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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
Sañosa, Jasmine
Saquitan, RJ
Saring, Marie
Sherman, Myrna
Solatre, Carlo
Tabieros, Kristine Joy
Taclas, Josid
Tobari, Diane
Ungos, AbbySubmitted 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 coveringthe lung to slide along the parietalpleura lining the thoracic cavityduring 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 dailyin 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 constantlyenters the pleural space from thecapillaries in the parietal pleura.
Almost all of this fluid is removed by thelymphatics in the parietal pleura, whichhave a capacity to remove at least 0.20mL/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 Webster’s 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 patient’s case there is presence of difficulty of breathing due to plural effusion the main goal is to secure patient’s 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 patient’s desirable body weight.
3. Eliminate body wastes. – There is presence or impaired gas exchange in the patient. The nurse’s 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 can’t even go to the bathroom by him self. The health care provider’s 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 provider’s 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 provider’s 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 patient’s 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 DataName: C.J.
Age: 17 years old
Birthday: February 12, 1993
Nationality: Filipino
Gender: Male
Civil Status: Single
Address: 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 doctor’s finding was pleural effusion.
D. Family history: Both of the patient’s 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. He’s 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. Patient’s 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 patient’s neck has fair skin complexion and muscle tone was fairly good and able to move his head. No masses palpated along lymph nodes. But there’s 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. Patient’s 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 patient’s right and left lower extremities are fair in complexion. Patient’s 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. Patient’s 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 patient’s neck has fair skin complexion and muscle tone was fairly good and able to move his head. No masses palpated along lymph nodes. But there’s 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. Patient’s 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 patient’s right and left lower extremities fair complexion. Patient’s 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 (GORDON’S)
AREA BEFORE HOSPITALIZATION
DURING HOSPITALIZATION (DAY1)
DURING HOSPITALIZATION (DAY2)
1. Social history The pt had an active lifestyle when he was still well. He plays basketball as his form of exercise. He socializes with his friends at school. At home, he was playing computer games such as dota from 7:00 pm until dawn
He socializes with the nurses and the doctors. He was accompanied by one of his parents. His classmates from FEU also visited him.
The patient was asleep throughout the day.
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 with his life as a student.
He was sad when he was alone but 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 working, able to perceive
The patient was able to The patient was asleep throughout
stimuli. perceive stimuli. the day but wakes up when feels the pain on his RLQ.
5. Motor Capabilities
Able to move his body with ease.
The patient is in strict bed rest.
The patient is in strict bed rest.
6. Respiratory RR: 4pm: 28 bpm
8pm: 27 bpm
RR: 4pm: 25 bpm
8pm: 28 bpm
7. Circulatory PR: 4pm: 70bpm
8pm: 100bpm
BP: 4pm: 110/80mmHg
8pm: 110/80mmHg
PR: 4pm: 98bpm
8pm: 90bpm
BP: 4pm: 120/80 8pm:110/80 mmHg
8. Body temperature
Temp: 4pm: 36’C
8pm: 37.1’C
Temp:4pm: 37.6’C
8pm: 37.9’C
9. Nutritional He eats all the foods he likes especially fried chicken. He just eats vegetables when his mother forced him to.
He is in soft diet. He only eats “lugaw”
He is in soft diet. He only eats “lugaw”
10. Elimination He urinates and defecates regularly.
Urine: 2
Stool: 1
Urine: 2
Stool: 1
11. State of physical rest & comfort
He usually sleeps around 10 in the evening when there’s a class on the ff morning.
He sleeps anytime of the day.
He sleeps throughout the day.
12. State of skin and appendices
Good skin turgor and warm feeling.
Incision on the RLQ. Wounds and lesions on the neck.
Incision on the RLQ. Wounds and lesions on the neck.
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
Organ Affected:LUNGS
Risk factors:Presence of Pulmonary Tuberculosis
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 areas of fluid, minimal or absence of breath sounds, and tracheal deviation from affected side.
Diagnostic Evaluation:
- CXR – pleural effusion in left hemithorax
- Thoracentesis
Clinical Manifestations:
DOB
Tachypnea
Chest pain
Diagnostic Evaluation:- CXR (lateral decubitis)- Chest CT scan- Ultrasound-Thoracentesis- Pleural Biopsy- Pleural fluid analysis
BOOK Patient
Laboratory Exam Results:
ARTERIAL BLOOD GAS
Date ordered Laboratory exams Results Normal values Significance
July 27, 2010 pH 7.388 7.35-7.45 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 intoxicationDecrease:
Strenuous physical exercise
Obesity Starvation Diarrhea Ventilatory failure More severe degrees
of Pulmonary Disease
More severe degrees of Congestive Heart Failure
Medical Management:- Thoracentesis- Chest tube and water-seal drainage; left side- Meds: ethambutol, corticosteroid (Prednisone), levofloxacin
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
Pulmonary edema Cardiac arrest Renal failure Lactic acidosis Ketoacidosis in
diabetesPCO2 40.1 35-45mmHg Increase:
Pulmonary edema Obstructive lung
diseaseDecrease:
Hyperventilation Hypoxia Anxiety Pregnancy Pulmonary Embolism
PO2 94.3 80-100mmHg Increase: Increased oxygen
levels in the inhaled air
PolycythemiaDecreased
Decreased oxygen levels in the inhaled air
Anemia Heart
decompensation Chronic obstructive
pulmonary disease Restrictive
pulmonary disease Hypoventilation
HCO3 23.6 22-26 mEq/L Decreased HCO3
Metabolic Acidosis
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
O2 saturation 97.1% 95-100% 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
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 Laboratory exams Results Normal values Significance
July 27, 2010 AST(SGOT) 25.3 0.00-35.00 U/L Increased- myocardial infarction, skeletal muscle disease, and liver disease.
ALT(SGPT) 17.9 0.00-45 U/L Same conditions as AST(SGOT), but increased is more marked in liver disease than AST(SGOT)
Creatinine 64.4 ↓ 72.00-127.00 umol/L
Increase- mascular dystrophy, fever, carcinoma of liver,
Potassium 3.58 3.50-5.50 mmol/L Increased- hemolysis, chronic renal failure, acidosis, cushing’s diease, corpus luteum cysts.
Decrease – diarrhea, adrenocortical insuffiency.
Sodium 132.7 ↓ 135.00-148.00 mmol/L
Increased- useful in detecting gross changes in water and salt balanced
COMPLETE BLOOD COUNT
Date ordered
Laboratory exams results Normal values Significant
August 5, 2010
WBC 11.7 ↑ 4.00-10.00 10^9/L Increased- neurosyphilis, anterior poliomyelitis, encephalitis lethargic.
RBC 4.01↓ 4.50-6.50 10^12/L Decreased- iron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic 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.
HCT 0.36↓ 0.40-0.54 Decrease in severe anemias, anemia in pregnancy, acute massive blood loss.
MCV 89 80.00-100.00 fl 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 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, myeloproliferative disease, rheumatoid arthritis, and postoperativerly; about 50% of patients with unexpected increase of platelet count will be found to have a malignancy;
Lymphocytes 0.19↓ 0.25-0.50 Increase with infectious mononucleosis, viral and some
bacterial infections, hepatitis; decreased with aplastic anemia, SLE, immunodeficiency including 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.
Neutrophils 0.80 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.
Eosinophils 0.00-0.05 Increase in allergy, parasitic disease, collagen disease, subacute infections; decrease with stress, use of some medications(ACTH,
epinephrine, thyroxin
COMPLETE BLOOD COUNT
Date ordered
Laboratory exams results Normal values Significance
August 1, 2010
WBC 18.3↑ 4.00-10.00 10^9/L Increased- neurosyphilis, anterior poliomyelitis, encephalitis lethargic.
RBC 3.58↓ 4.50-6.50 10^12/L Decreased- iron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic disease, hereditary anemia, free radical pathology, toxic metals, catabolic methabolism.
HGB 103↓ 130.00-170.00 g/L Decreased in various anemias, pregnancy, severe of prolonged hemorrhage, and with excessive fluid intake.
HCT 0.32↓ 0.40-0.54 Decrease in severe anemias, 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, myeloproliferative disease, rheumatoid arthritis, and postoperativerly; 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, immunodeficiency including AIDS.
Monocytes 0.02-0.10 Increase with viral infections, parasitic disease, collagen and hemolytic disorder; decreased with use of corticosteroids, RA, HIV infection.
Neutrophils 0.94 ↑ 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.
Eosinophils 0.00-0.05 Increase in allergy, parasitic disease, collagen disease, subacute infections; decrease with stress, use of some medications(ACTH,
epinephrine, thyroxin
COMPLETE BLOOD COUNT
Date ordered
Laboratory exams results Normal values Significant
July 27, 2010 WBC 15.2↑ 4.00-10.00 10^9/L Increased- neurosyphilis, anterior poliomyelitis, encephalitis lethargic.
RBC 3.58↓ 4.50-6.50 10^12/L Decreased- iron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic disease, hereditary 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.
HCT 0.37↓ 0.40-0.54 Decrease in severe anemias, 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 502 150.00-350.00 10^9/L
Increased in malignancy, myeloproliferative disease, rheumatoid arthritis, and postoperativerly; about 50% of patients with unexpected increase of platelet count will be found to have a malignancy;
Lymphocytes 0.05↓ 0.25-0.50 Increase with infectious mononucleosis, viral and some
bacterial infections, hepatitis; decreased with aplastic anemia, SLE, immunodeficiency including AIDS.
Monocytes 0.02-0.10 Increase with viral infections, 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.
Eosinophils 0.00-0.05 Increase in allergy, parasitic disease, collagen disease, subacute infections; decrease with stress, use of some medications(ACTH,
epinephrine, thyroxin
Total Protein and A/G
Date ordered Laboratory exams
Results Normal values
Significance
July 27, 2010 Total Protein 65.5 66.00-83.00 G/L
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 and with conditions that cause malabsorption, such as Celiac disease or inflammatory bowel disease (IBD).
INCREASE
High total protein levels may be seen with chronic inflammation or infections such as viral hepatitis or HIV. They may be caused by bone marrow disorders such as multiple myeloma.
Albumin 24.6 ↓ 35.00-52.00 G/L
Albumin's role in the body is to maintain osmotic pressures and to also transport hydrophobic substances
Globulin 40.9 ↑ 15.00-30.00
G/L
A/G ratio 0.60 ↓ 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 myeloma or autoimmune diseases, or underproduction of albumin, such as occurs with cirrhosis, or selective loss of albumin from the circulation, as occurs with kidney disease (nephrotic syndrome)
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
Ordered
Medication Action Indication Nursing Intervention
July 28,2010
GN:
BN: Omeprazole
Dosage: 40mg
Frequency: OD
Route: IV
To treat several conditions related to the esophagus, stomach, and 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.
Monitor patients hypersensitivity to omeprazole and its components
July 28, 2010
GN: Piperacillin
BN:Tazocin
Dosage: 2.2g
Frequency: Q8
Route: IV
TAZOCIN is for treatment of the following systemic and/or local bacterial infections in which susceptible organisms have been detected or are suspected:
Children
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 gram-positive and gram-negative aerobic and/or anaerobic organisms are suspected (intra-abdominal, skin and skin structure, lower respiratory tract)
Monitor bleeding manifestations or significant leukopenia following prolonged administration have occurred in some patients receiving b-lactam antibiotics, including piperacillin
July 28, 2010
GN: Digoxin
BN:Lanoxin
Dosage: 25mg
Frequency: OD
Route:
Lanoxin is used to treat congestive heart failure
Lanoxin is also used to slow the heart 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).
Before giving the drug ask the patient about allergic reactions to digoxin
August 06,2010
Maalox Suspenscion
Dosage: 30cc
Frequency: Stat
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
August 06,2010
GN: Meperidine
BN:Demerol
Dosage: 25mg
Route: IV
Frequency: Now
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 morphine.
Monitor patient include hyperexcitability, convulsions, tachycardia, hyperpyrexia, and hypertension
Reassess patient’s level of pain.
August 04,2010
GN: Metronidazole
BN: Flagyl
Dosage: 1gm/
Metronidazole is an antibiotic effective against anaerobic bacteria and certain parasites
Metronidazole is used alone or in combination with other antibiotics in treating abscesses in the liver, pelvis, abdomen and brain caused by susceptible anaerobic
Safety and effectiveness in pediatric patients have not been established, except for the treatment of amoebiasis.
tab
Frequency: Q12
bacteria.
Medication Action Indication Nursing Consideration
Generic Name: ethambutol
Brand Name: Myrin P Forte
3tabAC breakfastOD
Inhibits the growth or other myobacteria. THERAPEUTIC EFFECTS: Tuberculostatic effects against susceptible organisms.-PHARMACOLOGIC ACTION: antituberculars
Active tuberculosis or other mycobacterial disease (with at least one other drug)
- Mycobacterial studies and susceptibility tests should be performed before and periodically during therapy to detect possible resistance.
- Assess lung sounds and character and the amount of sputum periodically during therapy.
Generic Name: furosemide
Brand Name: N/A
40mg/IVSTAT
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
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 potassium-depleting effect of diuretics.
ACTION: loop diuretics.
Generic Name: ketorolac
Brand Name: Ketoradol
30mg/IVq6
Inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Also has antipyretic and anti-inflammatory properties. THERAPEUTIC EFFECTS: Decreased pain. PHARMACOLOGIC EFFECT: pyrroziline carboxylic acid.
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 increased BUN, serum creatinine, or potassium concentrations.
Generic Name: tramadol
Brand Name: Tramadin
100mg/IVq8
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.
- 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.
Generic Name: corticosteroids
Brand Name: Prednisone
20mg/tab1tab BID
Decreases inflammation by reversing increased cell capillary permeability and inhibiting migration of polymorphonuclear leukocytes. Suppresses immune system by reducing lymphatic activity. THERAPEUTIC EFFECT: Suppression of inflammation and modification of the
It is prescribed in the treatment of severe inflammation and for immunosuppression.
- 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
normal immune response. PHARMACOLOGIC EFFECT: corticosteroids (systemic)
dyspnea. Notify health care professional if these occur.
Generic Name: celocoxib
Brand Name: Celebrex
400mg/tab1tab OD
Inhibits the enzyme COX-2. This enzyme is required for the synthesis of prostaglandins. Has analgesic, anti-inflammatory, and antipyretic properties. THERAPEUTIC EFFECTS: Decreased pain and inflammation caused by arthritis or spondylitis.
Management of acute pain including primary dysmenorrhea.
- Assess ROM, 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.
Generic Name: scopolamine
Brand Name: Buscopan
1ampSTAT
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
Preoperatively to produce amnesia and to decrease salivation and excessive respiratory secretion.
- 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: levofloxacin
Brand Name: Levox
750mg/tab1tab 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 /tab1tab BID
Reduces the metabolic damage caused during ischemia, by acting on a critical step in cardiac metabolism: fatty acid β-oxidation.
IX. Nursing Management
Assessment Planning Nursing Intervention EvaluationSubjective:
Dyspnea
Objectives:
The patient manifested the following:
Tachypnea RR of 28
The patient may manifest the following:
Pallor skin Orthopnea
Nursing Diagnosis:
Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea, and dyspnea
After 1-2 hours of nursing interventions the patient will demonstrate appropriate coping behaviors and methods to improve breathing pattern.
Monitor and record vital signs
R. To obtain baseline data
Provide relaxing environment
R. To promote adequate rest periods to limit fatigue
Assist client in the use of relaxation technique
R. To provide relief of causative factors
Administer prescribed medications as ordered
R. For the pharmacological management of the patient’s condition
Encourage adequate rest periods between activities
R. to limit fatigue
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.
Acute Pain
Assessment Planning Intervention EvalutaionSubjective:“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 painRestlessnessRR- 28PR- 98
Nursing Diagnoses:Acute pain related to surgical procedure.
After 1-2 hours of nursing intervention the patient will verbalize that pain scale of 9/10 will reduce to 5/10.
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 maximum dosage as needed.
R: To maintain acceptable level of pain.
After 1-2 hours of nursing interventions, patient verbalized that pain scale of 9/10 was reduced to 5/10.
Imbalanced Nutrition: Less than body requirements
Assessment Planning Intervention EvaluationSubjective
Objective:Weight before hospitalization: 50 kgHeight: 165 cmBMI: 18.4
Weight: 45 kgHeight: 165 cmBMI= 16.5Underweight: <18.5
Diagnosis:Imbalanced Nutrition: Less than body requirements related to absence of physical conditions that would explain weight loss or prevent weight gain.
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
Record the patient’s 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-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.
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
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 patient’s actual caloric intake and eating behaviors.
Activity Intolerance
Assessment Planning Intervention Evaluation
Subjective: “nahihirapan ako gumalaw dahil masakit ang tagiliran ko”as verbalized by the patient.
Objectives:- Body weakness
- Limited range of motion.
- Unable to get up to go to the bathroom
Nursing Diagnosis:
Activity intolerance related to insufficient oxygen, generalized weakness and complete bed rest.
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 client’s 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
Risk for InfectionAssessment Planning Intervention Evaluation
Subjectivenone
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/insertion site
Diagnosis:Risk for infection related to tissue trauma secondary to surgical procedure ( CTT and appendectomy)
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
IndependentMonitor 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 pt’s robes
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
R: To promote comfort and hygiene. To prevent growth of microorganisms in linens and robes
Encourage patient to verbalize any untoward feelings esp. discomfort or pain on operative/insertion site
R: To allow continuous monitoring and assessment of patient condition Instruct the patient to refrain from touching or scratching the operative/insertion site
R: To prevent contamination of operative/insertion site. To maintain intactness of dressings and CTT.
Instruct patient and his relatives to immediately report when dressings are soaked or when water-sealed bottle is almost full
R: For immediate replacement and to prevent contamination
Demonstrate to patient and his relatives the proper way of giving wound care and assisting with drainage the water sealed bottle with emphasis on proper hand washing
R: To facilitate cooperation of pt. and his relatives in pt managementTo broaden the patient’s and his relatives knowledge on such interventionTo emphasize importance of aseptic technique in preventing infection/contamination.
DependentAdminister antibacterial antibiotics as ordered
R: Inhibits bacterial wall synthesis making the pathogen vulnerable to changing osmotic pressures thereby rendering microorganism weak until it dies.
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 patient’s condition.
Spiritualism – joining to some activities like bible studies and attending events to further develop the client’s condition after being discharged from the hospital.
Prognosis
The client’s 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.
