World Citi Colleges 960 Aurora Blvd.

Quezon City Case Presentation In NCM 103

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

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

I.

Introduction

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

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

II.

Objectives

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

III.

Theoretical Framework

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

Virginia Henderson did not state her own definition of health. But in her writing, she equated health with independence. Environment Again, Henderson did not give her own definition of environment. Instead, she used Websters New Collegiate Dictionary, 1961, which defined environment as the aggregate of all the external conditions and influences affecting the life and development of organism. Person Henderson viewed the patient as an individual who requires assistance to achieve health and independence or peaceful death. The mind and body are inseparable. The patient and his or her family are viewed as a unit.

The 14 Basic Human Needs 1. Breathe normally.- In our patients case there is presence of difficulty of breathing due to plural effusion the main goal is to secure patients breathing. 2. Eat and drink adequately. There is presence of malnutrition because of sudden weight loss due to having PTB. Our concern is to regain patients desirable body weight. 3. Eliminate body wastes. There is presence or impaired gas exchange in the patient. The nurses responsibility is to correct this problem to provide comfort to the patient. 4. Move and maintain desirable postures. The patient is now bed ridden due to his illness and cant even go to the bathroom by him self. The health care providers responsibility is to take care and give as much care as possible to the patient to give the best care while in recovery. 5. Sleep and rest. The patient is usually sleeping during his hospitalization period the goal of the health care provider is to give as much comfort as possible to the patient while sick. 6. Select suitable clothes--dress and undress. Give proper clothing to help in breathing and comfort. Health care provider should advise patient to wear the suitable clothing as needed. 7. Maintain body temperature within normal range by adjusting clothing and modifying the environment. The health care providers responsibility is to constantly check the VS of the patient to check if there are abnormalities or significant changes noted and to give proper action as soon as possible.

8.

Keep the body clean and well groomed and protect the integument. It is important to maintain the hygiene of the patient to avoid any complication such as infection and to give comfort while sick, recovering or well. 9. Avoid dangers in the environment and avoid injuring others. Make sure that the patient as well as the people surrounding him is safe the health care providers job is to ensure the safety of the patient and the people around him such as advising relatives or visitors to wear mask for precaution and as for the patient putting side rails to avoid falling in from bed. 10. Communicate with others in expressing emotions, needs, fears or opinions.- Proper communication is a good way to show care, Establishing rapport is a good way of better relationship as patient nurse interaction. 11. Worship according to one's faith. Respecting the patients spirituality is an important factor in good relationship between health care provider and patient. 12. Work in such a way that there is a sense of accomplishment. Make sure to finish what you start. 13. Play or participate in various forms of recreation. 14. Learn - Discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.

IV. Nursing Assessment

A. Personal Data Name: Age: Birthday:

C.J.

17 years old February 12, 1993

Nationality: Filipino Gender: Civil Status: Address: Male Single Marikina City

Occupation: HRM 2nd year Student Adm. Date: July 26, 2010 Adm. Time: 12:15 am Chief complaint: DOB Difficulty of Breathing

Clinical Impression:Pleural effusion probable secondary to PTB stage 3. B. History of Present illness: 2 days prior to admission the patient complains chest pain and difficulty of breathing especially at night. When he takes a rest, it lessens the pain. He also complains stomach ache. Then few hours prior to admission the patient DOB, fever and accompanying pain in his right lower quadrant. He was then immediately rushed to WCMC on June 27, 2010

C. Past Health history: June 17, 2010 he was admitted to St.Victoria Hospital in Marikina City and was confined for 1 week. Chief Complaint is fever. The doctor gave medication of Myrin P forte & Iberet ordered to take for a month, because the doctors finding was pleural effusion. D. Family history: Both of the patients parents have no history of illness. But the grandfather on his father side died due to Cardiac Arrest. His grandmother on his father side has a history of Hypertension. Also, his grandfather and grandmother on his mother side has a history of Hypertension

E. Social History: The patient is 17 years old. Hes taking up Hotel Restaurant Management 2nd year student. His usual daily activity is playing basketball 3 times a day. During high school he was a varsity in basketball on his school. He also spends a lot of time in front of the computer. The earliest time he finish his stuff is 12 midnight & most late is 2am. He also wants to hang out with his friends.

PHYSICAL ASSESSMENT

Day 1 HAIR Black, thin, straight, shiny and short SCALP White, oily w/ presence of dandruff FACE Symmetrical facial movement, he is exhausted due to lack of sleep and pain EYES The outer cantus of the patient eyes were symmetrical to the pinna of his ears. The eyebrows were thin but evenly distributed and have short eyelashes. Patients was observed to have white sclera, pale conjunctivas, and black equally rounded pupils. Constriction were observed when light stimulation done at varying distance. NOSE The patient has pointed nose, with dry mucus membranes. EARS Tip of the ear is aligned with the outer canthus of the eye. Ear wax observed when exposed to pen light. He is able to hear from both ears because he was able to respond to the questions that was asked to him. MOUTH He is able to open and close with ease. TEETH He has a complete white tooth w/ no dentures and any dental carries.

TONGUE The patient has moist with white patches over the tongue. LIPS Dry and pale in color. NECK

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

Day 2 HAIR Black, thin, straight, shiny and short SCALP White, smooth scalp, oily w/ presence of dandruff FACE Symmetrical facial movement, he is more exhausted. He is sleeping during assessment because of Demerol administration to ease his pain on his RLQ.

EYES The outer cantus of the patient eyes were symmetrical to the pinna of his ears. The eyebrows were thin but evenly distributed and have short eyelashes. Patients was observed to have white sclera, pale conjunctivas, and black equally rounded pupils. Constriction and dilation were observed when light stimulation done at varying distance. NOSE The patient has pointed nose, with dry mucus membranes EARS Tip of the ear is aligned with the outer canthus of the eye. Ear wax observed when exposed to pen light. He is able to hear from both ears. MOUTH The patient is able to open and close with ease. TEETH He has a complete white tooth w/ no dentures and any dental carries. TONGUE The patient has moist with white patches over the tongue. LIPS Dry and pale in color.

NECK The patients neck has fair skin complexion and muscle tone was fairly good and able to move his head. No masses palpated along lymph nodes. But theres a presence of wounds & lesions. The carotid pulse is palpable. CHEST Chest is symmetrical during respiration, fair skin in color and smooth with respiratory rate of 28 bpm. The patient has test tube drainage for his pleural effusion. ABDOMEN Undergo appendectomy on his RLQ. He is wearing a binder.

UPPER EXTREMETIES The patient is having difficulty in lifting his left arm due to the edema. Has fair complexion but pale. Patients both arms are edematous and palms were dry, warm to touch with dry. Capillary refill was within 3 seconds. The patient has an IV fluid of 5% Dextrose in water 250 ml on his right hand. LOWER EXTREMETIES The patients right and left lower extremities fair complexion. Patients legs and feet is edematous were dry and warm to touch. Capillary refill was within 3 seconds.

Vital Signs Day 1, 4pm (August 05, 10): T: 36'C, P: 70bpm, R: 28bpm, BP: 110/80 Day 1, 8pm: 37.1'C, P: 100bpm, R: 28bpm, BP: 110/80 U: 2, S: 1 Day 2, 4pm (August 06, 10): T: 37.6'C, P: 98bpm, R: 25bpm, BP: 120/80 Day 2, 8pm: 37.9'C, P: 90bpm, R: 28bpm, BP: 110/80 U: 2 S: 1

V. Usual pattern of ADL (GORDONS)

AREA

BEFORE HOSPITALIZATION The pt had an active lifestyle when he was still well. He plays basketball as his form of exercise.

DURING HOSPITALIZATIO N (DAY1) He socializes with the nurses and the doctors. He was accompanied by one of his parents.

DURING HOSPITALIZA TION (DAY2) The patient was asleep throughout the day.

1. Social history

He socializes with His classmates his friends at from FEU also school. At home, he visited him. was playing computer games such as dota from 7:00 pm until dawn 2. Mental Conscious and aware of time, date and reality. Able to do his task as a student. Conscious and aware of time, date and reality. Able to answer the questions when asked to. The patient was asleep throughout the day.

3. Emotional

He was contented He was sad when with his life as a he was alone but student. he cheers up when his relatives, classmates and friends visited him.

The patient was asleep throughout the day.

4. Sensory perception

His sensory were all The patient was The patient working, able to able to perceive was asleep perceive stimuli. stimuli. throughout the day but wakes up when feels the pain on his RLQ. Able to move his The patient is in The patient is body with ease. strict bed rest. in strict bed rest. RR: 4pm: 28 bpm 8pm: 27 bpm RR: 4pm: 25 bpm 8pm: 28 bpm

5. Motor Capabilitie s 6. Respirator y

7. Circulatory

PR: 4pm: 70bpm 8pm: 100bpm

PR: 98bpm

4pm:

BP: 4pm: 8pm: 90bpm 110/80mmHg BP: 4pm: 8pm: 110/80mmHg 120/80 8pm:110/80 mmHg 8. Body temperatu re Temp: 4pm: 36C 8pm: 37.1C Temp:4pm: 37.6C 8pm: 37.9C

9. Nutritional

He eats all the foods He is in soft diet. He is in soft he likes especially He only eats diet. He only fried chicken. He lugaw eats lugaw just eats vegetables when his mother forced him to. He urinates and Urine: 2 defecates regularly. Stool: 1 Urine: 2 Stool: 1

10. Elimi nation

11. Stat e of physical rest & comfort

He usually sleeps He sleeps anytime He sleeps around 10 in the of the day. throughout the evening when day. theres a class on the ff morning. Incision on the Incision on the RLQ. Wounds and RLQ. Wounds lesions on the and lesions on neck. the neck.

12. Stat Good skin turgor e of skin and warm feeling. and appendice s

VI. ANATOMY AND PHYSIOLOGY

The respiratory system is an intricate arrangement of spaces and passageways that conduct air from outside the body into the lungs and finally into the blood as well as expelling waste gasses. This system is responsible for the mechanical process called breathing. When engaged in strenuous activities, the rate and depth of breathing increases in order to handle the increased concentrations of carbon dioxide in the blood. Breathing is typically an involuntary process, but can be consciously stimulated or inhibited as in holding your breath. Upper Respiratory System Nostrils/Nasal Cavities During inhalation, air enters the nostrils and passes into the nasal cavities where foreign bodies are removed, the air is heated and moisturized before it is brought further into the body. It is this part of the body that houses our sense of smell. Pharynx The pharynx, or throat carries foods and liquids into the digestive tract and also carries air into the respiratory tract. Larynx The larynx or voice box is located between the pharynx and trachea. It is the location of the Adam's apple, which in reality is the thyroid gland and houses the vocal cords. Trachea The trachea or windpipe is a tube that extends from the lower edge of

the larynx to the upper part of the chest and conducts air between the larynx and the lungs. Lungs The lungs are the organ in which the exchange of gasses takes place. The lungs are made up of extremely thin and delicate tissues. At the lungs, the bronchi subdivides, becoming progressively smaller as they branch through the lung tissue, until they reach the tiny air sacks of the lungs called the alveoli. It is at the alveoli that gasses enter and leave the blood stream. Lower Respiratory System Bronchi The trachea divides into two parts called the bronchi, which enter the lungs. Bronchioles The bronchi subdivide creating a network of smaller branches, with the smallest one being the bronchioles. There are more than one million bronchioles in each lung. Avleoli The alveoli are tiny air sacks that are enveloped in a network of capillaries. It is here that the air we breathe is diffused into the blood, and waste gasses are returned for elimination. Gas Exchange The major function of the respiratory system is gas exchange. As gas exchange occurs, the acid-base balance of the body is maintained as part of homeostasis. If proper ventilation is not maintained two opposing conditions could occur: 1) respiratory acidosis, a life threatening condition, and 2) respiratory alkalosis.

VII. Pathophysiology
Risk factors: Presence of Pulmonary Tuberculosis

Organ Affected:

LUNGS

Disease Process: An exudative effusion results from increased capillary permeability characteristic of the inflammatory reaction. This type of effusion occurs secondary to other conditions.

Clinical Manifestations: Some symptoms are caused by the underlying disease. Size of effusion & the time course of development determine the severity. - Large effusion: SOB to acute respiratory distress - Small Moderate: Dyspnea may not be present - Dullness/Flatness to percussion over Diagnostic Evaluation: - CXR (lateral decubitis) - Chest CT scan - Ultrasound -Thoracentesis - Pleural Biopsy - Pleural fluid analysis

Clinical Manifestations:

DOB Tachypnea Chest pain

Diagnostic Evaluation: - CXR pleural effusion in left hemithorax - Thoracentesis

Medical Management: - Thoracentesis - Chest tube and water-seal drainage - Chemical pleurodesis - Surgical pleurectomy - Educate pt and family about management of drainage system with outpatient therapy

Medical Management: - Thoracentesis - Chest tube and water-seal drainage; left side - Meds: ethambutol, corticosteroid (Prednisone), levofloxacin

Pati ent

BOO K

Laboratory Exam Results:

ARTERIAL BLOOD GAS Date ordered July 27, 2010 Laboratory exams pH Results 7.388 Normal values 7.35-7.45 Significance Increase: Hyperventilation Anxiety, pain Anemia Shock Some degrees of Pulmonary disease Some degrees of Congestive heart failure Myocardial infarction Hypokalemia (decreased potassium) Gastric suctioning or vomiting Antacid administration Aspirin intoxication Decrease: Strenuous physical exercise Obesity Starvation Diarrhea Ventilatory failure More severe degrees of Pulmonary Disease More severe degrees of Congestive Heart Failure Pulmonary edema

PCO2

40.1

35-45mmHg

Cardiac arrest Renal failure Lactic acidosis Ketoacidosis in diabetes Increase: Pulmonary edema Obstructive lung disease Decrease: Hyperventilation Hypoxia Anxiety Pregnancy Pulmonary Embolism

PO2

94.3

80-100mmHg

Increase: Increased oxygen levels in the inhaled air Polycythemia Decreased Decreased oxygen levels in the inhaled air Anemia Heart decompensation Chronic obstructive pulmonary disease Restrictive pulmonary disease Hypoventilation Decreased HCO3 Metabolic Acidosis

HCO3

23.6

22-26 mEq/L

Increased HCO3 Metabolic

Alkalosis BE 1.3 +/- 2 mEq/L More Negative Values of Base Excess may Indicate: Lactic Acidosis Ketoacidosis Ingestion of acids Cardiopulmonary collapse Shock More Positive Values of Base Excess may Indicate: Loss of buffer base Hemorrhage Diarrhea Ingestion of alkali Oxygen Saturation will fall if: Inspired oxygen levels are diminished, such as at increased altitudes. Upper or middle airway obstruction exists (such as during an acute asthmatic attack) Significant alveolar lung disease exists, interfering with the free flow of oxygen across the alveolar membrane. Oxygen Saturation will rise if: Deep or rapid breathing occurs Inspired oxygen

O2 saturation

97.1%

95-100%

levels are increased, such as breathing from a 100% oxygen source PO2 (A-a) 55.1 It is an important factor affecting the amount of oxygen that is bound to hemoglobin.

BLOOD CHEMISTRY Date ordered July 27, 2010 Laboratory exams AST(SGOT) Results 25.3 Normal values 0.00-35.00 U/L Significance Increasedmyocardial infarction, skeletal muscle disease, and liver disease. Same conditions as AST(SGOT), but increased is more marked in liver disease than AST(SGOT) Increasemascular dystrophy, fever, carcinoma of liver,

ALT(SGPT)

17.9

0.00-45 U/L

Creatinine

64.4

72.00-127.00 umol/L

Potassium

3.58

3.50-5.50 mmol/L

Increasedhemolysis, chronic renal failure, acidosis, cushings diease, corpus luteum cysts. Decrease diarrhea, adrenocortical insuffiency.

Sodium

132.7

135.00-148.00 mmol/L

Increaseduseful in detecting gross changes in water and salt balanced

COMPLETE BLOOD COUNT Date ordered August 5, 2010 Laboratory exams WBC results 11.7 Normal values 4.00-10.00 10^9/L Significant Increasedneurosyphilis, anterior poliomyelitis, encephalitis lethargic. Decreasediron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic

RBC

4.01

4.50-6.50 10^12/L

disease, hereditary anemia, free radical pathology, toxic metals, catabolic methabolism. HGB 109 130.00-170.00 g/L Decreased in various anemias, pregnancy, severe of prolonged hemorrhage, and with excessive fluid intake. Decrease in severe anemias, anemia in pregnancy, acute massive blood loss. Increase in macrocytic anemias; decrease in microcytic anemia MCH 27.2 27.00-32.00 pg Increase in macrocytic anemias; decrease in microcytic anemia MCHC 306 320.00-360.00 g/L Decreased in severe

HCT

0.36

0.40-0.54

MCV

89

80.00-100.00 fl

hypocromic anemia. Increased and decreased is same with MCV two exceptions in spherocytosis, the MCHC is elevated but not in pernicious anemia PLT Increased 150.00-350.00 10^9/L Increased in malignancy, myeloproliferat ive disease, rheumatoid arthritis, and postoperativerl y; about 50% of patients with unexpected increase of platelet count will be found to have a malignancy; Increase with infectious mononucleosis , viral and some bacterial infections, hepatitis; decreased with aplastic anemia, SLE, immunodeficie ncy including

Lymphocytes

0.19

0.25-0.50

AIDS. Monocytes 0.01 0.02-0.10 Increase with viral infections, parasitic disease, collagen and hemolytic disorder; decreased with use of corticosteroids, RA, HIV infection. Increase with acute infection, trauma or surgery, leukemia, malignant disease, necrosis; decrease with viral infections, bone marrow suppression, primary bone marrow disease. Increase in allergy, parasitic disease, collagen disease, subacute infections; decrease with stress, use of some medications(A CTH,

Neutrophils

0.80

0.50-0.80

Eosinophils

0.00-0.05

epinephrine, thyroxin

COMPLETE BLOOD COUNT Date ordered August 1, 2010 Laboratory exams WBC results 18.3 Normal values 4.00-10.00 10^9/L Significance Increasedneurosyphilis, anterior poliomyelitis, encephalitis lethargic. Decreasediron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic disease, hereditary anemia, free radical pathology, toxic metals, catabolic methabolism. Decreased in various anemias, pregnancy, severe of prolonged hemorrhage, and with excessive fluid intake. Decrease in severe anemias,

RBC

3.58

4.50-6.50 10^12/L

HGB

103

130.00-170.00 g/L

HCT

0.32

0.40-0.54

anemia in pregnancy, acute massive blood loss. MCV 80.00-100.00 fl Increase in macrocytic anemias; decrease in microcytic anemia MCH 27.00-32.00 pg Increase in macrocytic anemias; decrease in microcytic anemia MCHC 320.00-360.00 g/L Decreased in severe hypocromic anemia. Increased and decreased is same with MCV two exceptions in spherocytosis, the MCHC is elevated but not in pernicious anemia PLT Increased 150.00-350.00 10^9/L Increased in malignancy, myeloproliferat ive disease, rheumatoid arthritis, and postoperativerl y; about 50%

of patients with unexpected increase of platelet count will be found to have a malignancy; Lymphocytes 0.06 0.25-0.50 Increase with infectious mononucleosis , viral and some bacterial infections, hepatitis; decreased with aplastic anemia, SLE, immunodeficie ncy including AIDS. Increase with viral infections, parasitic disease, collagen and hemolytic disorder; decreased with use of corticosteroids, RA, HIV infection. Increase with acute infection, trauma or surgery, leukemia, malignant disease, necrosis;

Monocytes

0.02-0.10

Neutrophils

0.94

0.50-0.80

decrease with viral infections, bone marrow suppression, primary bone marrow disease. Eosinophils 0.00-0.05 Increase in allergy, parasitic disease, collagen disease, subacute infections; decrease with stress, use of some medications(A CTH, epinephrine, thyroxin

COMPLETE BLOOD COUNT Date ordered July 27, 2010 Laboratory exams WBC results 15.2 Normal values 4.00-10.00 10^9/L Significant Increasedneurosyphilis, anterior poliomyelitis, encephalitis lethargic. Decreasediron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic disease, hereditary

RBC

3.58

4.50-6.50 10^12/L

anemia, free radical pathology, toxic metals, catabolic methabolism. HGB 108 130.00-170.00 g/L Decreased in various anemias, pregnancy, severe of prolonged hemorrhage, and with excessive fluid intake. Decrease in severe anemias, anemia in pregnancy, acute massive blood loss. Increase in macrocytic anemias; decrease in microcytic anemia MCH 27.00-32.00 pg Increase in macrocytic anemias; decrease in microcytic anemia MCHC 320.00-360.00 g/L Decreased in severe hypocromic anemia.

HCT

0.37

0.40-0.54

MCV

80.00-100.00 fl

Increased and decreased is same with MCV two exceptions in spherocytosis, the MCHC is elevated but not in pernicious anemia PLT 502 150.00-350.00 10^9/L Increased in malignancy, myeloproliferat ive disease, rheumatoid arthritis, and postoperativerl y; about 50% of patients with unexpected increase of platelet count will be found to have a malignancy; Increase with infectious mononucleosis , viral and some bacterial infections, hepatitis; decreased with aplastic anemia, SLE, immunodeficie ncy including AIDS. Increase with viral infections,

Lymphocytes

0.05

0.25-0.50

Monocytes

0.02-0.10

parasitic disease, collagen and hemolytic disorder; decreased with use of corticosteroids, RA, HIV infection. Neutrophils 0.92 0.50-0.80 Increase with acute infection, trauma or surgery, leukemia, malignant disease, necrosis; decrease with viral infections, bone marrow suppression, primary bone marrow disease. Increase in allergy, parasitic disease, collagen disease, subacute infections; decrease with stress, use of some medications(A CTH, epinephrine, thyroxin

Eosinophils

0.00-0.05

Total Protein and A/G Date ordered July 27, 2010 Laboratory exams Total Protein Results 65.5 Normal values 66.0083.00 G/L Significance DECREASE Low total protein levels can suggest a liver disorder, a kidney disorder, or a disorder in which protein is not digested or absorbed properly. Low levels may be seen in severe malnutrition an d with conditions that cause malabsorption, such as Celiac disease or inflammator y bowel disease (IBD). INCREASE High total protein levels may be seen with chronic inflammati on or infections such as viral hepatitis or HIV. They may be caused by bone marrow disorders such as multiple myeloma. Albumin 24.6 35.0052.00 G/L Albumin's role in the body is to maintain osmotic pressures and to also transport hydrophobic substances

Globulin A/G ratio

40.9 0.60

15.0030.00 G/L 1.50-2.50 A high A/G ratio suggests underproduction of immunoglobulins as may be seen in some genetic deficiencies and in some leukemias A low A/G ratio may reflect overproduction of globulins, such as seen in multiple

Body Fluid Cell Count (July 27, 2010) Appearance before centrifugation- yellow/turbid Appearance after centrifugation- yellow/ clear Total Volume: 3mL RBC Count: 1950 cells/ cu.mm WBC Count: 2250 cells/ cu.mm Total Cell Count: 4,200 Differential Count: Neutrophils- 0.49 Lymphocytes: 0.51 RBC Morphology: Creanated RBC- 100% Non-creanated-

Gram Stain Result (July 27, 2010) Polymorphonuclear cells= Few No microorganisms seen Chest X-ray(July 30, 2010) Recheck chest x-ray after 2 days show diminution in the pleural effusion in the left hemithorax A T-Tube is seen in situ

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

Monitor patients hypersensitivity to omeprazole and its components

Dosage: 40mg

Frequency:

OD

Route: IV

July 28, 2010

GN: Piperacillin

BN:Tazocin

Dosage: 2.2g

TAZOCIN is for treatment of the following systemic and/or local bacterial infections in which susceptible organisms have been detected or are suspected: Children

Frequency: Q8

Route: IV

Appendicitis complicated by rupture with peritonitis and/or abscess formation in children aged 2 12 years. Bacterial infections in neutropenic children in combination with an aminoglycoside.

TAZOCIN is indicated for the treatment of polymicrobic infections including those where grampositive and gramnegative aerobic and/or anaerobic organisms are suspected (intraabdominal, skin and skin structure, lower respiratory tract)

Monitor bleeding manifestations or significant leukopenia following prolonged administration have occurred in some patients receiving blactam antibiotics, including piperacillin

July 28,

GN: Digoxin

Lanoxin is used to treat congestive

Lanoxin is also used to slow the heart

Before giving the drug ask the

2010 BN:Lanoxin

heart failure

Dosage: 25mg

rate in patients with chronic atrial fibrillation, a heart rhythm disorder of the atria (the upper chambers of the heart that allow blood to flow into the heart).

patient about allergic reactions to digoxin

Frequency: OD

Route: August 06,201 0 Maalox Suspenscio n

Dosage: 30cc

Maalox is a balanced mixture of 2 antacids: Aluminum hydroxide is a slow-acting antacid and magnesium hydroxide is fast acting. Antacid therapy in gastric and duodenal ulcer, gastritis, heartburn and gastric hyperacidity.

Gastritis & duodenitis accompanied by flatulence, post-op gas pain.

Make sure patient has food intake 20 minutes 1 hour before taking maalox

Frequency: Stat

August 06,201 0

GN: Meperidine

BN:Demerol

Dosage:

Demerol is used for the relief of moderate to severe pain, most commonly in obstetrics and post-operative conditions.

The principal actions of therapeutic value in Demerol are analgesia and sedation. Demerol is a narcotic analgesic with effects similar to

Monitor patient include hyperexcitability, convulsions, tachycardia, hyperpyrexia, and hypertension

25mg

morphine. Reassess patients level of pain.

Route: IV

Frequency: Now

August 04,201 0

GN: Metronidaz ole

Metronidazole is an antibiotic effective against anaerobic bacteria and certain parasites

BN: Flagyl

Dosage: 1gm/ tab

Metronidazole is used alone or in combination with other antibiotics in treating abscesses in the liver, pelvis, abdomen and brain caused by susceptible anaerobic bacteria.

Safety and effectiveness in pediatric patients have not been established, except for the treatment of amoebiasis.

Frequency: Q12

Medication Generic Name: ethambutol Brand Name: Myrin P Forte 3tab AC breakfast OD

Action Inhibits the growth or other myobacteria. THERAPEUTIC EFFECTS: Tuberculostatic effects against susceptible organisms. PHARMACOLOGIC

Indication Active tuberculosis or other mycobacterial disease (with at least one other drug)

Nursing Consideration - Mycobacterial studies and susceptibility tests should be performed before and periodically during therapy to detect possible resistance. - Assess lung sounds and

ACTION: antituberculars

character and the amount of sputum periodically during therapy.

Generic Name: furosemide Brand Name: N/A 40mg/IV STAT

Generic Name: ketorolac Brand Name: Ketoradol 30mg/IV q6

Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium. Effectiveness persists in impaired renal function. THERAPEUTIC EFFECTS: Diuresis and subsequent mobilization of excess fluid (edema, pleural effusion). Decrease blood pressure. PHARMACOLOGIC ACTION: loop diuretics. Inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Also has antipyretic and antiinflammatory properties. THERAPEUTIC EFFECTS: Decreased pain.

Edema due to heart failure, hepatic impairment or renal disease. Hypertension.

Monitor blood pressure and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patient treated for hypertension. Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digoxin are at risk of digoxin toxicity because of the potassiumdepleting effect of diuretics.

Short-term management of pain (no to exceed 5 days total for all routes combined)

Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. May cause prolonged bleeding time that may persist for 24-48 hr following discontinuation of therapy. May cause

Generic Name: tramadol Brand Name: Tramadin 100mg/IV q8

PHARMACOLOGIC EFFECT: pyrroziline carboxylic acid. Binds action to mu-opioid receptors. Inhibits reuptake of serotonin and nonepinephrine in the CNS. THERAPEUTIC EFFECTS: Decreased pain. PHARMACOLOGIC ACTION: analgesics (centrally acting)

Moderate to moderately severe pain.

Generic Name: corticosteroids Brand Name: Prednisone 20mg/tab 1tab BID

Decreases inflammation by reversing increased cell capillary permeability and inhibiting migration of polymorphonucle ar leukocytes. Suppresses immune system by reducing lymphatic activity. THERAPEUTIC EFFECT: Suppression of inflammation and modification of the normal immune response. PHARMACOLOGIC EFFECT: corticosteroids (systemic) Inhibits the

It is prescribed in the treatment of severe inflammation and for immunosuppressi on.

increased BUN, serum creatinine, or potassium concentrations. Assess type, location, and intensity of pain before and 2-3hr (peak) after administration. Assess blood pressure and respiratory rate before and periodically during administration. Respiratory depression has not occurred with recommended doses. Assess patient for signs of adrenal insufficiency (hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness). Monitor intake and output ratios and daily weights. Observes patient for peripheral edem, steady weight gain, rales/crackles, or dyspnea. Notify health care professional if these occur.

Generic Name:

Management of

Assess ROM,

celocoxib Brand Name: Celebrex 400mg/tab 1tab OD

enzyme COX-2. This enzyme is required for the synthesis of prostaglandins. Has analgesic, antiinflammatory, and antipyretic properties. THERAPEUTIC EFFECTS: Decreased pain and inflammation caused by arthritis or spondylitis. Inhibits the muscarine activity of acetylcholine. Corrects the imbalance of acetylcholine and norepinephrine in the CNS, which may be responsible for motion sickness. THERAPEUTIC EFFECT: Reduction of nausea and vomiting. Preoperative amnesia and decreased secretions. PHARMACOLOGIC ACTION: anticholinergics

acute pain including primary dysmenorrhea.

degree swelling, and pain in affected joints before and periodically throughout therapy. Assess patient for allergy to sulfonamides, aspirins, or NSAIDs. Patients with these allergies should not receive celecobix. Assess patient for sign of urinary retention periodically during therapy. Monitor heart rate periodically during parenteral therapy. Assess patient for pain prior to administration. Scopolamine may act as a stimulant in the presence of pain, producing delirium if used without morphine and meperidine.

Generic Name: scopolamine Brand Name: Buscopan 1amp STAT

Preoperatively to produce amnesia and to decrease salivation and excessive respiratory secretion.

Generic Name: levofloxacin Brand Name: Levox 750mg/tab 1tab OD

Inhibit the bacterial DNA synthesis by inhibiting DNA gyrase. THERAPEUTIC EFFECTS: Death of susceptible bacteria. PHARMACOLOGIC ACTION: fluoroquinolones

Treatment of bacterial infections such as respiratory tract infection.

Assess for infection (vital signs; appearance of wounds, sputum, urine, and stool; WBC; urinalysis; frequency and urgency of urination; cloudy or foul-smelling urine) prior to and during therapy. Obtaining specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results.

Generic Name: trimetazidine Brand Name: Vastarel Mr 35mg /tab 1tab BID

Reduces the metabolic damage caused during ischemia, by acting on a critical step in cardiac metabolism: fatty acid -oxidation.

IX. Nursing Management Assessment Subjective:

Dyspnea

Objectives: The patient manifested the following:

Tachypnea RR of 28

The patient may manifest the following:

Planning Nursing Intervention After 1-2 hours of nursing Monitor and record interventions the vital signs patient will demonstrate R. To obtain appropriate baseline data coping behaviors and methods to Provide relaxing improve environment breathing pattern. R. To promote adequate rest periods to limit fatigue Assist client in the use of relaxation technique R. To provide relief of causative factors

Evaluation After 1- 2 hours of nursing intervention the patient has demonstrate improve breathing pattern because he was able to answer the questions that was being asked to him.

Pallor skin Orthopnea

Nursing Diagnosis: Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea, and dyspnea

Administer prescribed medications as ordered R. For the pharmacological management of the patients condition Encourage adequate rest periods between activities R. to limit fatigue

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

maximum dosage as needed. R: To maintain acceptable level of pain.

Imbalanced Nutrition: Less than body requirements

Assessment Subjective Objective: Weight before hospitalization: 50 kg Height: 165 cm BMI: 18.4 Weight: 45 kg Height: 165 cm BMI= 16.5 Underweight: <18.5 Diagnosis: Imbalanced Nutrition: Less than body requirements related to absence of physical conditions that would explain

Planning After 1-2 hours of nursing the patient and his relatives will be able to verbalize and demonstrate ways of nutritional status, food and fluid intake and weight control

Intervention Record the patients weight and height on intake. Weigh regularly, maintaining standard conditions R: This ensures accurate record of weight changes. Conduct a nutritional assessment R: It is critical that the health care provider openly discuss and have an understanding of the complex food and weight-

Evaluation After 1-2 hours of nursing the patient and his relatives has able to verbalize and demonstrate ways of nutritional status,food and fluid intake and weight control

weight loss or prevent weight gain.

related behaviors of the patient so that appropriate supports can be integrated into the treatment plan. Assess cardiovascular, metabolic, renal, gastric, hematological, and endocrine system functioning. R: Assessment provides data on the severity of malnutrition.

Monitor intake (i.e., daily food plans that track eating trends along with emotional states and triggering events). Record intake and output for the hospitalized patient. R: These data help determine the patients actual caloric intake and eating behaviors.

Activity Intolerance

Assessment

Planning

Intervention

Evaluation

Subjective: nahihirapan ako gumalaw dahil masakit ang tagiliran koas verbalized by the patient. Objectives: - Body weakness Limited range of motion. Unable to get up to go to the bathroom

After 1-2 hours of nursing interventions, the patient will use identified techniques to improve activity intolerance

Independent: *Note client reports of weakness, fatigue, pain. R: Symptoms may be result of/or contribute to intolerance of activity. Provide the patient with a calm and quiet environment R: To provide relaxation *Promote comfort measures and provide for relief of pain. R: to enhance ability to participate in activities. *Plan for maximal activity within the clients activity. R: to determine current status and needs associated with participation in needed or desired activities

The patient shall have used identified techniques to improve activity intolerance

Nursing Diagnosis: Activity intolerance related to insufficient oxygen, generalized weakness and complete bed rest.

Risk for Infection

Assessment Subjective none Objective *T- 36.5 *P- 73bpm *R- 27bpm *BP- 90/70 mmHg *S/P CTT Insertion *With CTT connected to one way water sealed bottle *With dry and intact dressing on operative/insertio n site Diagnosis: Risk for infection related to tissue trauma secondary to surgical procedure ( CTT and appendectomy)

Planning After 2-3 hours of nursing intervention the patient and his relatives will be able to verbalize and demonstrate ways in preventing infection specifically proper hand washing, proper wound care and water-sealed drainage bottle

Intervention Independent Monitor vital signs and records R: To provide baseline data for comparison. Elevation in rates may signal infection Assess insertion site for signs of infection R: To check for skin integrity and identify need for further management Assess patency and intactness of water sealed bottle R: Any obstructions and kink may delay flow. Absence of fluctuations and excessive bubbling may indicate leaks Monitor and record amount and characteristics of drainage R: Increase amount s of drainage may signal worsening condition Provide regular wound dressing and tube care R: To promote comfort and hygiene. To prevent growth of microorganisms in dressings, tube Change linens and pts robes R: To promote comfort and hygiene. To prevent growth of microorganisms in linens and robes

Evaluation After 2-3 hours of nursing intervention the patient and his relatives has able to verbalize and demonstrate ways in preventing infection specifically proper hand washing, proper wound care and water-sealed drainage bottle

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

Hygiene: Educate patient on the proper self hygiene techniques to prevent any further complications. Like brushing teeth to avoid any further infections. Out Patient: Remind patient about upcoming check ups needed to increase the patients health. Also advice patient about any further appointments that need to be made. Educate the patient about physical limitations and the time needed to make a full recovery before resuming normal activates before hospitalization. Diet: low sodium and low fat diet. Avoid foods that will cause constipation and strain during bowel movements. Stick to a soft diet to ease the digestion process. To avoid any further complications with the patients condition. Spiritualism joining to some activities like bible studies and attending events to further develop the clients condition after being discharged from the hospital.

Prognosis The clients prognosis is not that good though he is showing some progress like being able to communicate well to the relatives and nurses, able to move on his own and even smiling while talking even though he is suffering from pain. After having been admitted at WCMC, the patient is more comfortable and showed an increase in sense of energy and communication.