Republic of the Philippines University of Northern Philippines Tamag, Vigan City

College of Nursing

A Case Study on Pleural Effusion In partial fulfilment Of the requirements Of the course

NCM 102 Nursing Care Management: Curative and Rehabilitative Nursing Care Related learning Experience Hospital Duty

Presented to: JEVIE A. ABELLA, R.N., MAN Clinical Instructor

Presented by: Celedonia Bravo BSN-III DAFFODIL

JANUARY 2012 1

TABLE OF CONTENTS PAGE I. II. III. IV. V. FRONTPAGE TABLE OF CONTENTS GRADING SHEET INTRODUCTION AND OBJECTIVES PATIENTS PERSONAL DATA (NURSING HISTORY OF PAST AND PRESENT ILLNESS) VI. VII. PEA/RSON ASSESSMENT DIAGNOSTIC PROCEDURE A. Actual B. Ideal VIII. PATHOPHYSIOLOGY A. ALGORITHM B. EXPLANATION IX. MANAGEMENT A. MEDICAL-SURGICAL Actual Ideal i ii iii

B. NURSING CARE PLAN C. PROMOTIVE AND PREVENTIVE X. XI. XII. XIII. XIV. DRUG STUDY DISCHARGE PLAN UPDATES ORGANIZATION BIBLIOGRAPHY

I. INTRODUCTION AND OBJECTIVES

Potts disease is apresentation of extrapulmonary tuberculosis that affects the spine, akind of tuberculous arthritis of the intervertebral joints. Scientifically, it is called tuberculous spondylitis. Potts disease is the most common site of bone infection in TB; hips and knees are also often affected. Potts disease, which is alsonown as Potts caries, Davids disease, and POtts curvature, is a medical condition of the spine. Individuals suffering from Potts disease typically experience back pain, night sweats, fever, weight loss, and anorexia. They may also develop a spinal mass, hich results in tingling, numbness, or a general feeling of weakness in the leg muscles. Often, the pain associated with Potts disease causes sufferer to walk in an upright and stiff position. Potts disease is caused when the vertebrae become soft and collapsed as a result of caries or osteitis. Typically,this is cause by mycobacterium tuberculosis. As a result, a person with Potts disease often develops kyphosis, which results in a hunchback. This is often referred to as Potts curvature. In some cases, a person with Potts disease may also develop paralysis, referred to as Potts paraplegia. The above information overviews the present condition of patient Jane, 5 years old, who was admitted at Philippine Orthopedic Center last March 21, 2012 at 12:55 PM and was placed in Childrens ward cubicle 6. Her chief complaint was a 1 week-old poor healing wound on her left foot. After thorough physical and medical history assessment, the physician concluded on her diagnosis that the patient has Type 2 Diabetes Mellitus as evidenced by the diagnostic procedures done earlier. This study was under the consent of the said patient, thus all of the data used in this study are under legal circumstances. The data were gathered through an assessment conducted last November 20, 2011. Nursing interventions were rendered limitedly within the shift. This case study was organized having the following objectives: To expand knowledge regarding Pleural Effusion To gather appropriate and sufficient data to trace the history of the present illness To be able to make a PEA/RSON Assessment To know about the different diagnostic procedures ideally performed to patients with this condition To be able to formulate different management of the condition To study about the drugs prescribed to treat the condition To be able to plan a rehabilitative management upon discharge To be aware of the new advances, researches, studies and updates regarding the condition To evaluate effectiveness of the study

PATIENTS PERSONAL DATA NAME: Patient X GENDER: Female CIVIL STATUS: Child AGE: 5 y/o ADDRESS: Gate 58Area H, Parola, Binondo Manila DATE OF BIRTH: May 9, 2006 NATIONALITY: Filipino RELIGION: Roman Catholic INSTITUTION: Philippine Orthopedic Center WARD: Childrens Ward, Cubicle 6 ATTENDING PHYSICIAN: Dr. Velasco DATE AND TIME OF ADMISSION: March 21, 2012 at 12:55 PM DATE AND TIME OF DISHARGE: TOTAL NUMBER OF DAYS: CHIEF COMPLAINT: mass at low back area,weakness of both lower extremities ADMITTING DIAGNOSIS: T/C Potts Disease R/O new growth FINAL DIAGNOSIS: HISTORY OF PAST ILLNESS: According to the patient, her common illness was cough and colds. No home treatment was provided. Last September 28, 2008, she underwent a Cesarean Section (Low Transverse), done by Dr. Trillanes, on her first baby at Gabriela Silang General Hospital due to postmaturity. The underlying condition of the baby was pathologic jaundice. The baby underwent phototherapy for 7 days. The patient took home medications particularly Cefuroxime and Mefenamic Acid for a week. Fortunately, the patient did not suffer from any complications after the operation. She was not using any family planning method then. She has neither obstetric nor gynaecologic nor history of illness nor familial history of hypertension, renal dysfunction and diabetes mellitus. Pt. couldnt remember her immunization status. HISTORY OF PRESENT ILLNESS: Twelve months prior to admission patient X while playing fall to the ground hitting her back on a cemented edge. Initially, the mother failed to consult a doctor and give medication to her child because of financial constraints. 9 months ago patient X started to Experience low back pain incuding weakness of both lower extremities and frequent cough relieved by salbutamol prescribed at Parola Local Health Center. No medical consult regarding her back symptoms. Five months ago the mother noticed the increasing size of mass prompted her to consult at St. Paul Hospital where X-ray done and was referred to Spinal Orthopedic but patient wasnt able to seek consult. On March 21 patient was brought at dr. Chan tabiljes Clinic and referred her to Philippine Orthopedic Center. PEA/RSON ASSESSMENT 1ST DAY 4

P (personal)

(November 30, 2010) Patient X, a 5 year-old child, is a patient suspected with Potts disease, residing at Binondo, Manila Youngest among her 3 siblings a Roman Catholic cheerful and talkative initiative vs guilt prefers birth spacing conscious and coherent, but fair in appearance with a 5 day-old LTCS incision scar with noted presence of firm mass at low back area has no bowel movement during the shift does not use any laxative voided twice at approximately 150 cc, yellow and clear, during the 4-hour shift no IFC inserted often lying on bed voiding in a bed pan cannot sleep well due to poorly ventilated ward and giving of meds no allergies to medications and food with an axillary temperature of 37.8 C admitted at OB Childrens Ward the bed was with side rails but sometimes have no companion the ward is poorly ventilated wears clean clothes that fit her size has a respiratory rate of 15 cpm, shallow and regular no dyspnea observed the ward is not well ventilated with good skin turgor febrile with an initial temperature of 37.8 C with no O2 supply inserted received on bed without IVF inserted on DAT diet with poor appetite encouraged to eat foods rich in calcium and vitamin D for stronger bones

(psychosocial) (psychosexual) (physical) E

A/R

DIAGNOSTIC PROCEDURE IDEAL EXAMINATION Radiography Radiographic changes associated with Potts disease present relatively late. The following are radiologic changes characteristic of spinal tuberculosis on plain radiography. Lytic destruction of anterior portion of vertebral body Increased anterior wedging Collapse of vertebral body Reactive sclerosis on progressive lytic process Enlarged psoas shaow with or without calcification Additional radiographic findings may include the following: Vertebral end plates are osteoporotic. Intervertebral disks may be shrunk or destroyed. Vertebral bodies show variable degrees of destruction. Fusiform paravertebral shadow suggest abscess formation. Bone lesions ay occur at more than 1 level

CT Scanning Providesmuch better bony detail irregular lytic leions, sclerosis, disk collapse, and distruption of bone circumference. Low contrast resolution provides better assessment of bone tissue, particularly in epidural and paraspinal areas. Ct scanning reveales early lesions and is more effective for defining the shape and calcification of soft tissue bscesses. MRI Is the criterion standard for evaluating disk-space infection andosteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissues and the spread of tuberculous debris under anteriorand posterior longtitudinal ligaments. MRI is also the most effective imaging study for demonstrating neural compression. Percutaneous CT-guided needle biopsy This is a safe procedure that also allows therapeutic drainage of large paraspinal abscess. Obtain a tissue sample of microbiology and pathology studies to confirm diagnosis

Complete Blood Count. This is used as a broad screening test to check for disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood which includes the following (Lab Test Online):

White blood cell (WBC) count is a count of the actual number of white blood cells per volume of blood. Both increases and decreases can be significant.

White blood cell differential looks at the types of white blood cells present. There are fivedifferent types of white blood cells e.g., neutrophils, lymphocytes, monocytes, eosinophil, and basophils. Each has its own function in protecting us from infection.

 Red blood cell (RBC) count. It is a count of the actual number of red blood cells per volume of blood. Both increases and decreases can point to abnormal conditions.

Hemoglobin measures the amount of oxygen-carrying protein in the blood.

Hematocrit measures the percentage of red blood cells in a given volume of whole blood.

The platelet count is the number of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting. Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow.

Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs. The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemia.

Mean corpuscular haemoglobin (MCH) is a calculation of the average amount of oxygen-carrying haemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a higher MCH, while microcytic red cells would have a lower value.

Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are seen in conditions where the hemoglobin is abnormally concentrated inside the red cells, such as in burn patients and hereditary spherocytosis, a relatively rare congenital disorder. Red cell distribution width (RDW) is a calculation of the variation in the size of your RBCs. In some anemias, such as pernicious anemia, the amount of variation (anisocytosis) in RBC size (along with variation in shape poikilocytosis) causes an increase in the RDW.
ACTUAL EXAMINATION A. Complete Blood Count PARAMETER Hematocrit Leukocytes Monocytes Eosinophils Platelet count RESULT L L H N H .29 0.27 0.14 0.3 727 NORMAL VALUE 0.31-0.54 0.31 0.10 0.3 698 7

MCV MCH MCHC

L L L

81Fl 25 pg 31

82-92 28-32 32-38

INTERPRETATION: WBC is above normal value, which is indicative of an infection. GRAN # is above normal value, which is also indicative of an infection. HGB is below normal value, which implies that there is a bone marrow problem or hypoxia. HCT is below normal level, which indicates anemia or polycythemia. MVC and MCH is below normal range, which is actually derived from Hct and RBC count. This implies disorder such as anemia. MCHC is below normal range, which is derived from hgb and hct count. This indicates hypoxia, anemia, and others. RDW-CV is above normal range, which implies possible blockage of arteries. MPV is below normal range, which indicates clotting disorder.

B. URINALYSIS PARAMETERS Color Specific Gravity Sugar Protein Pus cell Red cell Date: 11/26/10 Time: 4:56 pm INTERPRETATION: Color is Normal. Specific gravity is within normal range. There is no Sugar in the urine, indicating negative for glucosuria. There is no Protein in the urine, indicating negative proteinuria. Pus cell is within normal range, indicating negative pyuria. There is no presence of Red cell in the urine, indicating negative hematuria. RESULT Yellow 0.015 Negative Negative 2 Negative NORMAL RESULT Yellow 0.010 0.025 Negative Negative 13 Negative

PATHOPHYSIOLOGY OF PLANNED REPEAT CESAREAN A. ALGORITHM

B. EXPLANATION

Pleural effusion is an indicator of an underlying disease process that may be pulmonary or non-pulmonary in origin, acute or chronic. Normally, pleural fluid has the following characteristics: Clear ultrafiltrate of plasma that originates from the parietal pleura pH 7.60-7.64 protein contain less than 2% (1-2g/dL) fewer than 1000 WBCs per cubic millimetre glucose contain similar to that of plasma lactate dehydrogenase (LDH) less than 50% of plasma sodium, potassium and calcium concentration similar to that of the interstitial fluid Excess pleural fluid can either be in the form of exudate and transudate. Exudate, is a protein-rich fluid, developed when the blood vessels leak caused by inflammation of the pleura and when the patient is having infection or systemic inflammation. Transudate on the other hand, is formed when the pressure is high or plasma protein content is low in the blood vessels, the fluid leaks into the pleural space. It is commonly caused by heart failure and may also accompany renal failure, nephritis, liver failure and malignancy. Moreover, the following processes play a role in the increased production of pleural fluid: Altered permeability of the pleural membranes(e.g., inflammation, malignancy, pulmonary embolus)

Reduction in intravascular oncotic pressure(e.g., hypoalbuminemia, cirrhosis)

Increase capillary permeability or vascular disruption(e.g., trauma, malignancy, inflammation, infection, pulmonary infarction, drug hypersensitivity, uraemia, pancreatitis)

Increase capillary hydrostatic pressure in the systemic and/or pulmonary circulation (e.g., CHF, superior vena cava syndrome)

Reduction of pressure in the pleural space, preventing full lung expansion(e.g., extensiveatelectasis, mesothelioma)

Decrease lymphatic drainage or complete blockage, including thoracic duct obstruction or rupture (e.g., malignancy, trauma) Increase peritoneal fluid, with migration across the diaphragm via lymphatic or structural defect (e.g., cirrhosis, peritoneal dialysis) 9

Movement of fluid from pulmonary oedema across the visceral pleura

Persistent increase in pleural fluid oncotic pressure from an existing pleural effusion, causing for the fluid accumulation The net result of the effusion formation is a flattening or inversion of the diaphragm, mechanical disassociation of the visceral and parietal pleura, and a restrictive ventilatory defect. Possible Signs and Symptoms The most common manifestations, regardless of the type of fluid in the pleural space or its causes, are shortness of breath and chest pain because of large pleural effusion that compresses the adjacent lung tissue. However, some people with pleural effusion have no symptoms at all. When the parietal pleura is irritated, the patient may have mild pain that quickly passes or, sometimes, a sharp, stabbing pleuritic type of pain. Pain is often relieved by formation of an effusion, as the fluid reduces friction between inflamed visceral and parietal pleura. Some patients also will have a dry and unproductive cough. Tapping on the chest will show that the usual crisp sounds have become dull, and on listening with a stethoscope the normal breath sounds are muted. If the pleura is inflamed, there may be a scratchy sound called a pleural friction rub." Table 2. Possible and Actual Signs and Symptoms POSSIBLE ACTUAL COMPLAINT OF THE PATIENT Dyspnoea

Dry and unproductive cough Pleuritic pain Orthopneic Dyspnoea Sore throat

Dullness over chest wall

Productive cough

Decreased or absence of breath sound Pleural friction rub REFERENCE: Adele Pillitteri, Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family , 6th Edition, Vol. 1

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MANAGEMENT A. Ideal

Thoracentesis. A procedure is used to remove fluid from the space between the lungs and the chest wall called the pleural space. It is done by inserting a needle (sometimes a plastic catheter) into the chest wall and the pleural fluid is aspirated. The procedure is performed to remove the fluid, prevent the fluid from building up again and treating the cause of the fluid build-up. Under Water Seal Drainage (also called Chest Tube/Chest Drain/Tube Thoracostomy/Intercostal Drain) is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air (pneumothorax) or fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space(Wikipedia). Chest tubes are normally inserted under a local anaesthetic or under a general anaesthetic if the patient is undergoing chest surgery. The two common complications are the risk of infection and pain. Good hygiene practices including hand washing before contact with the patient will help minimize the infection risk.

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There can be a degree pain of which differs from patient to patient and should be discussed with the concern doctors and nurses. Pleurectomy (also known as recurrent pleural effusion). Thisis a surgical procedure to remove part of the pleura, the lining around the lungs. It is usually done to treat mesothelioma, a rare form of lung cancer most often related to asbestos exposure. It is performed under general anaesthesia. An incision is made above the affected area and the pleural layers are removed. Additional affected lung tissue may also be removed during the surgery. Stitches are made once the surgery is complete and the incision is cleaned and bandaged.
Pleurectomy/decortication: Appearances of the decorticated lung after the visceral and parietal pleurae have been resected (with diaphragm intact).

There is a risk for bleeding or infection after a pleurectomy. Patients should be on the lookout for symptoms like fever, drainage from the incision, or redness and swelling around the area of the incision. Once the patient returns home, he or she can usually resume normal activity within a week. It may take longer to gain the energy to perform vigorous tasks.

B. Actual REFERENCE: Adele Pillitteri, Maternal and Child Health Nursing Care of the Childearing and Childrearing Family, 6th Edition, Vol. 1, pg. 664-670.

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A. NURSING CARE PLAN CUES SUBJECTIVE: Medyo nasakit payla toy dait ko ngem kayak met nga tiisin. OBJECTIVE: presence of facial grimace and guarding behaviour whenever attempting to move diaphoresis with pain scale of 7/10 presence of surgical incision on the abdomen poor appetite initial V/S taken as follows: T 37.8 C NURSING DIAGNOSIS P - Acute pain E - r/t surgical trauma secondary to incision from caesarean section S as evidenced by the presence of facial grimace and guarding behaviour whenever attempting to move; diaphoresis; pain scale of 7/10; presence of surgical incision on the abdomen; poor appetite; hyperthermia with T of 37.8 C; tachycardia with PR of 108 bpm; and pts verbalization SCIENTIFIC BACKGROUND Local tissue damage from the incision site Initiation of nociceptors to respond to noxious stimulus Transmission of nerve impulses to the brain Pain sensation is experienced Increased metabolic rate GOAL/OBJECTIVES Date:11/30/10 Shift: 7 AM - 3 PM Time: 8:00 AM GOAL: After 5 hours, the pt will verbalize pain relief and demonstrate relaxation/ diversional activities OBJECTIVES: After 5 hours, facial grimace and guarding behaviour will decrease from frequent to moderate sweating will decrease pain scale will decrease to 4/10 appetite will increase T will decrease within 36.5-37.5 C pt will INTERVENTIONS INDEPENDENT: Established rapport Performed bedside care Obtained initial V/S Performed assessment of pain to include characteristic, location, frequency, duration, and severity of pain Noted location of surgical procedure Monitored V/S Provided TSB and increased hydration Instructed RATIONALE to gain the trust of the pt to enhance pts self-esteem and provide comfort to have a baseline data pt. may not verbalize pain and discomfort EVALUATION Date: 11/30/10 Shift: 7 AM 3 PM Time: 1:00 PM GOAL MET as evidenced by: facial grimace and guarding behaviour decreased sweating decreased pain scale decreased to 4/10 appetite increased with 2 cups of rice taken V/S stabilized within normal range and taken as follows: T- 37.2 C P- 94 bpm R- 20 cpm BP- 120/80 mmHg Pt 13

Diaphoresis Increased V/S REFERENCE: Suzanne C. Smeltzer, et. al.,

as this could influence to the severity of postoperative pain experienced Pain may increase temperature, PR and BP to relieve fever which may increase severity of pain to facilitate circulation and to relax muscles;

P 108 bpm R 20 cpm BP 120/80 mmHg

Brunner and Suddharths textbook of Medical-Surgical Nursing, 10th Edition, Vol 1, pg. 256

demonstrate 2/2 relaxation/ diversional activities

relaxation techniques such as focused breathing and repositioning such as splinting

Encouraged diversional activities such as chatting with significant others/other pts Opened the windows

Splinting reduces strain and stretching of incisional area and lessens pain and discomfort associated with movement of abdominal muscles. to and divert attention away from painful sensation pain can be eased through good ventilation NSAID can be used to relieve pain

demonstrated 2/2 relaxation/ diversional activities

DEPENDENT: Administered Mefenamic Acid 500 mg tablet PO, TID COLLABORATIVE: Monitored laboratory results

To determine progress of condition and obtain cues related to pts diagnosis.

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NURSING DIAGNOSIS Subjective: P- Impaired tissue Naut-ot payla integrity toy dait ko E- r/t mechanical trauma of Objective: surgical removal has a LTCS of skin and incision subcutaneous noted tissue secondary presence of to caesarean redness in the section incision site S- as evidenced noted by a LTCS presence of incision; swelling in the presence of incision site redness and has binder for swelling in the the incision incision site; and pts verbalization CUES

SCIENTIFIC BACKGROUND Planned repeat Cesarean section Abdominal and Uterine incision Destruction of skin layers Initiation of wound healing Occurrence of the cardinal signs Presence of redness(rubor) in the incision site Sensation of heat(calor) in the incision site Swelling(dolor) is observed Pain(tumor)

GOAL/OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION Date: December 17, 2010 Time 11:00 am

Date: 11/30/10 INDEPENDENT: Shift: 7:00 am 3: 00 Established pm rapport Time: 8:00 am Performed GOAL: bedside care After 2-3 weeks of rendering nursing Noted evidence interventions, the pt of tissue will display behaviour involvement and lifestyle changes Obtained history to promote healing of condition and prevent including color, complications; and smell, location will demonstrate and consistency timely wound healing. Rewrapped binder OBJECTIVES: redness in the incision site will decrease swelling in the Encouraged incision site will adequate rest decrease and sleep pt will enumerate Provided position 2/2 lifestyle changes such as changes and will sitting and lying apply them in the alternately after course of breastfeeding recovery Emphasized the importance of

to gain the trust of the pt to enhance pts self-esteem and GOAL MET as provide comfort evidenced by: to determine decreased which tissue is redness in the affected incision site to know the decreased progress of the swelling in the condition and incision site have a baseline pt enumerated data to plan for 2/2 lifestyle nursing changes and interventions applied them in to prevent the course f stretching of the recovery tissue which could pt verbalized, increase ok metten destruction and adding. pain discomfort Lumalaingen. to meet comfort needs to facilitate circulation and prevent excessive tissue pressure fiber promotes tissue healing and 15

sensation REFERENCE: Elaine Marieb, Anatomy and Physiology 9th Edition, pg. 463

adequate nutrition intake especially food rich in fiber and iron such as vegetables and red meat Encouraged skin hygiene

iron enhances clotting factor

Provided health teaching on wound dressing during home visits (addendum) DEPENDENT: Administered Cefuroxime 500 mg PO TID x 7 days COLLABORATIVE: Monitor laboratory results

Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. to motivate the pt for self-care

antibiotic can prevent postoperative complication

to determine changes indicative of healing; blood component can 16

be a determinant

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B. PROMOTIVE AND PREVENTIVE INTERVENTION FOR PLANNED REPEAT CESAREAN

Since the patient is post-CS, she is more likely experiencing acute pain and discomforts d/t skin tissue trauma. Likewise, an incision wound is present. Basically, postop patients are at higher risks of acquiring communicable diseases, infections and complications. Therefore, the focus of the promotive interventions is to ease post-operative pain and lessen discomfort. Promotion also includes wound healing and scar treatment. On the other hand, preventive interventions focus on the protection against communicable diseases and infections; and prevention of further complication related to underlying conditions. PROMOTIVE: Pain Management: Take analgesics such as Mefenamic acid to reduce the pain. Wound Treatment: Placing a hand firmly on the wound when you cough or move will counteract this pressure and reduce the pain. The pain is also due to tissue trauma therefore it may be necessary to take some painkillers. Keep the wound dry until any stitches are removed (normally about 7 days) so no bathing allowed. Use cotton dipped in salt water to soak and remove the scabs. Salt water also helps healing and reduces itching when the wound is healing. To help the wounds heal quickly, do not eat ginger for the first 10 days. After 2 weeks, massage the wound with vitamin E oil to prevent keloid formation. Do not worry if the wound feels itchy even after many weeks or months. Scar Treatment: Eating a diet rich in fruits and vegetables, which may help facilitate the healing process. Aloe vera (aloe barbadensis) and cucumber (curcumis sativus) can also be used directly on the targeted area to soothe and promote healing. PREVENTIVE: Take antibiotics such as Cefuroxime to prevent infection. Take extra vitamin C to boost immune system. Such foods are fruits including oranges, guavas and others. Observe overall hygiene to eliminate microorganisms that may cause a disease. Observe proper wound cleaning to prevent wound infection. Observe proper perineal care to prevent urinary tract infection which is very common among post-CS patients.

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DRUG STUDY NAME/CLASS 1. Cefuroxime (Antibiotic) DOSAGE/ROUTE 1.5 mg IV q8 (11/26/10) 500 mg tablet PO, TID (11/29/10) MECHANISM OF ACTION Bactericidal Inhibits synthesis of bacterial cell wall, causing cell death INDICATION ORAL/ PARENTERAL UTI caused by E. Coli, K. Pneumonia CONTRAINDICATION Contraindicated with allergy to cephalosporins or penicillins Use cautiously with renal failure, lactation, pregnancy ADVERSE EFFECTS CNS: headache, dizziness, paresthesia GI: nausea, vomiting, diarrhea, abdominal pain, flatulrnce GU: nephrotoxicity LOCAL: pain, abscess at injection site, inflammation at injection site NURSING RESPONSIBILITY ASSESSMENT: History: hepatic and renal impairment, lactation, pregnancy Physical: skin status, renal function test, ANST INTERVENTIONS: Give oral drug with food to decrease GI upset and enhance absorption Discontinue if hypersensitivity reaction occurs TEACHING POINTS: ORAL: Take full course of therapy even if feeling better Swallow the tablet whole; do not crush; take with food May experience diarrhea Report unusual effects PARENTERAL: Avoid alcohol while taking these drug May experience 19

2. Tramadol HCl (Analgesic)

50 mg IV q4 x 4 doses (11/26/10)

Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin

Relief of moderate to moderately severe pain Relief of moderate to severe chronic pain in adults who need around-theclock treatment for extended periods

Contraindicated with allergy to tramadol or opioids or acute intoxication with alcohol opioids, psychoactive drugs Use cautiously in pregnancy: lactation, seizures, renal and hepatic impairment

CNS: dizziness/vertigo, headache CV: hypotension, tachycardia, bradycardia DERMATOLOGIC: sweating, rash, pruritus, pallor, urticaria GI: nausea, vomiting, constipation, flatulence

3. Mefenamic Acid (NSAID)

500 mg tablet PO, TID (11/29/10)

Anti-inflammatory, analgesic and antipyretic activities related to inhibitin of prostaglandin synthesis

Relief of moderate pain when therapy will not exceed 1 wk

Contraindicated with hypersensitivity to mefenamic acid Use cautiously with renal and hepatic impairment,

CNS: headache, dizziness, insomnia, fatigue, tinnitus DERMATOLOGIC: rash, pruritus, sweating, dry mucous membrane

diarrhea Report unusual effects ASSESSMENT: History: hypersensitivity to tramadol, renal and hepatic impairment Physical: skin color, lesion,srenal function test INTERVENTIONS: Control environment if sweating or CNS effects occur TEACHING POINTS: May experience these side-effects: dizziness, drowsiness, nausea, loss of appetite Report severe nausea, severe dizziness and severe constipation ASSESSMENT: History: allergy, renal and hepatic impairment, pregnancy, lactation Physical: skin color and lesions, CBC, renal function test INTERVENTIONS: 20

pregnancy, lactation, hypertension

GI: nausea, dyspepsia, diarrhea, vomiting, constipation, flatulence GU: dysuria RESPIRATORY: dyspnea, hemoptysis, rhinitis

Give milk or food to decrease GI upset TEACHING POINTS: Take drug with food; follow the prescribed dosage; do not take beyond 1 wk Discontinue if rash, diarrhea or digestive problems occur

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DISCHARGE PLAN

A. Medication Comply with the treatment regimen. Use medication as ordered and complete the entire prescription. Provide schedule as when to take the medication. Do under dose or overdose by cutting breaking the medicine using hands. This will lessen the efficacy of the medicine and will only prolong the disease process. B. Exercise Exercise keeps you healthy. It is good for the heart and lungs and promotes blood circulation. Start with range of motion (ROM) exercises, it is a good choice e.g., stretching and flexing the joints. Decrease activities if you feel pain and tired. Do deep breathing and coughing exercise to lessen the pain sensation and promote lung expansion. Do it gradually. Ask your doctor to help you plan the best exercise program for you. It is best to start slowly and do more as you get stronger. C. Treatment Treatment of pleural effusion is always based on the underlying condition and whether the effusion is causing symptoms like difficulty in breathing or SOB. However, removal of fluid is always the first choice if fluid build-up is in large volume, preventing it from accumulating again and or addressing the underlying cause of the fluid build-up. Removal of fluid promotes lung expansion and easy breathing. D. Health Teaching Good personal hygiene is very important factor in daily living to keep us from getting infection. Hand washing. Correct technique must be applied especially after using the bathroom and before eating any food. Hand washing still the most effective way of eliminating microorganisms. Shower daily. Keep yourself clean daily to prevent accumulation of microorganisms on your skin. Use a deodorant spray instead of antiperspirant. Antiperspirants block sweat glands which can cause an infection. Brush teeth two to three times a day.Oral hygiene is the most effective way in preventing the spread of infection. Perineum care. Clean perineum area properly each time you pass urine and bowel. E. Follow-up Care He was advised to come to hospital after 1 month time for regular check-up. Follow other medical appointmentin orthopaedic clinic and IJN. He was informed that regular check-up isnecessary to help ensure that any changes in his health are noted and treated if needed. If any health problems between check-ups are encountered, contact his doctor immediately or come to the hospital.
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F. Diet Limit intake of food loaded with salt e.g., salted fish, eggs, sauces, seasoning and vegetables. Salt causes water retention in people with heart failure and result to edema in lungs, ankles, and abdomen. Be smart in buying food, read label of nutritional value in packed food. Eat variety of healthy foods from all the food groups e.g., whole grains, green leafy vegetables, apples, soy,oats, olive oils, salmons and almonds Eating healthy foods may help you feel better and have more energy. You may need to make diet changes depending on your underlying diseases. Eat small-frequent meal and snacks rather than 1 big meal to boost your metabolism.

Drink Fluids:Restrict fluid intake from 800 1000 mls. per day or as prescribed by your physician to avoid fluid overload which causes SOB and dyspnea. Choose healthy like water, fresh fruit juices, and milk rather than caffeinated/carbonated drinks which is loaded with sugar. Rest:Limit your activities in a day to reduce oxygen consumption.

G. Seek Care Immediately If You Have: Pleuritic pain. An early signs of effusion. Trouble breathing. Increasing dyspnea or SOB Cough and hemoptysis

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UPDATES RELATED TO PLANNED REPEATED CESAREAN Early Planned C-Sections Put Baby at Risk Study Shows 36% of Planned C-Sections Are Performed Before 39 Weeks of Gestation Jan. 7, 2009 -- More than a third of babies born by planned, repeat C-section in the U.S. are delivered before 39 weeks gestation, and these babies are at increased risk for birth-related health problems as a result, a study shows. These days, nearly one in three births in the U.S. is a cesarean delivery, up from around one in five births in the mid-1990s. The increase is largely because far fewer women who have had C-sections are attempting vaginal births for subsequent pregnancies. National figures show that 40% of the 1.3 million cesarean deliveries performed each year in the U.S. are repeat procedures and the majority of these are planned. In the absence of medical need, planned, elective C-section before 39 weeks gestation is not recommended by the American College of Obstetrics and Gynecology (ACOG), unless testing shows that the baby's lungs are mature enough for delivery. Due Date Minus 7 The new study shows that 36% of planned cesarean births were performed before 39 weeks. Researchers tracked more than 24,000 repeat C-section deliveries performed at 19 of the nation's top teaching hospitals. They found that: Just under one in three deliveries (29.5%) was performed at 38 weeks and 6% were performed at 37 weeks. Babies delivered in their 37th or 38th week had a higher incidence of birth-related adverse outcomes, including respiratory problems and sepsis (serious infection), than babies delivered in their 39th week. Compared to babies delivered during their 39th week, babies born between 38 and 39 weeks gestation had up to double the risk of adverse birth-related complications; babies born between their 37th and 38th weeks had up to a fourfold increase in risk.

The study appears in the Jan. 8 issue of the New England Journal of Medicine. "There appears to be a window of safety that is smaller than has generally been thought," obstetrics professor and study co-author John M. Thorp, MD, of the University of North Carolina, Chapel Hill tells WebMD. "A woman's due date minus seven days seems to be the optimal time for a planned C-section." Alan Tita, MD, PhD, who led the research team, tells WebMD that the number of women in the U.S. who are having early, planned C-sections may be even higher than the study suggests. That's because the women in the study gave birth between 1999 and 2002, and the rate of cesarean deliveries has increased since then.

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REFERENCE: http://www.webmd.com/baby/news/20090107/early-planned-c-sectionsput-baby-at-risk

REACTION:

New policy aims to cut repeat C-sections Obstetricians ease 'once a cesarean, always a cesarean' restrictions WASHINGTON Most women who've had a C-section, and many who've had two, should be allowed to try labor with their next baby, say new guidelines a step toward reversing the "once a cesarean, always a cesarean" policies taking root in many hospitals. Wednesday's announcement by the American College of Obstetricians and Gynecologists eases restrictions on who might avoid a repeat C-section, rewriting an old policy that critics have said is partly to blame for many pregnant women being denied the chance. Fifteen years ago, nearly 3 in 10 women who'd had a prior C-section gave birth vaginally the next time. Today, fewer than 1 in 10 do. Last spring, a National Institutes of Health panel strongly urged steps to reverse that trend, saying a third of hospitals and half of doctors ban women from attempting what's called VBAC, for "vaginal birth after cesarean." The new guidelines declare VBAC a safe and appropriate option for most women now including those carrying twins or who've had two C-sections and urge that they be given an unbiased look at the pros and cons so they can decide whether to try. Women's choice is "what we want to come through loud and clear," said Dr. William Grobman of Northwestern University, co-author of the guidelines. "There are few times where there is an absolute wrong or an absolute right, but there is the importance of shared decision-making." Overall, nearly a third of U.S. births are by cesarean, an all-time high. Cesareans can be lifesaving but they come with certain risks and the more C-sections a woman has, the greater the risk in a next pregnancy of problems, some of them life-threatening, like placenta abnormalities or hemorrhage. The main debate with VBAC: That the rigors of labor could cause the scar from the earlier surgery to rupture. There's less than a 1 percent chance of that happening, the ACOG guidelines say. Also, with most recently performed C-sections, that scar is located on a lower part of the uterus that's less stressed by contractions. Of those who attempt VBAC, between 60 percent and 80 percent will deliver vaginally, the guidelines note. The rest will need a C-section after all, because of stalled labor or other factors. Success if more likely in women who go into labor naturally although induction doesn't rule out an attempt and less likely in women who are obese or are carrying large babies, they say. Thus the balancing act that women and their doctors weigh: A successful VBAC is safer than a planned repeat C-section, especially for women who want additional children but an emergency C-section can be riskier than a planned one. Because of those rare uterine ruptures, the obstetricians' group has long recommended that only hospitals equipped for immediate emergency C-sections attempt VBACs. Many smaller or rural hospitals can't do that, and that recommendation plus high-dollar lawsuits have been blamed for some hospital VBAC bans. "Restricting access was not the intention," the new guidelines say. They say hospitals ill-equipped for immediate surgery should help women find care elsewhere,

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have a plan to manage uterine ruptures anyway, and not coerce a woman into a repeat C-section. Educating women about their options early enough in pregnancy for them to make an informed choice is key, said Dr. F. Gary Cunningham of the University of Texas Southwestern Medical Center, who chaired the NIH panel on repeat C-sections. It requires a fair portrayal of risks and benefits that can differ by patient, added Dr. Howard Minkoff of Maimonides Medical Center in Brooklyn, N.Y., which has women sign a special VBAC consent after counseling yet has a higher-than-average VBAC rate of 30 percent. "There's no doubt that how things get framed influences how people act," he said. While the guidelines cannot force hospital policy changes, some women's groups welcomed them. "I feel like ACOG has really listened to how their previous policies have impacted women," said Barbara Stratton of the International Cesarean Awareness Network's Baltimore chapter, adding that she'll advise women seeking a VBAC to hand a copy of the guidelines to caregivers who balk. But she called for reducing overuse of first-time C-sections, too, so that repeats become less of an issue. Reference: http://www.msnbc.msn.com/id/38349267/ns/health/ REACTION:

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C-Sections and the Prevention of Newborn HIV Frederick R. Jelovsek MD If a woman gets infected with the human immunodeficiency virus (HIV) and becomes pregnant, then the primary medical goal is to prevent the baby from becoming infected. Recent studies have helped clarify whether a planned Cesarean section can prevent what is called vertical transmission. In other words, some exposure of the baby to HIV virus does not occur until mother undergoes labor and delivery. At that time the virus must cross over from mother's blood to baby's blood. The question has been asked for quite a while as to whether C-section could prevent any instances of transmission. Before treatment with the antiviral drug zidovudine (ZDV), it did not seem that C-section had much effect. However ZDV has been shown to reduce the transmission rate itself and most women are now on ZDV therapy during pregnancy. recent publication from the American College of Obstetricians and Gynecologists, Scheduled Cesarean delivery and the prevention of vertical transmission of HIV infection. ACOG Committee Opinion. 1999;219:1-3, has given us information about HIV and pregnancy. How likely is the baby to get infected with HIV? Without any ZDV treatment or C-section, about 25% of babies become infected with the HIV virus. When ZDV therapy is given to a woman during pregnancy, the incidence of infection is reduced to about 5-8%. When C-section is performed and ZDV is given during labor, the infection rate is further reduced to about 2%. It is on this basis that current recommendations are to perform scheduled C-Section after 39 weeks in order to minimize the chance of newborn infection. Won't a Cesarean section result in many more complications for a woman with HIV than a vaginal delivery? Women who have low CD4 cell counts seem to have the most postpartum complications. This makes sense because those women have the most active disease with probably the greatest viral loads. Women with very low viral load counts of less than 1000 viral copies per ml of plasma (presumably due to effective ZDV therapy) actually have very low rates of the baby being infected. In these cases, C-section does not actually improve the newborn infection rate. What if a woman with HIV doesn't want to have a C-section? Women always have autonomy in whether or not to have surgery regardless of the effect on the baby. Courts have long upheld that a woman can refuse surgery even though that refusal may result in the baby dying or being significantly harmed directly due to that refusal.Informed consent for this scheduled delivery is necessary and whatever a woman decides should be honored. What kind of drug treatment should be given around the time of delivery? Women with HIV should receive during pregnancy whatever antiviral chemotherapy is recommended according to current adult guidelines. Then in addition, they should receive intravenous therapy with an antiviral like ZDV starting about 3 hours before and 27

then during the Cesarean delivery. The baby will then receive oral ZDV syrup for the first 6 weeks of life. Right now this is the best therapy for minimizing HIV infection in the newborn. Reference: http://www.wdxcyber.com/npreg13.htm REACTION:

HOME VISIT

A nice snapshot taken at the residence of Mrs. Pascua last December 17, 2010 in Capangpangan, Vigan. She is cuddling her 2nd child, a baby girl, who is in good condition at the moment. On the patients testimony, she is not suffering post-operative pain anymore as she has been taking her due meds, Cefuroxime 500 mg and Mefenamic acid 500 mg both taken three times a day for 7 days. The patient understands the action of the drugs as she quoted, jay Cefuroxime ket antibiotic ken jay Mefenamic acid ket pangikkat ut-ot. The patient also performs breastfeeding. Vital Signs taken as follows: T= 36.5 C P= 86 bpm R= 20 cpm 28

BP= 120/80 mmHg Prior to this was another home visit last December 11, 2010 at the pts residence. Health teaching was conducted on wound dressing. The pt. verbalized, Mangmanganak met ti nateng ading. Ket manmanu kami lang met mangan ti karne. The wound demonstrated timely progress in healing. Pt is afebrile.

BIBLIOGRAPHY BOOKS: Elaine Marieb, Anatomy and Physiology 9th Edition Adele Pillitteri, Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 6th Edition, Vol.1 Janet Weber, Nurses Handbook of Health Assessment 6th Edition Joyce Y. Johnson, Handbook fo rBrunner and Suddarths Textbook of Medical Surgical Nursing 11th Edition Lippincotts Nursing Drug Guide 2009 Grodner, et. al., Foundations and Clinical Applications of Nutrition, 4th Edition ONLINE: http://www.wdxcyber.com/npreg13.htm http://www.msnbc.msn.com/id/38349267/ns/health/ http://www.webmd.com/baby/news/20090107/early-planned-c-sections-putbaby-at-risk www.babycenter.com

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