Bulacan State University College of Nursing City of Malolos A CASE STUDY OF A 51 YEAR OLD CLIENT WITH PNEUMOTHORAX SUBMITTED

BY: BSN 3C-GROUP 3 Magallanes, Marialyn V. Manarang, Diana Rose A. Marquez, Camille Mejia, Jerlie Mendiola, Ma. Vanessa G. Nejar, Ma. Luz Teresa L. Ortega, Raquel Ortega, Danny Boy T. Palencia, Marah Pangilinan, Marygrace Quillosa, Shydney Faye Reyes, Clarizza Roxas, Paulo Raphael SUBMITTED TO: CON LEVEL III CLINICAL INSTRUCTORS March 31-June 1, 2012

I. INTRODUCTION Pneumothorax is an abnormal collection of air or gas in the pleural space that separates the lung from the chest wall, and that may interfere with normal breathing. It tends to occur in young adults without underlying lung problems, and usually causes limited signs and symptoms. Chest pain and sometimes mild breathlessness are the usual predominant presenting features. It occurs in individuals with significant underlying lung disease. Signs and symptoms is tend to be more severe, as the unaffected lung is generally not capable of replacing the loss of function in the affected lung. Hypoxemia (decreased blood oxygen levels) is usually present and may be observed as cyanosis (blue discoloration of the lips and skin). Hypercapnia (accumulation of carbon dioxide in the blood) is sometimes encountered; this may cause confusion and if very severe - may result in coma. It is often characterized with an increased heart rate (tachycardia), rapid breathing (tachypnea) and low blood pressure (hypotension) in the initial stages. Risk factors include smoking, family history of pneumothorax, and other significant lung disease like chronic obstructive pulmonary disease, asthma and tuberculosis. Diagnostic exams include a plain radiograph of the chest, ideally with the X-ray beams being projected from the back (posteroanterior, or "PA"), has been the most appropriate first investigation. These are usually performed during maximal inspiration (holding one's breath); no added information is gathered by obtaining a chest X-ray in expiration (after exhaling). The treatment of pneumothorax depends on a number of factors, and may vary from discharge with early follow-up to immediate needle decompression or insertion of a chest tube. Treatment is determined by the severity of symptoms and indicators of acute illness, the presence of underlying lung disease, the estimated size of the pneumothorax on X-ray, and - in some instances - on the personal preference of the person involved. A chest tube (or intercostals drain) is the most definitive initial treatment of a pneumothorax. These are typically inserted in the mid the (armpit) called the "safe triangle", where damage to internal organs can be avoided; this is delineated by a horizontal line at the level of the nipple and two muscles of the chest wall (latissimusdorsi and pectoralis major). The chest tube remains in as long as necessary until the air in the pleural space is gone and doesn't recur when the chest tube is clamped and checked with an X-ray. Although it's often not possible to prevent a pneumothorax, stopping smoking is an important way to reduce your risk of a first pneumothorax and avoid a recurrence. The nursing interventions for pneumothorax includes listen to patients fear and concerns, keep the patient as comfortable as possible, administer analgesics as necessary, assess the patients respiratory status, monitor ABG levels regularly as ordered, watched for complications signaled by pallor, grasping respirations and sudden chest pain, encourage the person to perform deep breathing exercise every hour when awake, carefully monitor vital signs at least every hour for indications of shock, listen for breath sounds of both lungs, prepare the patient for thoracotomy as indicated. Death from pneumothorax is very uncommon. British statistics show an annual mortality rate of 1.26 and 0.62 deaths per million person-years in men and women, respectively. A significantly increased risk of death is seen in older victims and in those with secondary pneumothorax.. The prevalence of 18.57% in cases of pneumothorax resulted in death in the Philippines 2010 (World Health Organization).

Significance of the study: The third group of third year students choose this case to challenge their mind in analyzing the problem and to enhance their knowledge about the disease and also to gain new experiences for new learning of the member of the group. This case study will help the group in understanding the disease process of the patient. This also helps the group in identifying the primary nursing care and interventions to be done in patient with pneumothorax. . This case study would also equip the group with knowledge, skills and attitude on how to render care and management to the future patients with the similar disease.

OBJECTIVES: GENERAL OBJECTIVE: After doing the case study, the group will be able to develop knowledge, skills and attitude about the disease process of Pneumothorax to emphasize the importance of enabling action to be able to render effective nursing care to the patient conducive to good health. STUDENT-CENTERED SPECIFIC OBJECTIVES: Before the completion of the case study, the students would be able to KNOWLEDGE: > Define what Pneumothorax is > Know the anatomy and physiology as well as the pathophysiology of the patients disease. > Familiarize with the patients care including medical, pharmacological, and nursing interventions. SKILLS: > Apply our knowledge in assessing the patient with Pneumothorax. > To formulate make a nursing health education, preventive management of the disease

> Provide due care to the patient which includes medical, pharmacological and nursing interventions. ATTITUDE: > Establish appropriate behavior such as being courteous and reliable in approaching a patient who had undergone chest tube insertion. > Develop professionalism in performing our nursing responsibilities especially after chest tube insertion. > Show genuine concern and willingness in serving the client. CLIENT-CENTERED SPECIFIC OBJECTIVES: Before the completion of the case study and after the initial nurse-patient interaction, the client will: KNOWLEDGE: >Raise awareness about Pneumothorax. >To impart knowledge about the importance of healthy lifestyle >Understands the disease process and complications. SKILLS: >Cooperate in different activities and management done. >Provide pertinent data and cooperate in physical assessment procedures >Comply with the treatment and management at hand. ATTITUDE: >Build up a therapeutic relationship with the student nurse. >Acknowledge the presence of the student nurse as part of the health care team responsible in taking care of the patients condition. >Gain empowerment and responsibility of maintaining health.

II. NURSING ASSESSMENT A. Biographical Data Name: Patient A.G Address: Tuktukan, guiguinto, Bulacan Age: 51 yrs. old Sex: Male Race: Filipino Religious Orientation: Roman Catholic Marital Status: Married Occupation: Self-employed (Slipper maker) Educational Attainment: High School Graduate Admission Diagnosis: Pneumothorax Principal Diagnosis: Pneumothorax Date of Admission: April 27, 2012 Date of Operation: April 27, 2012 Time started: 10:20 a.m. Health care financing and usual source of medical care: SSS B. Chief complaint or reason for visit nahihirapanakonghuminga pang-apatnaarawna. as verbalized by the client. C. History of Present Illness Four days prior to admission, a 51 y/o patient had a sudden onset of difficulty of breathing. Also, he was not able to do his work at home and his job in making slippers properly because of shortness of breath but no meds or consultation has been done. Four days PTA, he has previously noted difficulty of breathing that lasted for about 2 hours and sought medical advice. After an hour, patient was brought to Bulacan Medical Center and conducted an x-ray examination which revealed Pneumothorax. And so, he was advised to correct the condition. On April 27, 2017, few hours PTA, a chest tube was inserted at the right thoracic area and connected to bottle.

Time: 1:30a.m. Time ended: 11:15 a.m.

He reports pain at the area of the test tube but no nausea and vomiting. Since his arrival to the medical ward the patients complain of difficulty in breathing lessened. . He admits to a number of previous episodes in the recent past. Upon admission, Mr. AG has vital signs of BP-120/80mmHg; PR- 66 bpm; RR- 25cpm; and temperature of 36.8 C. Upon handling patient A.G (May 28, 2012), he already underwent surgery last April 27, 2012. He can answer well and cooperatively to our questions but still needs assistance whenever he needs to go to restroom. He still urinates normally but with assistance in walking toward the rest room. He can eat biscuits and can drink in semi-fowlers position with Diet as tolerated as ordered but with strict aspiration precaution. Upon this day he is complaining pain on his incision site with pain scale of 8 out of 10. D. Past History The client claimed to have never been hospitalized before until now. He has only experienced minor illnesses such as fever, cough, colds and attack of asthma since childhood. He said he is using salbutamol whenever his asthma attacks. He only self-medicated using over-the-counter drugs to treat these conditions. He grew up as a healthy kid and did not get sick much. He denied having any allergic reaction to certain foods or medications. According to our client whenever he had colds, he only takes over-the-counter drugs like neozep 500 mg, solmux for his cough and biogesic 500 mg whenever he has headache. Upon interview, he said that he loves to eat fish and fruits. He also is a heavy smoker when he was 18 y/o until he was 29 years old. He smokes 1 pack of cigarettes per day. He stopped smoking for almost 22 years now.

E. Family history of Illness Our clients family has no history of Pneumothorax. The familial history of illness in their family was only asthma at the side of his father. When asked about the cause of death of his father was asthma and the cause of death of his mother was due to old age.

GENOGRAM Deceased Old age Male Patient Old age

Female LEGENDS EG 72 Old age asthma MG 86 old age

MG 67 A/W

VG 65 A/W

EG 63 Asthma

IG 61 A/W

LG 60 A/WA/W

RG 59 Asthma

JG 57 A/W

CG 55

CaG 54 A/WA/W

MG 52 Asthma

AG 51 A/W

RG 54

F. FUNCTIONAL HEALTH PATTERN

FUNCTIONAL HEALTH PATTERN

PRIOR TO HOSPITALIZATION

DURING HOSPITALIZATION

1. HEALTH PERCEPTION OR HEATH MANAGEMENT PATTERN

He rates his health as 8/10 because for him he doesnt have any serious disease thats why he concluded that he is a healthy individual. He only seeks for nursing or medical advice when he feels something wrong like fever, severe headache or when advised by his family and friends. He doesnt believe in albularyo or any quack doctors because for him their teachings are not effective but he believes in the power of hilot. His vices include drinking alcoholic beverages. She takes over the counter drugs like paracetamol and eats fruits and vegetables to be healthy. April 24, 2012 April 25, 2012 Breakfast 240ml of coffee 1 cup of rice 5 slices of bacon 960ml of water April 26, 2012 Breakfast 240ml of coffee 1 cup of rice 2 pcs of itlogna pula 720ml of water

He rates his health as 6/10. He said he feels that the reason why hes sick is because of smoking for almost 11 years when he was younger and drinking alcoholic beverages until before his hospitalization. Siguro ang dahilan ng pagkakasakit ko ay ang paninigarilyo ko dati at pag-inom ko nitong mga nakakaraan as verbalized by Mr A.G but he still thinks that he will be healthy again after he recovers to his situation.

May 28, 2012 Breakfast 240ml of coffee

May 29, 2012 Breakfast 240 ml of coffee 1 pc of banana cake 480ml of water

May 30, 2012 Breakfast 240ml of coffee

2. NUTRITIONAL METABOLIC PATTERN

Breakfast 240ml of coffee 1 cup of rice 2 pcs of tuyo 1 scrambled egg 480ml of water Lunch

Lunch

Lunch 2 cups of rice 1 serving of sinigang na bangus 960 ml of water Miryenda 240ml of coffee Lunch 1 cup of rice Lunch 1 cup of rice Lunch 1 cup of rice

1 serving of Paksiw 4 cups of rice na bangus 1 pc. Sardines 4 cups of steamed rice 500 ml of water 720 ml of water Miryenda Miryenda

1 serving of sinigang 1 serving of nilagang 1 serving of pinakbet na baboy baboy 960ml of water 1 banana 720ml of water 720ml of water

1 serving of instant 240ml of coffee noodles (lucky me beef) 480 ml of water

Dinner

Dinner

Dinner

G. GROWTH AND DEVELOPMENT

Theory

Ericksons Psychosocial Development Theory 25-65 years old Generativity versus stagnation

Freuds Human Development Theory Genital Stage Puberty-onwards

Piagets Cognitive Development Theory Formal operational thought 12 years old and onwards

Kohlbergs Moral Theory Post - Conventional Stage 5

Stage

Definition

People extend their concern from just themselves and their families to the community and the world.

The individual has his sexual pleasure through genitals. The individual becomes independent of parents and responsible for himself.

Can solve hypothetical problems with scientific reasoning; understands causality and can deal with the past, present, and future. POSITIVE The client can solve problems and is conscious enough in what happening in his past, present and

The social rules are not the sole basis for decision and behavior because the person believes a higher moral principle applies such as equality, justice or due process.

Analysis

POSITIVE Patient can cope up on the concerns of his family and aware on the events in the

POSITIVE The patient has his sexual satisfaction and knows his responsibilities to his own family.

POSITIVE The clients do his best just to sustain the necessity of his family in acceptable way such as searching for a job.

Theory

Ericksons Psychosocial Development Theory community.

Freuds Human Development Theory

Piagets Cognitive Development Theory future.

Kohlbergs Moral Theory

III. ANATOMY AND PHYSIOLOGY THE HUMAN RESPIRATORY SYSTEM The primary function of the respiratory system is to supply the blood with oxygen in order for the blood to deliver oxygen to all parts of the body. The respiratory system does this through breathing. When we breathe, we inhale oxygen and exhale carbon dioxide. This exchange of gases is the respiratory system's means of getting oxygen to the blood.

The Nose The technical medical term for nose is nares. It contains ciliated cells and goblet cells The Pharynx The Naso-Pharynx is the junction of the nasal passage and the buccal cavity. A muscular tube lined with mucous membrane, which extends from the beginning of the oesophagus (gullet) up to the base of the skull. It is divided into the: Nasopharynx Oropharynx

 Larynx

Laryngopharynx

Known colloquially as the Voice Box, the larynx contains vocal cords that vibrate when sound is made. The vocal cords are also known as the vocal folds.

Trachea The windpipe, the part of the air-passage between the larynx and the main bronchi (i.e. from just below the Adams Apple, passing behind the notch of the sternum). This is kept open by a C-shaped ring of cartilage the hyoid bone. The upper part of the trachea lies just below the skin, except where the thyroid gland is wrapped around it. The lower part of the trachea divides into two bronchi (one for each lung). These lead to the upper and lower bronchioles, and eventually the alveolar ducts. Bronchi The bronchi are air passages beyond the trachea, which have cartilage and mucus glands in their walls. The trachea divides into two main bronchi, which divide successively into five lobar bronchi, 20 segmental bronchi, and two or three further divisions

Bronchioles Pleura The pleural cavity is the body cavity that surrounds the lungs. The pleura is a serous membrane which folds back onto itself to form a two-layered, membrane structure. The thin space between the two pleural layers is known as the pleural cavity; it normally contains a small amount of pleural fluid. o Visceral - The covering of the lungs. Bronchioles are subdivisions of the bronchial tree that do not contain cartilage or mucus glands in their walls. They (bronchioles) open from the 5th or 6th generation of bronchi and extend for up to 20 more generations before reaching the terminal bronchioles. Each terminal bronchiole divides into a number of respiratory bronchioles, from which the alveoli open.

o Parietal - The covering of the inner surface of the chest wall. Alveoli Diaphragm An alveolus in the lung is a blind-ended air sac of microscopic size. About 30 alveoli open out of each alveolar duct, which leads from a respiratory bronchiole. The alveolar walls, which separate alveoli contain capillaries. The alveoli are lined by a single layer of pneumocytes, which thus form a very thin layer between air and blood so that exchange of oxygen and carbon dioxide is normally rapid and complete. The diaphragm is a thin musculomembranous dome-shaped muscle that separates the thoracic and abdominal cavities. It is attached to the lower ribs at each side, and to the breast bone and the backbone at the front and back. It bulges upwards against the heart and lungs, arching over the stomach, liver, and spleen. There are openings in the diaphragm through which the esophagus, blood vessels, and nerves pass.

IV. PATIENT AND HIS ILLNESS A. Pathophysiology

Physical Assessment Name: Patient A.G Date Assessed: May 29, 2012 Vital Signs: BP:110/ 70 mmHG PR: 102 bpm RR: 25 cpm Temp: 36. 2 C Age: 51 years old

BODY PART ASSESSED C. SKIN A. GENERAL APPEARANCE BODY BUILTcolor Skin Presence of Edema Skin lesions POSTURE GAIT Skin moisture DRESS, GROOMING AND HYGIENE Skin temperature BREATH AND BODY ODOR SIGNS OF HEALTH OR ILLNESS Skin turgor B. MENTAL STATUS D. NAILS LEVEL OF CONSCIOUSNESS Fingernail plate shape ORIENTATION EMOTIONAL STATUS LANGUAGE AND COMMUNICATION

TECHNIQUE INSPECTION INSPECTION

NORMAL FINDINGS Varies from light to dark. Proportionate varies w/ lifestyle No edema. No abrasions or other lesions Relaxed,erect posture Coordinated movements Moisture in skin folds and axillae Clean,neat Uniform, within normal range No body36.5OC-37.5OC odor of odor, no breath Healthy appearance When pinched, skin springs back to previous state. Responsive; Convex Cooperative curvature, about 160 degrees Appropriate to situation Understandable;exhibits thought association

ACTUAL FINDINGS Pale in color Proportionate Weight- 110 lbs Length- 54 ft No edema. No abrasions or other lesions Not assessed Not assessed Moisture in skin folds and axillae Neat, Uniform, within normal range of c body36.5OC-37.5OC odor odor and breath Distress, pale and weak in -36.7 C appearance, with facial grimace When pinched, skin springs back to previous state. Responsive

REMARKS Normal BMI: wt ( in kg) M Normal The BMI of 20-25 is consider withinNormal limits normal

INSPECTION INSPECTION AND PALPATION INSPECTION INSPECTION INSPECTION AND PALPATION INSPECTION PALPATION INSPECTION INSPECTION INSPECTION

Normal

normal Normal normal Deviation from normal due to presences of contraptions (CTT inserted at his right side of his Normal chest)

INSPECTION INSPECTION INSPECTION INSPECTION INSPECTION

Normal Oriented, Cooperative Clubbing, concave curvature, Appropriate to situation Understandable;exhibits thought association Normal Normal Normal Normal

Color INSPECTION Fingernail and toenail texture Tissue surrounding nails Capillary refill

Pinkish

Pale

Normal

PALPATION INSPECTION INSPECTION

Smooth texture Intact epidermis Prompt return of usual color

Smooth texture Intact epidermis Prompt return of usual color less than 3 seconds

Normal Normal

Normal

E. EYES 1.Eyebrows

INSPECTION

2.Eyelids 3.Eyelashes 4.Conjunctiva

INSPECTION INSPECTION INSPECTION AND PALPATION INSPECTION INSPECTION INSPECTION

Hair evenly distributed;skinintac;eyebrows symmetrically aligned;equal movement Skin intact;nodischarge;no discoloration Equally distributed,curled slightly outward Bulbar:transparent;capillariess ometimesevident;Palpebral:shi ny;smooth;pink or red White,shiny Transparent,shiny and smooth,details of the iris are visible Round,the color varies

Evenly distributed intact, symmetrically aligned and has equal movement It is intact,nodischarge&discoloration Equally distributed,curled slightly outward Bulbar-transparentPalpebral-pink in color Yellowish in color Transparent, details of the iris are visible Round,black color

Normal

Normal Normal Normal

5.Sclera 6.Cornea 7.Iris

Normal Normal Normal

8.Pupils 9.Visual Acuity 10.Lacrimal apparatus

INSPECTION INSPECTION INSPECTION AND PALPATION

Black in color,equal in size,normally 3-7mm in diameter. Able to read newsprint No edema or tearing

Black in color,equal in size,37mm in diameter He can read newspaper but when the reading material is far from him he doesnt able to read it No edema and tearing

Normal Normal Normal

F.HEAD AND FACE 1.Skull 2.Scalp 3. Hair 4.Face (symmetry and movement)

INSPECTION INSPECTION AND PALPATION INSPECTION AND PALPATION INSPECTION

Normocephalic and symmetrical:smooth skull contour Smooth;uniformconsistency;absence of nodules or masses Evenly distributed;Silky,resilienthair.thick hair Symmetrical facial features and movements;palpebral fissures equal in size

Normocephalic and symmetrical:smooth skull contour, absence of masses Scalp is smooth without nodules or masses. Not evenly distributed has thick hair, with some white hair Symmetrical facial features and facial movements

Normal

Due to baldness and his age of 51. Normal

G. EARS 1.Auricles 2.Pinna 3.External Ear Canal 4.Hearing Acuity H.NOSE

INSPECTION AND PALPATION PALPATION INSPECTION INSPECTION

Color same as facial skin;symmetrical aligned with the lower canthus of the eye Mobile;firm;pinna recoils after it is folded No discharge Normal voice tones audible

Color same as facial skin;symmetrical aligned in the lower canthus of the eye It recoils after it is folded No discharge Voice audible

Normal Normal Normal Normal

1.External 2.Septum 3.Mucous Membrane 4.Patency 5.Nasal Cavities 6.Sinuses I.MOUTH 1.Lips 2.Mucosa 3.Tounge 4.Teeth 5.Gums

INSPECTION INSPECTION INSPECTION PALPATION INSPECTION PALPATION

Symmetric and straight;no discharge or flaring;uniform in color Intact and midline Pinkish Air moves freely in and out of her nasal cavities No obstruction Not tender

No lesion,uniform in color Intact and in midline Pink in color Air move freely on both nares No obstruction Not tender

Normal Normal Normal Normal Normal Normal

INSPECTION INSPECTION AND PALPATION INSPECTION AND PALPATION INSPECTION INSPECTION AND PALPATION

Uniform pink color;soft;moist;smoothtextur e;symmetry of contour Uniform pink color Central position;pinkcolor;movesfreel y;no tenderness 32 pieces of teeth Pink gums;moist firm texture

Dark brown color,soft,smooth&symmetrical Pink in color It is in the center,pink in color,no tenderness and moves freely Yellowish in color with 10 upper teeth, 15 lower teeth Darken in color

Normal Normal Normal Deviation from normal due to tooth decay. Deviation due to smoking when he was a teenager

J.NECK 1.Muscle Strength 2.Trachea

PALPATION INSPECTION AND PALPATION

Coordinated,smooth movements with no discomfort Midline of the neck

Coordinated,smooth movements with no discomfort At the midline

Normal Normal

K. THORAX AND LUNGS Posterior Shape and symmetry Spine alignment INSPECTION AND PALPATION INSPECTION Anteroposterior to transverse diameter in ratio of 1:2; symmetric chest Spine is vertically aligned, spinal column is straight, right and left shoulders are straight and hips are in the same alignment. Skin intact, uniform temp. no tenderness and no masses Percussion notes resonate, except over scapula; lower point of resonance is at diaphragm Excursion is 3-5 cm bilaterally in women and 5-6 cm Bilateral symmetry of vocal fremitus Not symmetrically aligned. Deviation from normal due to excessive water in the left lung. Normal

Spine is vertically aligned, spinal column is straight, right and left shoulders are not straight and hips are in the same alignment. Skin intact has a warm temperature, no tenderness and no masses. Pigeon chest. Not Done

Chest

INSPECTION AND PALPATION PERCUSSION

Normal

Posterior thorax

Not Done

Not done Diaphragmatic excursion INSPECTION AND PALPATION INSPECTION AND PALPATION Not done

Vocal fremitus

Not symmetric on the other side of the lung.

Deviation from normal due to pleural effusion. Normal

Posterior chest

AUSCULTATION

Bronchiovesicular and vesicular breath sounds

Bronchiovesicular and vesicular breath sounds

Anterior Breathing pattern Costal angle

INSPECTION

Quiet, rhythmic, effortless

Effortless breathing pattern.

Normal

INSPECTION

Costal angle is less than 90OC, and the ribs insert into the spine at approximately at 45OC Full symmetric expansion; thumbs normally separate 3 to 5 cm Same as posterior vocal fremitus is normally decreased over heart and breast tissue Bronchial and tubular breath sounds Bronchiovesicular and vesicular breath sounds Percussion notes resonate down to the 6th rib at the level of diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and

Costal angle is less than 90OC, and the ribs insert into the spine at approximately at 45OC Thumbs separate about 1cm.

Normal

Respiratory excursion

PALPATION

Normal

Tactile fremitus

PALPATION

Same as posterior vocal fremitus where it is normally decreased over heart and breast. Bronchial and tubular breath sounds Bronchiovesicular and vesicular breath sounds Percussion notes resonate down to the 6th rib at the level of diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying

Normal

Trachea

INSPECTION, AUSCULTATION & PALPATION AUSCULTATION PERCUSSION

Normal

Anterior chest Anterior thorax

Normal Normal

tympanic over the underlying stomach N.ABDOMEN 1.Skin condition 2.Contour and symmetry INSPECTION INSPECTION Uniform color Symmetric contour;flat,rounded No evidence of enlargement of liver or spleen Audible bowel sounds No tenderness

stomach

Uniform in color No enlarge liver or spleen found

Normal Normal

3.Bowel sounds 4.Presence of muscle gurding distention and rebound tenderness

AUSCULTATION INSPECTION AND PALPATION

Bowel sounds audible No tenderness

Normal Normal

O.UPPER EXTREMITIES 1.Motor strength 2.Muscle tone 3.Presence of lesions and deformities P.LOWER EXTREMITIES 1.Motor strength 2.Muscle tone 3.Presence of lesions and deformities Summary

INSPECTION PALPATION INSPECTION

Equal strength on each body side Normally firm No lesions;nodeformities;no tenderness Equal strength on each body side Normally firm No lesions;nodeformities;no tenderness

Equal strength on each body side Not firm No lesions

Normal Normal Normal

INSPECTION PALPATION INSPECTION

Equal strength on each body side Normally firm Absence of lesions

Normal Normal Normal

SIGNS OF HEALTH OR ILLNESS - Distress, pale and weak in appearance, with facial grimace. Deviation from normal due to presences of contraptions (CTT inserted at his right side of his chest) INSPECTION AND PALPATION- Not evenly distributed has thick hair, with some white hair. Deviation due to baldness and his age of 51. TEETH INSPECTION -Yellowish in color with 10 upper teeth, 15 lower teeth. Deviation from normal due to tooth decay. Pink gums;moist firm texture Darken in color. Deviation due to smoking when he was a teenager

GUMS INSPECTION AND PALPATION

POSTERIOR THORAX SHAPE AND SYMMETRY INSPECTION- Not symmetrically aligned. Deviation from normal due to excessive water in the left lung. Diagnostic Procedure / Laboratory Date Ordered, Date Result Indication/Purposes Components Normal Values Actual Values Analysis/ Interpretation

Laboratory Procedure

Nursing Responsibil

Hematology

Date Ordered: April 28, 2012 Date Result: April 28, 2012

A complete blood count (CBC) is a series of tests use to evaluate the composition and concentration of the cellular components of blood. It measures the ff: The number of red blood cells (RBCs) The number of white blood cells (WBCs) The total amount of hemoglobin in the blood

WBC LYM% MON% GRA% RBC HGB HCT MCV MCH MCHC RDW

4.1 - 10.5 16.0 43.3 2.8 10.2 48.5 80.3 4.30 5.80 131 - 167 0.399 0.510 83 -98 27.0 32.2 318 - 327 11.9 14.8

10.3 15.3 5.4 79.3 5.41 158 0.455 84 29.3 325 14.0

Interpretation: Prior: All are in normal levels Anticipate the except for the needs of the m lymphocytes. tech. During: Analysis: Assist the Med A low LYM indicates Tech. of having a viral infection which return After: in normal level after a Place the clien weeks or the infection comfortable

Date Ordered: May 04, 2012 Date Result: May 05,2012

The fraction of blood composed of RBC (hematocrit) Mean corpuscular volume (MCV) the average, or mean volume, or size, of a single RBC. Mean corpuscular hemoglobin (MCH) an expression of the amount (weight) of hemoglobin per average, single RBC. Mean corpuscular hemoglobin concentration (MCHC) the average amount of hemoglobin in each red cell, expressed as a percentage of the volume of the RBC. Red blood cell distribution width (RDW) calculates the varying sizes of red blood cell (RBC) volume in a blood sample Platelet Count (PLT) MPV is mean platelet volume.

PLT MPV PCT PDW

180 - 379 6.08 10.1 0.150 0.500 11.0 18.0

337 6.7 0.226 12.9

is resolved.

position.

A complete blood count (CBC) is a series of tests use to evaluate the composition and concentration of the cellular components of blood. It measures the ff: The number of red blood cells (RBCs) The number of white blood cells (WBCs)

WBC LYM% MON% GRA% RBC HGB HCT MCV MCH

4.1 - 10.5 16.0 43.3 2.8 10.2 48.5 80.3 4.30 5.80 131 - 167 0.399 0.510 83 -98 27.0 32.2

7.0 16.4 7.6 76.0 4.47 125 0.370 83 27.9

Interpretation: Prior: Hemoglobin and Anticipate the Hematocrit are both beyond needs of the m in below normal ranges tech. while Platelet is elevated. During: WBC, RBC, PCT, MCV, Assist the Med MCH, MCHC, RDW, Tech. MPV, PDW, LYM%, MON %, GRA%, #LYM, #MON, After:

The total amount of hemoglobin in the blood The fraction of blood composed of RBC (hematocrit) Mean corpuscular volume (MCV) the average, or mean volume, or size, of a single RBC. Mean corpuscular hemoglobin (MCH) an expression of the amount (weight) of hemoglobin per average, single RBC. Mean corpuscular hemoglobin concentration (MCHC) the average amount of hemoglobin in each red cell, expressed as a percentage of the volume of the RBC. Red blood cell distribution width (RDW) calculates the varying sizes of red blood cell (RBC) volume in a blood sample Platelet Count (PLT) MPV is mean platelet volume. Date Ordered: May 09, 2012 Date Result: A complete blood count (CBC) is a series of tests use to evaluate the composition and concentration of the cellular components of blood. It measures the ff: The number of red blood cells (RBCs)

MCHC RDW PLT MPV PCT PDW

318 - 327 11.9 14.8 180 - 379 6.08 10.1 0.150 0.500 11.0 18.0

338 13.7 457 6.8 0.312 13.5

#GRA are all in normal ranges. Analysis: There are low content of hematocrit and hemoglobin because of low concentration of plasma in the blood and there are elevated platelet count because of presence of medical problem.

Place the clien comfortable position.

WBC LYM% MON% GRA% RBC HGB HCT

4.1 - 10.5 16.0 43.3 2.8 10.2 48.5 80.3 4.30 5.80 131 - 167 0.399 0.510

5.9 21.9 9.1 69.0 4.66 120 0.379

Interpretation: Hemoglobin and Hematocrit are both beyond in below normal ranges while Platelet is elevated. # of MCH and MCHC are both below in normal while

. Prior: Anticipate the needs of the m tech. During: Assist the Med Tech.

May 10,2012

Date Ordered: May 19, 2012 Date

The number of white blood cells (WBCs) The total amount of hemoglobin in the blood The fraction of blood composed of RBC (hematocrit) Mean corpuscular volume (MCV) the average, or mean volume, or size, of a single RBC. Mean corpuscular hemoglobin (MCH) an expression of the amount (weight) of hemoglobin per average, single RBC. Mean corpuscular hemoglobin concentration (MCHC) the average amount of hemoglobin in each red cell, expressed as a percentage of the volume of the RBC. Red blood cell distribution width (RDW) calculates the varying sizes of red blood cell (RBC) volume in a blood sample Platelet Count (PLT) MPV is mean platelet volume.

MCV MCH M CHC RDW PLT MPV PCT PDW

83 -98 27.0 32.2 318 - 327 11.9 14.8 180 - 379 6.08 10.1 0.150 0.500 11.0 18.0

81 25.8 317 15.2 598 6.6 0.396 13.8

# of RDW is above normal. WBC, RBC, PCT, MCV, After: MPV, PDW, LYM%, MON Place the clien %, GRA%, #LYM, #MON, comfortable #GRA are all in normal position. ranges. Analysis: There are low content of hematocrit and hemoglobin because of low concentration of plasma in the blood and there are elevated platelet count because of presence of medical problem.

A complete blood count (CBC) is a series of tests use to evaluate the composition and concentration of the cellular components of blood. It measures the ff:

WBC LYM% MON% GRA% RBC HGB

4.1 - 10.5 16.0 43.3 2.8 10.2 48.5 80.3 4.30 5.80 131 - 167

10.9 12.0 3.9 79.8 4.83 124

Interpretation: WBC and platelet increased while Lyphocyte and hemoglobin are below in normal . # of MCV,MCH,MCHC are

Prior: Anticipate the needs of the m tech. During:

Result: May 19, 2012

Date Ordered: May 25, 2012

The number of red blood cells (RBCs) The number of white blood cells (WBCs) The total amount of hemoglobin in the blood The fraction of blood composed of RBC (hematocrit) Mean corpuscular volume (MCV) the average, or mean volume, or size, of a single RBC. Mean corpuscular hemoglobin (MCH) an expression of the amount (weight) of hemoglobin per average, single RBC. Mean corpuscular hemoglobin concentration (MCHC) the average amount of hemoglobin in each red cell, expressed as a percentage of the volume of the RBC. Red blood cell distribution width (RDW) calculates the varying sizes of red blood cell (RBC) volume in a blood sample Platelet Count (PLT) MPV is mean platelet volume. A complete blood count (CBC) is a series of tests use to evaluate the composition and concentration of the cellular components of blood.

HCT MCV MCH MCHC RDW PLT MPV PCT PDW

0.399 0.510 83 -98 27.0 32.2 318 - 327 11.9 14.8 180 - 379 6.08 10.1 0.150 0.500 11.0 18.0

0.390 81 25.6 317 15.2 655 6.6 0.492 19.8

below normal while the r est are all in normal. Analysis: A low lymphocytes and high WBC indicates of having a viral infection which return in normal level after a weeks or the infection is resolved.There are low content of hematocrit and hemoglobin because of low concentration of plasma in the blood and there are elevated platelet count because of presence of medical problem.

Assist the Med Tech.

After: Place the clien comfortable position. .

WBC LYM% MON% GRA%

4.1 - 10.5 16.0 43.3 2.8 10.2 48.5 80.3

8.4 18.2 7.4 74.4

Interpretation: There is an elevated platelet count but the rest are in normal level.

Prior: Anticipate the needs of the m

Date Result: May 25,2012

It measures the ff: The number of red blood cells (RBCs) The number of white blood cells (WBCs) The total amount of hemoglobin in the blood The fraction of blood composed of RBC (hematocrit) Mean corpuscular volume (MCV) the average, or mean volume, or size, of a single RBC. Mean corpuscular hemoglobin (MCH) an expression of the amount (weight) of hemoglobin per average, single RBC. Mean corpuscular hemoglobin concentration (MCHC) the average amount of hemoglobin in each red cell, expressed as a percentage of the volume of the RBC. Red blood cell distribution width (RDW) calculates the varying sizes of red blood cell (RBC) volume in a blood sample Platelet Count (PLT) MPV is mean platelet volume. . Tests that measure the concentration of electrolytes are useful in the

RBC HGB HCT MCV MCH MCHC RDW PLT MPV PCT PDW

4.30 5.80 131 - 167 0.399 0.510 83 -98 27.0 32.2 318 - 327 11.9 14.8 180 - 379 6. 08 10.1 0.150 0.500 11.0 18.0

4.50 116 0.357 85 27.9 326 14.3 549 6.7 0.367 13.2

Analysis: An elevated platelet count approximately greater than 420 is known as thrombocytosis.

tech. During: Assist the Med Tech.

After: Place the clien comfortable position.

Electrolytes

Date Ordered: April 30,

Sodium Potassium

135-148mmol/L 3.5 5.3

125.1 4.39

Interpretation: Prior: Sodium is below normal but

2012 Date Result: April 30, 2012

emergency room and to obtain clues for the diagnosis of specific diseases. Electrolyte tests are used for diagnosing dietary deficiencies, excess loss of nutrients due to urination, vomiting, and diarrhea, or abnormal shifts in the location of an electrolyte within the body

Calcium

mmol/L 1.1 1.32mmol/L

1.24

Potassium and calcium is in normal level. Analysis: it occurs when excessive water dilutes the amount of sodium in the body or when not enough total sodium is present in the body. A common classification of hyponatremia is based on the amount of total body water that is present. Interpretation: Sodium and Cloride is below normal but Potassium is in normal level. Analysis: Lower level of sodium occurs when excessive water dilutes the amount of sodium in the body or when not enough total sodium is present in the body. A common classification of hyponatremia is based on the amount of total body water that is present. Chloride is normally lost in

Anticipate the needs of the m tech. During: Assist the Med Tech.

After: Place the clien comfortable position.

Date Ordered: May 10, 2012 Date Result: May 11, 2012

. Tests that measure the concentration of electrolytes are useful in the emergency room and to obtain clues for the diagnosis of specific diseases. Electrolyte tests are used for diagnosing dietary deficiencies, excess loss of nutrients due to urination, vomiting, and diarrhea, or abnormal shifts in the location of an electrolyte within the body

Sodium Potassium Chloride

135-148mmol/L 3.5 5.3 mmol/L 96-107mmol/L

124.5 4.27 94.4

Prior: Anticipate the needs of the m tech. During: Assist the Med Tech.

After: Place the clien comfortable position.

the urine, sweat, and stomach secretions. Excessive loss can occur from heavy sweating, vomiting

CXR PA (Chest Radiology postanterior)

Date Ordered: May 12, 2012 Date Result: May 12, 2012

Chest radiographs are used to diagnose many conditions involving the chest wall, bones of the thorax, and structures contained within the thoracic cavity including the lungs, heart, and great vessels. Pneumonia and conges tive heart failure are very commonly diagnosed by chest radiograph. Chest radiographs are used to screen for jobrelated lung disease in industries such as mining where workers are exposed to dust.

Interpretation: Follow-up since May 5, Prior: 2012. Shows again right Instruct the cli pnuemorhorax with slight on how to hol increase in amount of air his breath and component and do deep breath diminution of fluid Instruct the cli component. to remove met True Cardiac cannot be like jewelries ascertained.Subcutaneous from the chest emphysema in thoracic During: wall shows slight Assist patient diminution. Right chest is seen. No other After: significant interval Assist the pati findings of note. in comfortable position. Analysis: Clear Lungs. True Cardiac Site cannot be ascertained. Atheromatous Aorta. Interpretation: Shows again right

CXR PA

Date

Chest radiographs are used to

Prior:

(Chest Ordered: Radiology postanterior) Date Result:

diagnose many conditions involving the chest wall, bones of the thorax, and structures contained within the thoracic cavity including the lungs, heart, and great vessels. Pneumonia and conges tive heart failure are very commonly diagnosed by chest radiograph. Chest radiographs are used to screen for jobrelated lung disease in industries such as mining where workers are exposed to dust.

pneumothorax with Instruct the cli increase in amount of air on how to hol component and his breath and diminution of fluid do deep breath component. Instruct the cli True Cardiac cannot be to remove met ascertained.Subcutaneous like jewelries emphysema in thoracic from the chest wall shows slight During: diminution. Right chest is Assist patient seen. No other significant interval After: findings of note. Assist the pati in comfortable Analysis: position. Consider to pneumothorax in R lung. True Cardiac Site cannot be ascertained. Atheromatous Aorta. Normal: < =5.2 4.5 mmol/L Interpretation: Normal Analysis:

Lipid Profile Date Ordered: May 29,2012 Date Result: May 30,2012 Sputum Microscopy Date Ordered: . May 06, 2012

Biochem Cholesterol

Visual Appearance Laboratory Diagnosis

Salivary 0

Salivary 0

Interpretation: No growth after 3 days of incubation.

Date Result: May 07,2012 V. THE PATIENT AND HIS CARE A. Medical Management: a. Intravenous Fluids, Oxygen inhalation, Incentive Spirometry. Medical management Date ordered, date given/changed/ discontinued Date ordered: April 27, 2012 @ 11 pm Date changed: April 30, 2012 @2 pm General description Indication/purposes Clients response

Analysis: Negative.

Nursing responsibilities (prior, during, after) Prior: notify the physician order Indentify the client and explain the purpose of IVF. Check the expiration date of IVF. Practice strict asepsis. PRIME IV tubing to expel air. This will prevent air embolism. label the IVF bottles and indicating the date and time it was stared with the ordered regulation During: Regulate IV every 15-20 minutes to ensure administration of proper volume of IV fluid as ordered. Observe for potential complications.

D5LR 1L x 10o

Hypertonic -Nonpyrogenic, parenteral fluid,electrolyte and nutrient replenished

Replacement therapy for needing extracalories who cannottoleratefluidoverload.

Clients fluids and electrolytes was replenished.

 monitor fluid intake and output and weight carefully monitor for sign and symptoms of hypervolemia Instruct pt. to notify a nurse if they develop breathing difficulties. Change/alter needle insertion site every 72 hours to prevent thrombophlebitis. After: remove the IVF tube as ordered document all the findings

Medical management

PNSS 1L x 8o

Date ordered, date given/changed/ discontinued Date ordered: April 30, 2012 @ 2 pm Date changed: May 15, 2012 @8 pm

General description

Indication/purposes

Clients response

Nursing responsibilities (prior, during, after) Prior: notify the physician order Indentify the client and explain the purpose of IVF. Check the expiration date of IVF. Practice strict asepsis. PRIME IV tubing to expel air. This

Saline solution is the common name for a sterile solution of sodium chloride (salt) in water. Saline is often administered into the body intravenously

Replacement and maintenance of fluid of fluid and electrolytes

Client responded to treatment without any allergic/anaphylactic reaction.

will prevent air embolism. label the IVF bottles and indicating the date and time it was stared with the ordered regulation During: Regulate IV every 15-20 minutes to ensure administration of proper volume of IV fluid as ordered. Observe for potential complications. monitor fluid intake and output and weight carefully monitor for sign and symptoms of hypervolemia Instruct pt. to notify a nurse if they develop breathing difficulties. Change/alter needle insertion site every 72 hours to prevent thrombophlebitis. After: remove the IVF tube as ordered document all the findings

Medical management

D5NSS 1L x 8o

Date ordered, date given/changed/ discontinued Date ordered: May 15, 2012 @8 pm

General description

Indication/purposes

Clients response

Nursing responsibilities (prior, during, after)

Isotonic Solution -have roughly the same amount of dissolved particles as plasma and good choice of fluid replacement.

It is given to the client to serve as good fluid replacers and maintenance.

Clients fluids and electrolytes was replenished

Prior: notify the physician order Indentify the client and explain the purpose of IVF. Check the expiration date of IVF. Practice strict asepsis. PRIME IV tubing to expel air. This will prevent air embolism. label the IVF bottles and indicating the date and time it was stared with the ordered regulation During: Regulate IV every 15-20 minutes to ensure administration of proper volume of IV fluid as ordered. Observe for potential complications. monitor fluid intake and output and weight carefully monitor for sign and symptoms of hypervolemia Instruct pt. to notify a nurse if they develop

breathing difficulties. Change/alter needle insertion site every 72 hours to prevent thrombophlebitis. After: remove the IVF tube as ordered document all the findings

Medical management

Oxygen inhalation @ 2-3 lpm via face mask

Date ordered, date given/changed/ discontinued Date ordered: April 27, 2012 @ 11 pm Date changed: May 3, 2012 @ 7 pm to 8-10 lpm via face mask

General description

Indication/purposes

Clients response

Nursing responsibilities (prior, during, after)

Face mask that cover the client nose and mouth be used for oxygen inhalation. Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape.

To provide moderate O2 support and a higher concentration of oxygen and / or humidity than is provided by nasal cannula.

Clients difficulty of breathing was lessen.

Prior: check the doctors order explain to the client about the purpose and the procedure. ensure the equipment is functioning correctly at beginning of each shift During: monitored vital sign of the patient specially the heart rate monitored ABG After:

Take the vital sign to compare. dispose all the material use. encourage to breathing exercise document all the procedure

Medical management

Incentive spirometry

Date ordered, date given/changed/ discontinued Date ordered: April 27, 2012 @ 11 pm Date given: April 28, 2012 @ 8 am

General description

Indication/purposes

Clients response

Nursing responsibilities (prior, during, after)

It is a method of deep breathing that provides visual feedback to encourage the patient to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis.

To promote the expansion Clients inhales 8of the alveoli an to 10 times deeply. prevent or treat atelectasis.

PRIOR Check for doctors order. Inform patient about the importance of the activity. DURING Placing the patient in the proper position Teaching the technique for using the incentive spirometer. Setting realistic goals for the patient. AFTER Advice patient to repeat it at home. Recording the results of the therapy.

b. Drugs GENERIC NAME/ BRAND NAME paracetamol DATE ORDERED, DATE TAKEN/DATE GIVEN, DATE DISCONTINUED Date ordered: April 27, 2012 @ 11 pm Date taken/given: April 27,2012 @ 11:30pm Date modified: April 27, 2012 Date ordered: April 28, 2012 @ 2:30pm Date taken/given: April 28, 2012 @ 4am Route: through IV (TIV) Dosage: 300 mg Frequency: q4o, PRN (when necessary) ROUTE OF ADMINISTRATION, DOSAGE, FREQUENCY Route: by mouth Dosage: 500 mg/tab, 1 tab Frequency:q4 , PRN (when necessary)
o

GENERAL ACTION, CLASSIFICATION, MECHANISM OF ACTION General action: Used to treat mild pain and fever. Classification: Paraaminophenol derivative Mechanism of Action: This drug may relieve through central action in the hypothalamic heat regulating center.

INDICATION/ PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITIES (Prior, During, After)

It has given to lower the clients body temperature to normal (37.0oC).

Client has reported a decrease in body temperature to normal range.

Prior: 1. Verify doctors order. 2. Examine the medication administration record for accuracy and completeness. 3. Check clients VS. 4. Review information of drugs (effects rate, potential for incompatibility with other fluids or medications). 5. Determine equipment you will need. 6. Wash your hands. 7. Prepare materials needed. 8. Identify the client. During: 1. Explain procedure to the client.

2. Recheck IV site placements. 3. Check for ANST of the drug (if applicable). 4. Kink tubing and pierced through the Y-injection port and push prepared drug slowly. 5. Flush IV tubing after drug administration as ordered. After: 1. Always check for IVF patency and insertion site. 2. Evaluate if you have the ten rights of giving medications. 3. Observe patient for any untoward effects and reaction like hypoglycemia, luekopenia and neutropenia. 4. Document the medication dosage, route and time it was given and signature.

GENERIC NAME/ BRAND NAME tramadol

DATE ORDERED, DATE TAKEN/DATE GIVEN, DATE DISCONTINUED Date ordered: April 28, 2012 @ 8 am Date taken/given: April 28,2012 @ 6 am

ROUTE OF ADMINISTRATION, DOSAGE, FREQUENCY Route: through IV (TIV) Dosage: 1 amp

GENERAL ACTION, CLASSIFICATION, MECHANISM OF ACTION General action: Classification: Mechanism of Action:

INDICATION/ PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITIES (Prior, During, After)

Frequency: q8o, PRN (when necessary)

Prior: 1. Verify doctors order. 2. Examine the medication administration record for accuracy and completeness. 3. Check clients VS. 4. Review information of drugs (effects rate, potential for incompatibility with other fluids or medications). 5. Determine equipment you will need. 6. Wash your hands. 7. Prepare materials needed. 8. Identify the client. During: 1. Explain procedure to the client. 2. Recheck IV site placements. 3. Check for ANST of the

drug (if applicable). 4. Kink tubing and pierced through the Y-injection port and push prepared drug slowly. 5. Flush IV tubing after drug administration as ordered. After: 1. Always check for IVF patency and insertion site. 2. Evaluate if you have the ten rights of giving medications. 3. Observe patient for any untoward effects and reaction like hypoglycemia, luekopenia and neutropenia. 4. Document the medication dosage, route and time it was given and signature.

GENERIC NAME/ BRAND NAME cilostazol

DATE ROUTE OF ORDERED, ADMINISTRATION, DATE DOSAGE, TAKEN/DATE FREQUENCY GIVEN, DATE DISCONTINUED Date ordered: May Route: by mouth 21, 2012 @ 9:40 pm Dosage: 50 mg Date taken/given: May 22,2012 @ 6 Frequency: bid (twice a am day)

GENERAL ACTION, CLASSIFICATION, MECHANISM OF ACTION

INDICATION / PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITIES (Prior, During, After)

General action: Used to reduce symptoms of intermittent claudication. Classification:quinolonephospho diesterase inhibitor Mechanism of Action: A quinolone derivative thought to inhibit the enzyme phosphodiesterase III, thus inhibit ing platelet aggregation and causing vasodilation.

Prior: 1. Verify doctors order. 2. Examine the medication administration record for accuracy and completeness. 3. Check clients VS. 4. Review information of drugs (effects rate, potential for incompatibility with other fluids or medications). 5. Determine equipment you will need. 6. Wash your hands. 7. Prepare materials needed. 8. Identify the client. During: 1. Explain procedure to the client. 2. Recheck IV site

placements. 3. Check for ANST of the drug (if applicable). 4. Kink tubing and pierced through the Y-injection port and push prepared drug slowly. 5. Flush IV tubing after drug administration as ordered. After: 1. Always check for IVF patency and insertion site. 2. Evaluate if you have the ten rights of giving medications. 3. Observe patient for any untoward effects and reaction like dizziness, headache and palpitations. 4. Document the medication dosage, route and time it was given and signature.

GENERIC NAME/ BRAND NAME Losartan potassium

DATE ORDERED, DATE TAKEN/DATE GIVEN, DATE DISCONTINUED Date ordered:May 26, 2012 @ 4 pm Date taken/given: May 26,2012 @ 6 pm

ROUTE OF ADMINISTRATION, DOSAGE, FREQUENCY Route: by mouth Dosage: 50 mg Frequency: OD

GENERAL ACTION, CLASSIFICATION, MECHANISM OF ACTION General action: Used to treat hypertension. Classification: Angiotensin II receptor antagonists Mechanism of Action: Inhibits vasoconstrictive and aldosterone secreting action of angiotensin II by blocking angiotensin II receptor on the surface of vascular smooth muscle and other tissue cells.

INDICATION/ PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITIES (Prior, During, After)

The client has given this drug to treat hypertension.

The client doesnt report any adverse reaction like chest pain, fatigue and insomnia.

Prior: 1. Verify doctors order. 2. Examine the medication administration record for accuracy and completeness. 3. Check clients VS, especially BP. 4. Review information of drugs (effects rate, potential for incompatibility with other fluids or medications). 5. Determine equipment you will need. 6. Wash your hands. 7. Prepare materials needed. 8. Identify the client. During: 1. Explain procedure to the client. 2. Recheck IV site placements.

3. Check for ANST of the drug (if applicable). 4. Kink tubing and pierced through the Y-injection port and push prepared drug slowly. 5. Flush IV tubing after drug administration as ordered. After: 1. Always check for IVF patency and insertion site. 2. Evaluate if you have the ten rights of giving medications. 3. Observe patient for any untoward effects and reaction like chest pain, fatigue and insomnia. 4. Document the medication dosage, route and time it was given and signature.

c. Diet TYPE OF DIET DATE ORDERED, DATE CHANGED, DATE DISCONTINUED Date ordered: April 27, 2012 @ 11 pm Date changed: May 30, 2012 @ 9:45 pm GENERAL DESCRIPTION This particular diet is given when client can now tolerate any food she desires that is nutritious, and if this will not lead to any complications to her health; but, strict aspiration precaution is applied. INDICATION/PURPOSES SPECIFIC FOOD TAKEN CLIENTS REPONSE The client understands her diet and feels happy that she can now eat the food she wants and satisfy her needs. NURSING RESPONSIBILITIES Prior: Verify the doctors order. Identify the client. Assess for the clients status. Instruct the client and the significant others about the importance of the diet ordered. During: Monitor the clients VS. Re-instruct the client and significant others about the diet. After: Assess for the clients status.

Diet as tolerated with strict aspiration precaution

It is ordered when the client returns her ability to eat and her tolerance for certain foods she wants.

Document all necessary information.

TYPE OF DIET

Low salt, Low fat diet

DATE ORDERED, DATE CHANGED, DATE DISCONTINUED Date ordered: May 30, 2012 @ 9:45 pm

GENERAL DESCRIPTION A diet which includes low amount of sodium and fat in the diet to prevent the increase in blood pressure.

INDICATION/PURPOSES

SPECIFIC FOOD TAKEN May 30, 2012 Breakfast:

CLIENTS REPONSE The clients blood pressure is within normal range which is 100/70 mmHg.

NURSING RESPONSIBILITIES Prior: Verify the doctors order. Identify the client. Assess for the clients status. Instruct the client and the significant others about the importance of the diet ordered. During: Monitor the clients VS. Re-instruct the client and significant

This diet is given to the client to decrease the risk for hypertension.

others about the diet. After: Assess for the clients status. Document all necessary information. d. Activity/ Exercise EXERCISE Deep Breathing exercises GENERAL DESCRIPTION Deep breathing helps expand the lungs and forces better distribution of the air into all sections of the lung. The patient either sits in a chair or sits upright in bed and inhales, pushing the abdomen out to force maximum amounts of air into the lung. The abdomen is then contracted, and the patient exhales. Deep breathing exercises are done several times each day for short periods. INDICATION/ CLIENTS PURPOSES RESPONSE Fully aerate the lungs and Client will need to take 10help to prevent stasis of the 15 deep breaths every hour lungs(stasis tends to occur because the lungs are relatively quiet during surgery and mucus forms from irritation if general anaesthesia is used). Because stasis always has the potential for causing infection. NURSING RESPONSIBILITY PRIOR: Check for doctors order. Inform patient on importance of the activity. DURING: Encourage to simply inhale as deeply as possible, holding her breath for a second or two. Then exhale as deeply as possible. AFTER: Advise patient to repeat it at home. Document.

B. Surgical Management

CHEST TUBE THORACOSTOMY -is a surgical opening in the chest wall and inserting. A thoracostomy tube(chest catheter) is inserted into the chest wall above the area of the secondor third rib. A local anesthetic (xylocaine 1% or 2%) is administered and anincision is then made into the pleural space of the chest wall. The tube isinserted, positioned, and clamped, and silk sutures are use to secure the chesttube in place. The purposes of CTT are the following: Remove excess air, blood, or fluid from the pleural cavity, Reduce the size of the pleural space, and restore negative intrapleuralpressure to promote lung expansion. Remove tumors of the lung, bronchus or chest wall Repair or reverse structures contained in the thorax such as open heartsurgery or repair of a thoracic aneurysm. A Simple One - bottle system It provides water-seal gravity drainage. The gravity system allowsthe flow of air or water into the bottle when the pressure in the pleuralspace is sufficient to displace the water in the glass rod.

Nursing responsibilities

Prior Verify a signed inform consent for the procedure. Assess knowledge and understanding of the procedure and its purposes. Obtain a CTT tray and instruments, sterile gloves, injectable lidocaine ,povidone iodine, dressing supplies and an extra over table or mayo stand bed

During After Monitor vital signs. Monitor the amount of drainage and color. Apply a dressing over the puncture site, and position on the affected side for one hour. Label obtain specimen with name, date, source and diagnosis and specimen to the laboratory for analysis. Obtain a chest x-ray Position the patient in supine position. Inform the patient that although local anesthesia prevents pain as the needle is inserted sensation of pressure may be felt. Assist the physician in administering lidocaine.

C. Nursing Problem Prioritization:

Date Identified May 29, 2012

Nursing Problem SUBJECTIVE: Acute pain related to tissue trauma secondary to surgical incision as manifested by client verbalization and pain scale of 7/10

Assessement Sumasakit ang tagiliran ko na may tubo. as verbalized by the patient. OBJECTIVE: (+) Guarding behavior in the abdomen (+) Facial grimacing (+) Distraction behaviors Pain scale of 7/10

Justification Pain affects all the parts of the body we put Acute Pain as our first priority because it will be difficult to proceed with other lower nursing prioritization if we didnt reach the manageable pain level.

May 29, 2012 Impaired physical mobility related to pain / discomfort secondary to tissue trauma as manifested by limited range of motion

SUBJECTIVE: Hindi ako makagalaw nang maayos dahil sa tubo sa tagiliran ko. as verbalized by the patient. OBJECTIVE: (+) Limited range of motion (+) Difficulty in turning (+) Slowed movement (+) Decreased reaction time (+) Postural instability

Impaired Mobility is the second priority because the patient is at risk for falls and injury.

May 29, 2012

Imbalanced nutrition: less than body requirements related to loss of appetite secondary to pain / discomfort as manifested by loss of weight

SUBJECTIVE: Hindi ako makakain masyado dahil sa tubo sa tagiliran ko. as verbalized by the patient.

The third priority is the Imbalanced Nutrition Less than body requirements because this problem is not currently health threatening, but it could be if it were to persist. It will almost

OBJECTIVE: Verbalization of loss of appetite (+) Loss of weight May 29, 2012 Impaired Skin Integrity related to tissue trauma secondary to surgical incision Risk for Infection related to tissue trauma secondary to surgical incision -Disruption of skin surface -Destruction of skin layers -Invasion of body structure -Presence of tissue trauma due to surgical incision

certainly resolve in a day or two as the medical problem is treated. (Assigning Priorities to Nursing Diagnoses) Fundamentals of Nursing:Kozier [Page-304] This may result to further tissue damage that may lead to infection. Proper treatment for this may improves clients skin integrity. Bacteria can enter around the tube and cause an infection around the lung. The longer the chest tube stays in the chest, the greater the risk for infection.

May 29, 2012

D. NURSING CARE PLAN

ASSESSMENT SUBJECTIVE: Sumasakit ang tagiliran ko na may tubo. as verbalized by the patient.

DIAGNOSIS Acute pain related to tissue trauma secondary to surgical incision as manifested by client verbalization and pain scale of 7/10

BACKGROUND KNOWLEDGE Lung disease Pneumothorax or accumulation of air in the pleural space Chest tube thoracostomy performed as surgical management Tissue trauma in the right thorax for tube insertion Acute pain

PLANNING LONG-TERM: After 4 hours of nursing interventions, the patient will report pain is relieved or controlled by reporting a lowered pain scale of 4/10 SHORT-TERM: After 1 hour of nursing interventions, the patient will follow prescribed pharmacological regimen After 1 hour of nursing interventions, the patient will verbalize nonpharmacologic methods that provide relief After 2 hours of nursing interventions, the patient will demonstrate use of relaxation skills and diversional activities

NURSING INTERVENTION Independent Assess pain, noting locations, characteristics, and severity (0 to 10 scale). Investigate and report changes in pain, as appropriate.

RATIONALE Useful in monitoring effectiveness of medication and progression of healing. Changes in characteristics of pain may indicate developing complications requiring prompt medical evaluation and intervention. Being informed about the progress of situation provides emotional support, helping to decrease anxiety. Promotes normalization of organ function

EVALUATION LONG-TERM: (GOAL MET) After 4 hours of nursing interventions, the patient was able to report pain is relieved or controlled by reporting a lowered pain scale of 4/10 SHORT-TERM: (GOAL MET) After 1 hour of nursing interventions, the patient was able to follow prescribed pharmacological regimen After 1 hour of nursing interventions, the patient was able to verbalize nonpharmacologic methods that provide relief After 2 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills and diversional activities EVALUATION

OBJECTIVE: (+) Guarding behavior in the abdomen (+) Facial grimacing (+) Distraction behaviors Pain scale of 7/10

Provide accurate, honest information to patient or significant others.

Encourage ambulation. Refocuses attention, promotes relaxation, and may enhance coping abilities. Relief of pain facilitates cooperation with other therapeutic intervention such as ambulation

Provide diversional activities. Collaborative Administer analgesics as indicated.

ASSESSMENT

DIAGNOSIS

BACKGROUND KNOWLEDGE

PLANNING

NURSING INTERVENTION

RATIONALE

SUBJECTIVE: Hindi ako makagalaw nang maayos dahil sa tubo sa tagiliran ko. as verbalized by the patient.

Impaired physical mobility related to pain / discomfort secondary to tissue trauma as manifested by limited range of motion

Lung disease Pneumothorax or accumulation of air in the pleural space Chest tube thoracostomy performed as surgical management Tissue trauma in the right thorax for tube insertion Presence of pain and discomfort Impaired physical mobility

LONG-TERM: After 4 hours of nursing interventions, the patient will participate in ADLs and desired activities SHORT-TERM: After 1 hour of nursing interventions, the patient will verbalize understanding of situation and individual treatment regimen and safety measures After 2 hours of nursing interventions, the patient will demonstrate techniques / behaviors that enable resumption of activities After 1 hour of nursing interventions, the patient will maintain and increase strength and function of affected body part

Independent Note emotional / behavioral responses to problems of immobility Support affected body part using pillows / rolls Administer medications for pain relief prior to activities as needed Encourage participation in self-care and other activities Encourage adequate intake of fluid / nutritious food Collaborative Consult with physical / occupational therapist as indicated

Feelings of frustration / powerlessness may impede attainment of goals Maintains position of function and reduces risk for pressure ulcer Promotes maximal effort / involvement in activities Enhances self-concept and sense of independence Promotes well-being and maximizes energy production Develops individual exercise / mobility program

LONG-TERM: (GOAL MET) After 4 hours of nursing interventions, the patient was able to participate in ADLs and desired activities SHORT-TERM: (GOAL MET) After 1 hour of nursing interventions, the patient was able to verbalize understanding of situation and individual treatment regimen and safety measures After 2 hours of nursing interventions, the patient was able to demonstrate techniques / behaviors that enable resumption of activities After 1 hour of nursing interventions, the patient was able to maintain and increase strength and function of affected body part

OBJECTIVE: (+) Limited range of motion (+) Difficulty in turning (+) Slowed movement (+) Decreased reaction time (+) Postural instability

ASSESSMENT

DIAGNOSIS

BACKGROUND KNOWLEDGE

PLANNING

NURSING INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Hindi ako makakain masyado dahil sa tubo sa tagiliran ko. as verbalized by the patient.

Imbalanced nutrition: less than body requirements related to loss of appetite secondary to pain / discomfort as manifested by loss of weight

Lung disease Pneumothorax or accumulation of air in the pleural space Chest tube thoracostomy performed as surgical management Tissue trauma in the right thorax for tube insertion Presence of pain and discomfort Imbalanced nutrition: less than body requirements

LONG-TERM: After 4 hours of nursing interventions, the patient will demonstrate progressive weight gain toward goal SHORT-TERM: After 1 hour of nursing interventions, the patient will verbalize understanding of causative factors when known and necessary interventions After 2 hours of nursing interventions, the patient will demonstrate behavior / lifestyle changes in order to regain appropriate weight

Independent Assess weight; measure / calculate body fat and muscle mass Note age, body build, strength, activity / rest level Evaluate total daily food intake. Obtain a diary of calorie intake, patterns and time of eating Promote pleasant, relaxing environment and socialization when possible Prevent / minimize unpleasant odors / sights Collaborative Consult dietitian / nutritional team as indicated

Establishes baseline parameters Helps determine nutritional needs Reveals possible changes that could be made in clients intake May enhance the patients intake

LONG-TERM: (GOAL MET) After 4 hours of nursing interventions, the patient was able to demonstrate progressive weight gain toward goal SHORT-TERM: (GOAL MET) After 1 hour of nursing interventions, the patient was able to verbalize understanding of causative factors when known and necessary interventions After 2 hours of nursing interventions, the patient was able to demonstrate behavior / lifestyle changes in order to regain appropriate weight

OBJECTIVE: Verbalization of loss of appetite (+) Loss of weight (4kg)

May have a negative effect to appetite / intake Implements interdisciplinary team management

VII: CONCLUSION

This case study had a great impact to the group, it served as a realization for the group. It required thorough research about the clients condition against both theory and the large comparative environment. In this study, the objectives are important. Formulating objectives before conducting a case study of Pneumothorax was very challenging because it was unfamiliar for the group. After doing this case study, the group attained and formulated nurse-centered objectives. The group was able to enhance and to develop their knowledge, skills, and attitudes to provide effective nursing care to the patient conducive to good health. The group was able to come up with a comprehensive presentation of the disease condition by means of correct presentation of the data gathered through the use of nursing process. The group was able to review the anatomy and the physiology of Pneumothorax. The group became familiarized with the nursing interventions appropriate for the clients condition. And by means of this case study, the group was able to apply their knowledge, skills and attitudes to those patients having the same condition. With the help of proper education rendered during the period of assessment and care, the client was able to acknowledge the group as part of the health care team, and cooperate with the group in all the activities and management done. The client was able to understand recognize the disease condition. The client learned the importance of healthy lifestyle and complies with the treatment at hand.

VIII: BIBLIOGRAPHY

Books: Bare, Brenda G., Cheever, Kerry H., Hinkle, Janice L., Smeltzer, Suzanne C. Brunner &Suddarths Textbook of Medical- Surgical Nursing, 10thed. Vol.2 Doenges, Marilynn E., Moorhouse, Mary Frances, Murr, Alice Nurses Pocket Guide, 11thed. Joyce M. Black & Jane Hawks Medical Surgical Nursing 7thedition . pp. 1302-1314 Kozier&Erbs Fundamentals of Nursing 8th Edition Volume 2 Lewis et.al Medical Surgical Nursing 6th ed. pp.1142-11472011 Lippincotts Nursing Guide Drug Handbook Online Resources: http://digestive.niddk.nih.gov/statistics http://en.wikipedia.org/wiki http://www.google.com.ph/imglanding?q=lungs+respiratory+system&um=1&hl=tl&sa=N&tbs=isch:1&tbnid=RQfphKO5xG7KVM:&imgrefurl=http://www.ama-assn.org picture http://www.surgeryencyclopedia.com http://www.pneumothorax/stats-country.htm http://.www.wikinursing.com