ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC BASIS Pleural Effusion is collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion can result.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Ga sige rako ug ubo-ubo sir as verbalized by the patient. Objective: - cough - restlessness - yellowish sputum - tachycardia (PR=107 bpm) - pale - RR=26 cpm

Ineffective airway clearance related to retained secretions.

After 8 hours of care, patient will be able to: a. maintain airway patency b. expectorate/ clear secretions readily.

Independent: - Elevate head of the bed/change position every 2 hours. - Encouraged deep-breathing and coughing exercises. - Auscultate breath sounds and assess air movement. - Evaluate changes in sleep pattern.

-To take advantage of gravity decreasing pressure on the diaphragm. -To mobilize secretions.

-To ascertain status and note progress. -To assess changes.

After 8 hours of care Goals partially met. Patient was able to: a. Maintain airway patency. b. Expectorate clear secretions readily as evidenced by less secretions retained.

ASSESSMENT

NURSING DIAGNOSIS Impaired gas exchange related to alveolarcapillary membrane changes.

SCIENTIFIC BASIS Pleural Effusion is collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion can result.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Galisud ko ug ginhawa kung mahago ko ug ubo as verbalized by the patient. Objective: - RR=26 - Dyspnea - Restlessness - Tachycardia (PR=107 bpm) - Pale

After 8 hours of care patient will be able to: a. Participate in treatment regimen b. Demonstrate improve ventilation.

Independent: - To evaluate - Monitor vital signs degree of compromise. - Elevate head of bed/position client - To maintain appropriately. airway.

After 8 hours of duty goals not met.

Patient was not able to: a. Participate in - Maintain adequate - For mobilization of treatment regimen. I/O. secretions. b. Demonstrate Encourage frequent - To improve ventilation. position correct/improve changes and deep- existing condition breathing coughing exercises. deficiencies. Dependent: - Administer medications as indicated. -02 prn 24litres/min

-To treat underlying conditions.

ASSESSMENT

NURSING DIAGNOSIS Ineffective tissue perfusion (cardiopulmonary) related to impaired transportation of the oxygen across the alveolar and/or capillary membrane.

SCIENTIFIC BASIS Pleural Effusion is collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion can result.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Galisod ko ug ginhawa as verbalized by the patient. Objective: - RR=26 cpm - Irritability - Restlessness

After 8 hours of care patient will be able to: a. Demonstrate behaviors/lifestyle changes to improve circulation. b. Demonstrate increased perfusion as individually appropriate.

Independent: -Identify changes related to systemic or peripheral alterations in circulation. -Determine duration of problem. -Monitor vital signs -Investigate report of chest pain Dependent: -Administer medication as ordered

-To assess contributing factors

After 8 hours of care Goals met. Patient was able to: a. Demonstrate behaviors/lifestyle - To note degree of changes to improve impairment circulation - To maximize b. Demonstrate tissue perfusion increased perfusion - To note degree of as impairment individually appropriate. -To maximize tissue perfusion

ASSESSMENT

NURSING DIAGNOSIS Imbalanced nutrition, less than body requirement related to illness.

SCIENTIFIC BASIS Pleural Effusion is collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion can result.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Wala koy gana mo kaon maam as verbalized by the patient. Objective: - Poor muscle tone - Pale -weight loss - Weakness

After 8 hours of care patient will be able to demonstrate progressive good appetite.

Independent: -Identify underlying condition involved. -Identify clients at risk for malnutrition. - Discuss eating habits, including food preferences, intolerance. -Assess weight, age, body build, and strength of the client. Dependent: -Administer pharmaceutical agents as indicated.

-To assess causative factors.

After 8 hours of care Goals met. Patient was able to - to assess demonstrate contributing factors. progressive good appetite. -To appeal to clients like and dislike. - To evaluate degree of deficit.

-To evaluate degree deficit.

Name of drug Generic name: Levofloxacin Brand name: levaquin

Classification & mechanism of action -Antibiotic, Fluoroquinolone

Indication & dosage

contraindication Contraindicated with allergy to fluoroquinolones, lactation. Use cautiously with renal dysfunction, seizures, pregnancy.

Side effects/ adverse reaction CNS: Headache, dizziness, insomnia, fatigue, somnolence, blurred vision GI: Nausea, vomiting, dry mouth, diarrhea, abdominal pain (occur less with this drug than with oflaxacin), constipation, flatulence Hematologic: Elevated BUN, AST, ALT, serum creatinine, and alkaline phosphatase; neutropenia, anemia Other: Fever, rash, photosensitivity, muscle and joint tenderness

Nursing responsibilities Assessment: History: Allergy to fluoroquinolones, renal dysfunction, seizures, lactation, pregnancy Physical: Skin color, lesions; orientation, reflexes, affect; mucous membranes, bowel sounds; renal and liver function tests

-Treatment of adults with community-Bactericidal: acquired interferes with DNA pneumonia, acute by inhibiting DNA exacerbation of synapse replication chronic bronchitis, in susceptible complicated and gram- negative and uncomplicated skin gram- positive and skin structure bacteria, preventing infections, UTIs and cell production. acute pyelonephritis & acute maxillary sinusitis caused by susceptible bacteria
-Pneumonia: 500

Sinusitis: 500 mg

mg daily PO or IV

daily PO or IV daily PO or IV

Chronic bronchitis: 500 mg

Name of drug Generic name: Ascorbic Acid(Vitamin C) Brand name: cecon

Classification & mechanism of action - vitamin - Water-soluble vitamin essential for synthesis and maintenance of collagen and intercellular ground substance of body tissue cells, blood vessels, cartilage, bones, teeth, skin, and tendons. Unlike most mammals, humans are unable to synthesize ascorbic acid in the body; therefore it must be consumed daily.

Indication & dosage -Prophylaxis and treatment of scurvy and as a dietary supplement. -adult: PO/IV/IM/SC 150500 mg/d in 12 doses

contraindication Use of sodium ascorbate in patients on sodium restriction; use of calcium ascorbate in patients receiving digitalis.

Side effects/ adverse reaction GI: Nausea, vomiting, heartburn, diarrhea, or abdominal cramps (high doses). Hematologic: Acute hemolytic anemia (patients with deficiency of G6PD); sickle cell crisis. CNS: Headache or insomnia (high doses). Urogenital: Urethritis, dysuria, crystalluria, hyperoxaluria, or hyperuricemia (high doses). Other: Mild soreness at injection site; dizziness and temporary faintness with rapid IV administration.

Nursing responsibilities Assessment : -Lab tests: Periodic Hct & Hgb, serum electrolytes. -Monitor for S&S of acute hemolytic anemia, sickle cell crisis.

Name of drug Generic name: Acetylcysteine Brand name: Fluimucil granules

Classification & mechanism of action -Mucolytic -N-acetyl-L-cysteine (NAC), active ingredient of Fluimucil, exerts an intensive mucolyticfluidifying action on mucous and mucopurulent secretions, by depolymerizing the mucoproteic complexes and the nucleic acids which confer viscosity to the vitreous and purulent component of the sputum and of the secretions.

Indication & dosage -Treatment of respiratory affections characterized by thick and viscous hypersecretions: acute bronchitis, chronic bronchitis and its exacerbations; pulmonary emphysema, mucoviscidosis and bronchieactasis. -1 Acetylcysteine (Fluimucil) 600 mg effervescent tablet daily (preferably in the evening)

contraindication Known hypersensitivity to acetylcesteine. As Acetylcysteine (Fluimucil) granules and tablets contain aspartame, it is contraindicated in patients suffering from phenylketonuria.

Side effects/ adverse reaction bronchospasm, angioedema, rashes, pruritus, nausea and vomiting, fever, syncope, sweating, arthralgia, blurred vision, disturbances of liver function.

Nursing responsibilities Monitor effectiveness of therapy and advent of adverse/allergic effects. Instruct patient inappropriate use and adverse effects to report.

Name of drug Generic name: Piperacillin / Tazobactam Brand name: zosyn

Classification & mechanism of action -Antiinfective; Betalactam antibiotic -it is similar to that of other penicillins. Interfere with bacterial cell wall synthesis promotes loss of membrane integrity and leads to death of the organism

Indication & dosage -Treatment of moderate to severe appendicitis, uncomplicated and complicated skin and skin structure infections, nosocomial or community-acquired pneumonia caused piperacillin-resistant, piperacillin/tazobactam susceptible, betalactamase-producing bacteria. -280 mg IVTT every 12hr

contraindication Hypersensitivity to penicilli ns, cephalosphorins, or other drugs. Safety in children< 12 years old, pregnancy, lactation.

Side effects/ adverse reaction CNS: headache, insomnia, fever GI: diarrhea, nausea, constipation, vomiting, pseudo membranous colitis SKIN: Hypersensitivity reactions, rash, pruritus

Nursing responsibilities Obtain history of hypersensitiv ity to penicillins, cephalosphorins, or other drugs prior to administration - Obtain specimen for culture and sensitivity prior to first dose of the drug; start drug pending results. Periodic CBC with differential, platelet count, Hgb & Hgt, and serum electrolytes. - Monitor for hypersensitivity response; discontinue drug and notify physician if allergic response noted. -Monitor vital signs because of cardiac arrhythmias, hypertension and fever as adverse reactions.

SAPUGAYS FAMILY GENOGRAM

Female HTN

Female FEVER

W&A

W&A

W&A (MAID)

EDUARDO 56, M Massive Plueral Effusion

Male Paralized (HTN)

W&A

Legend: Male Female Deceased Patient