Higher doses inhibit the synthesis of
prostacyclin, a potent vasodilator and inhibitor of platelet aggregation.

Indications

 Mild to moderate pain

 Fever

 Inflammatory conditions—rheumatic fever, rheumatoid arthritis, osteoarthritis

 Reduction of risk of recurrent TIAs or stroke in males with history of TIA due to fibrin
platelet emboli

 Reduction of risk of death or nonfatal MI in patients with history of infarction or unstable

angina pectoris

 MI prophylaxis

 Unlabeled use: Prophylaxis against cataract formation with long-term use

Contraindications and cautions

 Contraindicated with allergy to salicylates or NSAIDs (more common with nasal polyps,
asthma, chronic urticaria); allergy to tartrazine (cross-sensitivity to aspirin is common);
hemophilia, bleeding ulcers, hemorrhagic states, blood coagulation defects,
hypoprothrombinemia, vitamin K deficiency (increased risk of bleeding)

 Use cautiously with impaired renal function; chickenpox, influenza (risk of Reye's
syndrome in children and teenagers); children with fever accompanied by dehydration;
surgery scheduled within 1 wk; pregnancy (maternal anemia, antepartal and postpartal
 hemorrhage, prolonged gestation, and prolonged labor have been reported; readily
crosses the placenta; possibly teratogenic; maternal ingestion of aspirin during late
pregnancy has been associated with the following adverse fetal effects: low birth weight,
increased intracranial hemorrhage, stillbirths, neonatal death); lactation.

Available forms

Tablets—81, 165, 325, 500, 650, 975 mg; SR tablets—650, 800 mg; suppositories—120, 200,
300, 600 mg

Dosages

Available in oral and suppository forms. Also available as chewable tablets, gum; enteric coated,
SR, and buffered preparations (SR aspirin is not recommended for antipyresis, short-term
analgesia, or children < 12 yr.)

ADULTS

 Minor aches and pains: 325–650 mg q 4 hr.

 Arthritis and rheumatic conditions: 3.2–6 g/day in divided doses.

 Acute rheumatic fever: 5–8 g/day; modify to maintain serum salicylate level of 15–
30 mg/dL.

 TIAs in men:1,300 mg/day in divided doses (650 mg bid or 325 mg qid).

 MI prophylaxis: 75–325 mg/day.

PEDIATRIC PATIENTS

 Analgesic and antipyretic: 65 mg/kg per 24 hr in four to six divided doses, not to exceed 3.6 g/day.
Dosage recommendations by age:

Age (yr) Dosage

(mg q 4 hr)

2–3 162

4–5 243

6–8 324

9–10 405

11 486
 ³ 12 648

 Juvenile rheumatoid arthritis: 60–110 mg/kg per 24 hr in divided doses at 6- to 8-hr

intervals. Maintain a serum level of 150–300 mcg/mL.

 Acute rheumatic fever: Initially, 100 mg/kg/day, then decrease to 75 mg/kg/day for 4–6
wk. Therapeutic serum salicylate level is 150–300 mg/dL.

 Kawasaki disease: 80–180 mg/kg/day; very high doses may be needed during acute
febrile period; after fever resolves, dosage may be adjusted to 10 mg/kg/day.

Pharmacokinetics

Route Onset Peak Duration

Oral 5–30 min 15–120 min 3–6 hr

Rectal 1–2 hr 4–5 hr 6–8 hr

Adverse effects

 Acute aspirin toxicity: Respiratory alkalosis, hyperpnea, tachypnea, hemorrhage,

excitement, confusion, asterixis, pulmonary edema, seizures, tetany, metabolic acidosis,
fever, coma, CV collapse, renal and respiratory failure (dose related, 20–25 g in adults, 4 g
in children)

 Aspirin intolerance: Exacerbation of bronchospasm, rhinitis (with nasal polyps, asthma,

rhinitis)

 GI: Nausea, dyspepsia, heartburn, epigastric discomfort, anorexia, hepatotoxicity

 Hematologic: Occult blood loss, hemostatic defects

 Hypersensitivity: Anaphylactoid reactions to anaphylactic shock

 Salicylism: Dizziness, tinnitus, difficulty hearing, nausea, vomiting, diarrhea, mental

confusion, lassitude (dose related)

Interactions

Drug-drug

 Increased risk of bleeding with oral anticoagulants, heparin

  Increased risk of GI ulceration with steroids, phenylbutazone, alcohol, NSAIDs

 Increased serum salicylate levels due to decreased salicylate excretion with urine
acidifiers (ammonium chloride, ascorbic acid, methionine)

 Increased risk of salicylate toxicity with carbonic anhydrase inhibitors, furosemide

 Decreased serum salicylate levels with corticosteroids

 Decreased serum salicylate levels due to increased renal excretion of salicylates with
acetazolamide, methazolamide, certain antacids, alkalinizers

 Decreased absorption of aspirin with nonabsorbable antacids

 Increased methotrexate levels and toxicity with aspirin

 Increased effects of valproic acid secondary to displacement from plasma protein sites

 Greater glucose lowering effect of sulfonylureas, insulin with large doses (> 2 g/day) of
aspirin

 Decreased antihypertensive effect of captopril, beta-adrenergic blockers with salicylates;

consider discontinuation of aspirin

 Decreased uricosuric effect of probenecid, sulfinpyrazone

 Possible decreased diuretic effects of spironolactone, furosemide (in patients with

compromised renal function)

 Unexpected hypotension may occur with nitroglycerin

Drug-lab test

 Decreased serum protein bound iodine (PBI) due to competition for binding sites

 False-negative readings for urine glucose by glucose oxidase method and copper
reduction method with moderate to large doses of aspirin

 Interference with urine 5-HIAA determinations by fluorescent methods but not by

nitrosonaphthol colorimetric method

 Interference with urinary ketone determination by the ferric chloride method

  Falsely elevated urine VMA levels with most tests; a false decrease in VMA using the
Pisano method

Nursing considerations

Assessment

 History: Allergy to salicylates or NSAIDs; allergy to tartrazine; hemophilia, bleeding

ulcers, hemorrhagic states, blood coagulation defects, hypoprothrombinemia, vitamin K
deficiency; impaired hepatic function; impaired renal function; chickenpox, influenza;
children with fever accompanied by dehydration; surgery scheduled within 1 wk;
pregnancy; lactation

 Physical: Skin color, lesions; T; eighth cranial nerve function, orientation, reflexes, affect;
P, BP, perfusion; R, adventitious sounds; liver evaluation, bowel sounds; CBC, clotting
times, urinalysis, stool guaiac, LFTs, renal function tests

Interventions

 Give drug with food or after meals if GI upset occurs.

 Give drug with full glass of water to reduce risk of tablet or capsule lodging in the
esophagus.

 Do not crush, and ensure that patient does not chew SR preparations.

 Do not use aspirin that has a strong vinegar-like odor.

 WARNING: Institute emergency procedures if overdose occurs: Gastric lavage, induction

of emesis, activated charcoal, supportive therapy.

Teaching points

 Take extra precautions to keep this drug out of the reach of children; this drug can be
very dangerous for children.

 Use the drug only as suggested; avoid overdose. Avoid the use of other over-the-counter
drugs while taking this drug. Many of these drugs contain aspirin, and serious overdose
can occur.
  Take the drug with food or after meals if GI upset occurs.

 Do not cut, crush, or chew sustained-release products.

 Over-the-counter aspirins are equivalent. Price does not reflect effectiveness.

 You may experience these side effects: Nausea, GI upset, heartburn (take drug with food);
easy bruising, gum bleeding (related to aspirin's effects on blood clotting).

 Report ringing in the ears; dizziness, confusion; abdominal pain; rapid or difficult
breathing; nausea, vomiting, bloody stools.

DOROTHEA OREM’S SELF-CARE MODEL

The self care model was developed during 1960. Orem was a well known and respected
nurse theorist from USA. The model was developed, tested, retested in 1960, 1970 and 1980. She
disseminated her work through consultation, conference and publications. The theory is
published in her book ‘Nursing Concepts of Practice’ in 1971, revised in 1980, 1985 and 1991.
Today this model is recognized and implemented in nursing educational institutions all over the
world.

The Concept of Self – Care:

Self – care is a process whereby a lay person functions on his/her own behalf in health
promotion and prevention and in disease detection and treatment. Levin, Katz & Holst (1979).

Orem describes health care as “Care that is performed by oneself for oneself when one
has reached a state of maturity that is enabling for consistent controlled, effective and
purposeful action.”

It is learned behavior aided by intellectual curiosity, instruction & supervision from

others & experience in performing self care measures.

Concepts of the Model:

Beliefs and Values:

The person:

All individuals have self care needs and that they have the right and ability to meet these needs
themselves, except when their ability is in some way compromised.

 The person who meets the self care needs is the self care agent. The normal, healthy,
mature adult is his own self-care agent.

 Parent is the self care agent for a new born infant and relative or nurse is self care agent
for an unconscious patient.

Six Premises on which Self Care is Founded (Joseph, 1980):

1. Self care is based on voluntary actions which humans are capable of undertaking.

2. Self care is based on deliberate and thoughtful judgment that leads to appropriate acts.

3. Self care is required of every person and is universal requisite for meeting basic human
needs.

4. Adults have the right and responsibility to care for themselves in order to maintain their
health, life and well being. They also have responsibilities for others including children
and elderly in the family
 5. Self care is a behavior that evolves through a combination of social and community
experience and is learned through one’s interpersonal relationships, communication and
culture.

6. Self care contributes to the self esteem and self image of a person and is directly affected
by self concept.

Self Care needs/Self care requisites:

They are universal, common to all, are basic human needs.

Universal Self-Care requisites are:

 The maintenance of a sufficient intake of air

 The maintenance of a sufficient intake of water.

 The maintenance of a sufficient intake of food.

 The provision of care associated with elimination, process and excrements.

 The maintenance of a balance between activity and rest

 The maintenance of a balance between solitude and social interaction.

 The prevention of hazards to human life, human functioning and human well being.

 The promotion of human functioning and development within social groups in

accordance with human potential, known human limitations and the human desire to be
‘normal’

Developmental Self Care requisites:

` Occur in the stage of development of the individual and the environment in which he/she
lives, in terms of its effects on development. They are related to either life changes in the
individual or life cycle stages.

NURSING DIAGNOSIS

1) Disturbed sensory perception R/T impaired vision

2) Ineffective breathing pattern R/T respiratory muscle weakness

3) Impaired physical mobility R/T Neuromuscular impairement & resulting muscle
weakness.

4) Impaired verbal communication R/T weakened speech muscles

5) Risk for aspiration R/T weakness of bulbar muscles.

ASSESSMENT DIAGNOSIS EOC PLANNING INTERVENTION RATIONAL EVALUATION

Subjective data Disturbed Patient will - Assess the visual - Visual acuity of - to know
sensory have his acuity of patient. patient is assessed i.e about base line
Patient telling that he is
perception R/T normal 3/6. information.
having problem with vision, - teach patient to
impaired vision.
specially having double open eye for short - Patient is taught - to avoid
vision
vision. interval. restrain on
For opening of eye for
eye.
-advice patient to short period of time.
wear sun glasses - to diminished
Objective data – - advised given to
the effect of
- advice patient to wear sunglasses.
-Patient ophthalmic bright light.
use patch on one
assessment shows that he is - Advised given for
eye. - to minimize
having blurred vision and using patch on one
diplopia.
problem of diplopia. - give psychological eye.
support to the - to make him
- patient visual acuity is 3/6. -psychological
patient. comfortable.
support is given to the
patient.

Subjective data – Ineffective Patient will have -Asses - Respiratory pattern, - To know EOC is achieved
breathing normal respiratory rate,depth, & breath about about completely as
Patient is telling that he
 is having problem in pattern R/T respiratory pattern, sound is assesd. baseline patient’s distress
respiration, he has to respiratory pattern rate,depth, & There is uneven information. is decrased due to
make more effort for muscle breath sound. pattern, repiratory the oxygen
- to know
respiration. weakness rate is more 29/min. insufficiency.
- check ABG about any
levels - Blood is sent for abnormality in
ABG. blood.
- Provide chest
physiotherapy - Chest - to lossen the
Objective data –
physiotherapy is secreations
- Provide
-Patient facial provided.
Suctioning -to remove the
expressions shows that
patient - suctioning done secreations
he is very restless, due
to the respiratory - Avoid - oxygen therapy - to maintain
difficulty. sedatives & the oxygen
Administered.
traqualizers level in blood
- Respiratory rate is 28/
min. - Administer
oxygen therapy

Subjective data - Impaired Patient will - Asses the physical - Physical immobility -To know
physical mobility do his daily immobility of the of the patient is about base line
R/T activities in patient. assessed. information.
Patient is telling that he Neuromusculim normal way.
- Encourage him for - To improve
is having problem with pairement &
doing his daily the muscle
his daily activities. Like resulting muscle -Patient is been
 bathing, clothing & weakness. activities by own. encouraged for doing strength.
eating due to the his daily activities by
- Teach him active - To improve
muscle weakness. own.
and passive the muscle
exercise. -Active and passive strength.
exercises are taught
Objective data - -instruct patient for - To improve
to the patient.
the importance of strength and
taking medication - instructions are endurance.
Patient body language on time. given to the patient
shows that patient is for taking medications
not able to do his daily on time.
activities.

ASSESSMENT DIAGNOSIS EOC PLANNING INTERVENTION RATIONAL EVALUATION

Subjective data Impaired Patient will - Asses the - Communication - -To know about
verbal have normal communication pattern of the patient base line
Patient is telling that he is
communicatio communicat pattern of the is assessed. information.
having problem with
n R/T ion pattern. patient.
changing of voice to some
weakened
extent - Encourage patient
speech - Patient is - To improve the
to talk in normal
Objective data muscles encouraged to ta;lk in communication.
way.
normal way.
Patient is having some - To improve the
amount of voice communication
impairement, as he is having - Teach patient
- Patient is taught
horesness of voice while different ways of
different waysof
communicating . communication.
communication.
- To improve the
communication

- Teach patient use

- Patient is taught
weakened muscles .
while speaking. To use weakened
muscles while
speaking.

ASSESSMENT DIAGNOSIS EOC PLANNING INTERVENTION RATIONAL EVALUATION

 Objective data Risk for Patient will - Assess for drolling, - Drolling, & - To know
aspiration R/T reduce the & regurgitation regurgitation through about status of
Patient is having
weakness of chances of through the nose. the nose is assessed. aspiration
weakness of the
bulbar aspiration.
muscles of the neck. - While suctioning - Instructions given to
muscles.
provide standby suction in upright
- To prevent
position. position.
aspiration
-Provide soft food - Advised given
which are easily
swallowed. To prevent
aspiration
- Encourage patient
for rest before meal. - Advised given to
patient and family
- While feeding To prevent
members.
place the patient in aspiration
upright position - Advised given to
To prevent
patient and
aspiration .
Relatives.
NURSES NOTES

NAME : - IPD NO. :- DIAGNOSIS :-

AGE :- OPD NO. :- DR. IN CHARGE :-

SEX :- BED NO. :- TREATMENT:-

OCCUPATION :- DOA :- DATE

SIGNATURE
Date MEDICATION DIET TIME NURSING OBSERVATION INTERVENTION & EVALUATION

Tab- Enam 10 m.g BREAK FAST 8.00 A.M -Patient is sleeping on his bed in supine position.
- OD
1 Cup tea - bed is looking untidy & unclean, bed making done.
Tab – Atex 25 m.g
- OD 2 slice of bread - Patient is in conscious state, but having problem in
Tab – Distinon 60 breathing and vision.
10.00A.M
m.g - QID
- Vital signs are checked, temp- 99F, pulse – 90/ min,
Tab – Azoran 10 LUNCH
respiration – 28/min, B.P – 130/90 mmof h.g
m.g - BD
1 Bowel dal
Tab –Wyselone 10 -Patient is well oriented to time place and person.
m.g - OD 3 Chapaties
- Medications are given to patient.
Tab – Rantac 150 12.00A.M
m.g - BD - Advised patient for active and passive exercise

Tab – Ecosprin 75
m.g - OD
NAME : -MR. MUKESH SHAH IPD NO. :- IL123

AGE : -46 YR OPD NO. :-OD235

SEX : - MALE BED NO. :- 10

OCCUPATION :- BUSINESS MAN DOA :- 23/03/18

NURSING OBSERVATION INTERVENTION &

Date MEDICATION DIET TIME SIGNATURE
EVALUATION

Tab- Enam 10 m.g BREAK FAST -Patient is sleeping on his bed in supine position.
- OD
1 Cup tea 8.00 A.M - bed is looking untidy & unclean, bed making done.
Tab – Atex 25 m.g
- OD 2 slice of bread
Tab – Distinon 60
-Vital signs are checked, temp- 99F, pulse – 90/ min,
m.g - QID
respiration – 28/min, B.P – 130/90 mmof h.g
Tab – Azoran 10 LUNCH
m.g - BD
1 Bowel dal 10.00A.M
Tab –Wyselone 10
-Patient is well oriented to time place and person.
m.g - OD 3 Chapaties

Tab – Rantac 150

m.g - BD
- Medications are given to patient.
Tab – Ecosprin 75 12.00A.M
m.g - OD - Advised patient for active and passive exercise

NAME : -MR. MUKESH SHAH IPD NO. :- IL123

AGE : -46 YR OPD NO. :-OD235

SEX : - MALE BED NO. :- 10

OCCUPATION :- BUSINESS MAN DOA :- 23/03/18

NURSING OBSERVATION INTERVENTION &

Date MEDICATION DIET TIME SIGNATURE
EVALUATION

Tab- Enam 10 m.g BREAK FAST -Patient is sleeping on his bed in supine position.
- OD
1 Cup tea 8.00 A.M - bed is looking untidy & unclean, bed making done.
Tab – Atex 25 m.g
- OD 2 slice of bread
Tab – Distinon 60
-Vital signs are checked, temp- 99F, pulse – 90/ min,
m.g - QID
respiration – 28/min, B.P – 130/90 mmof h.g
Tab – Azoran 10 LUNCH
m.g - BD
1 Bowel dal 10.00A.M
Tab –Wyselone 10
-Patient is well oriented to time place and person.
m.g - OD 3 Chapaties

Tab – Rantac 150

m.g - BD
- Medications are given to patient.
Tab – Ecosprin 75 12.00A.M
m.g - OD - Advised patient for active and passive exercise
 DISCHARGE PLANNING

Mr.Ramesh Shah is admitted on date 15/01/12 as case of Mysthenia gravis with the
complaints of diplopia, ptosis , weakness of the muscles of face, dyspnea and dysphonia.

So at the time of discharge following advices are given to the patient-

MEDICATIONS –

Take medications on time and according to the physicians order and timing of the
medication should be strictily followed.

EXERCISE

Patient is advised for regular exercises and fascial muscle exercise to improve the strength of
fascial muscles.

ACTIVITY

Advised for doing his daily routine activities by own.

DIETARY PATTERN

Patient is instructed to have food according to likes and dislikes, high protein and high
calorie diet.

FOLLOW UP

Patient is strictly advised for follow up according to the physicians advise.

SUMMARY

Mr.Ramesh Shah is admitted on date 23/03/18 as case of Mysthenia gravis with the
complaints of diplopia, ptosis , weakness of the muscles of face, dyspnea and dysphonia. On the
same day of admission treatment was started for myasthenia gravis, and patient had started
improving day by day, patient dyspnea is subside with in 3 days and patient is getting the
strength of his muscles back.

Patient and his family members are satisfied with the medical treatment and nursing
care is provided for the patient.
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478-485

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