final case pres 05-26-12
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UNIVERSITY OF MAKATI
College of Allied Health Studies
J.P. Rizal Extension, West Rembo, Makati City
A Case Presentation
On
Spontaneous Pneumothorax
In Partial Fulfillment of the Requirements in
Medical and Surgical Nursing I
Submitted By:
Aloba, Kenosis P.
De Asis, KennethGenerao, Ginalyn
Lupango, Jessa
Olino, Caren Rustia
Oliveros, Juan Miguel
Orillaneda, Jean
Pasco, John Carlo
Sale, Rhechell C.
Sulangi, Angela
MS1 Group 2
May 26, 2012
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TABLE OF CONTENTS
CHAPTER 1: INTRODUCTION 3Objectives 5
CHAPTER 2: HEALTH HISTORY
I. Patients Profile 6
II. Chief Complaint 7
III. History of Present Illness 7
IV.Past medical History 8
V. Family Medical History 9
VI.Personal and Social History 9
CHAPTER 3: PHYSICAL ASSESSMENT 10
CHAPTER 4: REVIEW OF SYSTEMS 13
CHAPTER 5: GORDONS FUNCTIONAL HEALTH PATTERN 15
CHAPTER 6: MEDICAL AND NURSING DIAGNOSIS 16
CHAPTER 7: LABORATORY EXAMS 17
CHAPTER 8: COURSE IN THE WARD 24
CHAPTER 9: ANATOMY AND PHYSIOLOGY 31
CHAPTER 10: DIFFERENTIAL DIAGNOSIS 34
CHAPTER 11: PATHOPHYSIOLOGY 35
CHAPTER 12: NURSING CARE PLAN 37
CHAPTER 13: DRUG STUDY 50
CHAPTER 14: DISCHARGE PLANNING 61
CHAPTER 15: REFERENCES 63
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CHAPTER 1: INTRODUCTION
Six members of the group have handled the case, Spontaneous Pneumothorax during their duty at
the General Ward of Ospital ng Makati last May 7 to May 8, 2012. The group has noticed Mr. E. T. L. among
other patients because they believe that a lot of people are still unaware about the condition, how it occurs
and how it is managed. Only few studies were made about spontaneous pneumothorax. Little information
was also provided even on books and on the internet. Our group wanted to expand and share what we have
learned about this study. For us to come up with a better study, our group has interviewed several health
care providers such as a doctor, a nurse, and a respiratory therapist. Mr. E. T. L. was conscious and coherent
throughout the interview and assessment, so he was able to express all of his concerns.
This study mainly focuses on the proper assessment, diagnosis, plan of care, and intervention for
spontaneous pneumothorax. It also gives on the understanding of the disease process in relation to the
patients medical history.
Pneumothorax (pl. pneumothoraces) 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 occurs when the
parietal or visceral pleura are breached and the pleural space is exposed to positive atmospheric pressure.
Normally, the pressure in the pleural space is negative. This negative pressure is required to maintain lung
inflation. When either of them is breached, air enters the pleural space and the lung or a portion of it
collapses. The types of pneumothorax include simple, traumatic, and tension pneumothorax.
A simple, or spontaneous, pneumothorax may occur in an apparently healthy person in the absence
of trauma due to rupture of an air-filled bleb, or blister, on the surface of the lung, allowing air from the
airways to enter the pleural cavity. The spontaneous pneumothorax is either a primary or a secondary
pneumothorax. Primary Spontaneous Pneumothorax is the air in the pleural space without preceding
trauma and without underlying clinical or radiologic evidence of lung disease. Secondary Spontaneous
Pneumothorax occurs in patients with underlying pulmonary structural pathology. Air can enter the pleural
space via distended, damaged, or compromised alveoli. It may present with more serious clinical symptoms
and sequel due to comorbidity. Pneumothorax can also develop as a result of underlying lung diseases,
including cystic fibrosis, chronic obstructive pulmonary disease (COPD), lung cancer, asthma, and infections
of the lungs.
A Traumatic Pneumothorax occurs when air escapes from a laceration in the lung itself and enters
the pleural space or from a wound in the chest wall. It may result from a blunt trauma (e.g. rib fractures),
penetrating chest or abdominal trauma (e.g. stab wounds or gunshot wounds), or diaphragmatic tears
Open Pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest
wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted
respiration. Such injuries are called sucking chest wounds due to the rush of air producing a sucking sound.
Not only does the lung collapse, but the structures of the mediastinum (heart and great vessels) also shift
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toward the uninjured side with each inspiration and in the opposite direction with expiration. This is called
the mediastinal flutter or swing.
A tension pneumothorax occurs when air is drawn into the pleural space from a lacerated lung or
through a small opening or wound in the chest wall. Relief of tension pneumothorax is considered an
emergency measure.
The risk factors that a person is more likely to develop pneumothorax include: sex (occurs more in
males than females, 4:1 ratio), age (20-40 yrs), tall and thin body built, history of smoking, change in
atmospheric pressure, previous history of pneumothorax, family history, underlying chronic lung disease
(e.g. emphysema, asthma, tuberculosis, pneumonia, cystic fibrosis and lung cancer), medical procedures
(e.g. Thoracentesis), and mechanical ventilation.
Symptoms of a pneumothorax include chest pain that usually has a sudden onset. The pain is sharp
and may lead to feelings of tightness in the chest. Shortness of breath, rapid heart rate, rapid
breathing, cough, and fatigue are other symptoms of pneumothorax. The skin may develop a bluish color
due to decreases in blood oxygen levels. Rapid, shallow and asymmetric respirations may be observed.
Hyperresonance upon chest percussion and diminished or absent breath sounds, and decreased tactile
fremitus on the affected lung field are evident.
Number of incidences:
According to the Stockholm study of worldwide frequency of pneumothorax 2011, one of the largest
epidemiologic studies performed, pneumothorax occurs in 18 per 100,000 men and 6 per 100,000 women
per year. The study also showed that COPD was the primary cause of pneumothorax development. About 22
of 45 patients with COPD develop pneumothorax. Recurrence will occur in about 30% of primary and 45% of
secondary pneumothorax. It often occurs within 6 months, and usually within 3 years.
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OBJECTIVES
A. General objective:
The study conducted by our group aims to acquire sufficient knowledge of the disease process, how
it develops and its management. Another objective is to gain full awareness of the medical procedures done
during hospitalization. The study also serves to aid us in formulating possible Nursing Care Plans for patients
with Pneumothorax. It will help us apply the knowledge and skills gathered from this case to other cases
that will be encountered in the future.
B. Specific objective:
Student-centered:
To conduct a research regarding the patients condition.
To discuss the underlying problem of our chosen case and give a clear view of it.
To be able to provide a comprehensive nursing history to identify the cause of Spontaneous
Pneumothorax
To enhance our nursing skills in identifying and classifying signs and symptoms of the patient with
Spontaneous Pneumothorax.
To hone us to become competitive nurses in the future.
To be able to execute the effective nursing interventions that may help promote the well being of
the patient and decrease risk for further complications.
To assess the patients response to the treatment and evaluate the effectiveness of the nursing care
given.
To review the Anatomy and Physiology of the system related to the disease.
To be aware of the pathophysiology of the disease.
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Client-centered:
The patient will become aware of his existing condition and the different treatment modalities that
are available to him.
For the client to realize factors that contributes to his disease and how he can modify these factors.
For the client to assist himself during discharge by health teaching contributed by the nurse.
For the client to turn towards the preventive behavior to avoid recurrence of the present condition
in the future.
CHAPTER 2: HEALTH HISTORY
I. PATIENTS PROFILE:Name: Mr. E. T. L.
Sex: Male
Age: 36 years old.
Civil Status: Married
Nationality: Filipino
Birth date: August 26, 1975
Birth Place: Valenzuela City
Address: Guadalupe, Makati
Religion: Roman Catholic
Educational Attainment: High School Graduate
Occupation: Bag seller at the Guadalupe market
Date and time of admission: May 6, 2012 8:15 AM
Mode of admission: Ambulatory
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Admitting Diagnosis: Spontaneous Pneumothorax
Preoperative Diagnosis: Massive Pneumothorax Left Secondary to Ruptured Bleb vs Idiopathic
Operation Performed: Emergency Chest Tube Thoracostomy, Left
Postoperative Diagnosis: Status post
Informant: The patient himself
Percentage Reliability: 90%
II. CHIEF COMPLAINT: Difficulty of breathing for two weeks.
III. HISTORY OF PRESENT ILLNESS:2 weeks Prior to Admission, the client experienced difficulty of breathing and had a fever of
38.1C. He was then rendered a tepid sponge bath by his wife and took a tablet of Paracetamol
500mg for his fever. After 1hour, his temperature went down from 38.1C to 37.7C, but his fever
persisted for 2 days. He also took Salbutamol 4mg for his difficulty of breathing during the night
and was able to fall asleep.
1 week and 4 days prior to Admission, the difficulty of breathing still persisted. Because of
that, the client used water steam inhalation and his wife did back clapping. He took again
Salbutamol 4mg, but only once per day. The symptoms were relieved only for a short time.
There was persistence of symptoms. No improvement or progression was stated.
2 days Prior to Admission, the client went to an OPD at Polymedic Clinic for consult and
was advised for admission. However, the client decided to stay at home against medical advice.
1 day Prior to Admission 8Pm, the client was sent to the emergency room at OSMAK with
difficulty of breathing and was subsequently diagnosed of impending thyroid storm. Oxygen was
then administered at 4L/M via nasal cannula. Intravenous Fluid of D5LR was also administered to
the patient. After that, he was then sent home.
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At home, the client experienced chest pain, palpitations and shortness of breath. Hence, he
went back to the emergency room at 1:27am, the next day, and was scheduled for an Emergency
Chest Tube Thoracostomy on the left lung.
IV. PAST MEDICAL HISTORY:The client received complete immunization during childhood. He was also never admitted to any
hospitals in the past. He has no known allergies. The client also has no history of injuries or falls. He has no
history of any type of pneumothorax. He goes to clinics for a check-up whenever he is feeling unwell. No
recent travel was also made.
DATE DIAGNOSIS HOSPITAL INTERVENTION MEDICATIONS
5 yrs old Bronchial Asthma None Prescribed Salbutamol
Poor
compliance
2005 Hyperthyroidism Manila Doctors
Hospital
Unmanaged Was only
compliant with
medications
from yr 2005-
2008.
Unrecalled
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V. FAMILY MEDICAL HISTORY:
Interpretation: The father and grandfather of Mr. E. T. L. died of emphysema. That means that he is at risk
of developing emphysema as well. His family also had a history of smoking. His uncle on the father
side and younger sister are asthmatic. On the mother side, his mother and aunt are hypertensive
and diabetic. His uncle is also known to be a diabetic. His eldest sister was also diagnosed with
hyperthyroidism.
VI. PERSONAL AND SOCIAL HISTORY:The client and his wife are bag sellers for 3 years with their own stall at the Guadalupe Market. Their
gross income is 20,000/month. He is a high school graduate at Bangkal High School in Makati City.
The client lives in his own house, together with his wife and mother. His house is a bungalow style
with two bedrooms. He stated that their environment is clean and has enough space for all of them. They
didnt have any children.The client started smoking at 15 years old and smokes at least half a pack of cigarettes per day and
also drinks alcohol occasionally.
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CHAPTER 3: PHYSICAL ASSESSMENT
DATE AND TIME: May 7, 2012 9:00am 11:00am
General appearance: (+) facial grimace
Conscious and coherent
Thin body figure
Cooperative and responds appropriately to every question asked at
moderate pace and as long as he can tolerate.
Anthropometric measures: Height: 172.72 cm
Weight: 54.4kg BMI *18.2 (Normal values are 18.5-25)
Vital signs: Temperature: 37.3 C
Respiratory rate: 27 cpm
Pulse rate: 105 bpm
Blood pressure: 130/80 mmHg
ORGAN/BODY PARTS METHODS USED FINDINGS SIGNIFICANCE
Skin Inspection
Palpation
*Hematomas on
antecubital and radial
surface on both arms
(-) cyanosisDark complexion
Intact skin
Good skin turgor
*Hematomas are due to
blood samples taken
Head Inspection Normocephalic
(-) Head injury
(-) Tenderness
(-) Lesions
Normal
Hair Inspection (-) hair parasites
(-) dandruffs
Hair is evenly
distributed
Normal
Face Inspection Normal facial
movements
Normal
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Eyes Inspection PERRLA:
Pupils are equal and
round, left eye 3 mm
reactive to light and
right eye 3 mm reactive
to light, good
accommodation noted.
*slightly protruding
eyes
*Dark circles around the
eyes
* Eye protrusion is one
of the signs of
hyperthyroidism
*Possible sleep
deprivation
Ears Inspection
Watch tick test
Palpation
Bilaterally equal in size
(-) lesions
(-) discharge
(-) redness
(-) bleeding
Able to hear sounds on
both ears and distance
Pinna is firm, non
tender and no pain
Normal
Nose: Inspection Symmetric and straight
(-) discharges
(-) nasal flaring
With O2 administered
at 4L/min via nasal
cannula
Normal
O2 Therapy is used to
benefit patient by
increasing the supply of
O2 to the lungs and
thereby increasing theavailability of O2 to the
body tissues
Mouth: Inspection *(+) dental carries
*Absence of teeth on
upper mandible
Uniform and pinkish
tongue with no lesion,
Moist pink buccal
mucosa
There could be difficulty
in mastication.
Neck: Inspection
Palpation
Symmetric and head
centered(+) swollen lymph nodes
(+) Lump on the center
of the neck
Size and location and
movability and
There could be
presence of infection
There is thyroid
enlargement
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tenderness
Upper Extremities Inspection
Palpation
With IV contraption on
R metacarpal infusing
PNSS 1L x 40cc/min
*20.5cm mid-upper arm
circumference
Equal pulses
*Normal value of MIUC
in adult males is 23cm.
This shows decreased
amounts of fat and
muscle mass in the
arms
Nails: Inspection
Palpation
(-)Pallor
(-) Indentations
Capillary refill less than
3 seconds
Normal
Thorax and lungs: Inspection
Auscultation
Percussion
Palpation
With CTT one-way
drainage system
inserted on the 5th ICS,
LMA line
(+)chest wall retraction
(+) use of accessory
muscles
(+) shallow breathing
Diminished breath
sounds and pleural rub
on left lung
Hyper resonance on left
lungTactile fremitus
decreased on left lung
*To remove air in the
pleural space
*Patient is having
problems with
oxygenation
*Air in the pleural space
dampens the
transmission of soundsand vibration.
Heart Inspection
Auscultation
(-) visible pulsation
No heart murmurs
auscultated over aortic,
pulmonic, tricuspid and
mitral area.
Normal heart rate and
regular rhythm
HR = 105bpm
(+)Tachycardia
Heart compensates to
increase oxygenationAbdomen Inspection
Auscultation
Palpation
(-)swelling
(+) bowel sounds on
four quadrants
(-) palpable masses and
no tenderness.
Normal
Genito-urinary Inspection No swelling, no lesions Normal
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noted
Lower Extremities Inspection Legs symmetric, no
ulcerations noted.
*(+) limited ROM
*(+) body malaise
Equal pulses
*Due to weakness
Nails: Inspection
Palpation
(-) Pail
(-) Indentations
Capillary refill less than
3 seconds
Normal
CHAPTER 4: REVIEW OF SYSTEMS
SYSTEM CUES INTERPRETATION SIGNIFICANCE
General Medyo nanghihina pa
ako.
(+) body malaise Body weakness is attributed to the
present condition
Skin/Integumentary
System
May konting sakit sa mga
parte na pinagkuhaan ng
dugo
(+) Tenderness Tenderness is due to puncture of skin
from obtaining blood specimen.
EENT
Ears
Eyes
Throat
Pantay ang pandinig ko.
Parehas malinaw ang
paningin ko.
Nahihirapan akong
lumunok,
Is able to hear on
both ears
Is able to see on
both eyes
Difficulty in
swallowing
Normal
Normal
Brought about by thyroid enlargement
Respiratory System Hirap akong huminga.
Masakit yung sa gilid ngdibdib ko, parang
tinutusok tusok.
DOB
Pain on the Leftlateral chest
P Exacerbates
when coughing
and moving.
Q- Stabbing pain
S- 6/10
Due to escape of oxygen into the pleural
space.
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R Radiates to
the left shoulder
T 5-10 sec
Cardiovascular
System
May oras na mataas ang
bp ko.
BP BP is due to increased force of cardiac
contractility and the bodys attempt toincrease tissue perfusion and oxygenation
Gastrointestinal
System
Hindi naman ako
nagtatae
Nagsuka ako kanina dahil
sa sama ng pakiramdam
ko.
(-) Diarrhea
Vomiting Attributed to present condition
Genitourinary
System
Regular ang ihi ko,
normal ang color at hindi
rin masakit umihi.
Wala akong mga
almoranas
Normal
Musculoskeletal
System
Madali akong mapagod. (+) muscle
weakness
Limited ROM
Weakness is attributed to present
condition and limited ROM
Neurologic Di naman ako ulyanin. Is able to
communicate
Normal
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CHAPTER 5: GORDONS FUNCTIONAL HEALTH PATTERN
Before hospitalization During hospitalization
Health perception and
Health Management
pattern
Client seeks medical
consultation every time
he feels that there is
something abnormal with
his health. He takes over
the counter drugs when
he experiences a cough or
cold.
Client is adherent to the treatment regimen
Nutritional andmetabolic pattern
He is fond of eating saltyand fatty foods.
*analysis and
interpretation
He eats what the dietary department serves.On low salt and low fat diet.
Elimination pattern He defecates at least 2
times a day and urinates
at least 6 times a day.
Client uses a urinal to urinate. He has not
made any bowel movement since
hospitalization.
Activity-exercisepattern
He plays badminton everyday.
Is unable to ambulate due to presence ofCTT.
Sleep-rest pattern Has lack of sleep. Has more difficulty of sleeping.
Cognitive perceptual
pattern
The client can hear
clearly. Cognitive and
alert..Client plays
crossword puzzles.
The client can hear clearly. PERRLA.
Self-perception and self
concept pattern
Confident and he has a
good outlook on the way
things are happening.
The client still has a positive outlook.
Role relationship Is satisfied with family,
work, and
He cannot perform his roles as of the
moment.
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social relationships
Sexual pattern Is satisfied with sexual
relationship. Sex with
other women.
He has no sexual activity.
Coping/ Stress
Tolerance
Client manages stress
listening to music.
Client handles stress of condition by
practicing a regular breathing pattern.
Value Belief Client prays often for
good health.
Client often reads the bible.
CHAPTER 6: MEDICAL AND NURSING DIAGNOSIS
Medical diagnosis: Spontaneous Pneumothorax
Nursing diagnosis:
1. Ineffective breathing pattern related to decreased lung expansion.2. Impaired gas exchange related to decreased lung expansion secondary to air
accumulation in the pleural space.
3. Acute Pain related to impaired pleural integrity4. Disturbed sleep pattern related to interruptions from therapeutic regimen,
monitoring and other generated awakening and excessive stimulation.
5. Activity intolerance r/t muscle weakness and fatigue6. Risk for injury related to dependence on chest tube drainage system.7. Risk for falls related to generalized weakness.8. Risk for deficient fluid volume related to treatment regimen.9. Risk for constipation related to changes in level of activity.10.Risk for prone behavior related to lack of knowledge about the disease.
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Lymphocytes
Monocytes
Platelet count
PT
% activity
INR
Activated PTT
0.16
0.4
202
16.3 secs
57.0%
1.52
48.0 secs
0.20-0.40
0.02-0.05
150-450 x10 g/L
10.4-14.05
73-127%
0.88-1.21
30.4-41.2
Decreased
Increased
Normal
Slow
Decreased
Increased
Slow
Low lymphocyte counts
may occur in normal
individuals. . A low
value doesnt
necessarily mean a
decrease in protection
against viruses.
The prothrombin time
can be prolonged as a
result of deficiencies in
vitamin K, warfarin
therapy, malabsorption
In addition, poor factorVII synthesis (due to
liver disease) or
increased consumption
(in disseminated
intravascular
coagulation) may
prolong the PT.
In chronic liver
disorders, anincreasing INR
indicates progression
to liver failure. The
INR does not increase
in mild hepatocellular
dysfunction and is
often normal in
cirrhosis.
Probable coagulation
factor deficiency (e.g.hemophilia).
Nursing implications: Assess for fatigue, dietary deficiencies and V/S. Assess fluid balance and respiratory
status.
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Clinical chemistry 05-07-12 2:50PM
Component Result Normal Value Interpretation Analysis
Sodium
Potassium
Chloride
Calcium, Ionized
Calcium, Total
Magnesium
Phosphorus
134 mmol/L
4.3 mmol/L
97 mmol/L
1.08 mmol/L
1.88 mmol/L
0.63 mmol/L
1.68 mmol/L
135 148 mmol/L
3.5 4.5 mmol/L
98 107 mmol/L
1.12-1.32 mmol/L
2.15-2.55 mmol/L
0.66-0.99 mmol/L
0.81-1.58 mmol/L
Decreased
Normal
Decreased
Decreased
Decreased
Decreased
Increased
contributory factor
to lethargy and
muscle weakness
Due to potassium
deficiency
Reason ofprolonged QT
interval in the ECG
and PT
Tends to cause low
serum calcium
concentration
Clinical chemistry 05-07-12 7:14AM
Component Result Normal Value InterpretationAnalysis
Glucose (fasting)
Cholesterol
Triglycerides
HDL -cholesterol
LDL cholesterol
6.84 mmol/L
2.73 mmol/L
0.83 mmol/L
0.51 mmol/L
1.66 mmol/L
4.1 - 5.5 mmol/L
0.05.2 mmol/L
0.0 2.3 mmol/L
0.9 1.45 mmol/L
0.0 2.59 mmol/L
Increased
Normal
Normal
Decreased
Normal
May predispose
the client to DM
May predispose
the client to
development of
CAD
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Blood chemistry 05-07-12
Component Result Normal Value Interpretation Analysis
Blood Urea
Nitrogen
Serum creatinine
3.9 mmol/L
60 mmol/L
2.1-7.1 mmol/
45-104 mmol/L
Normal
Normal
BUN is affected by
hydration, hepatic
metabolism of protein
and reduced GFR
BUN indicates kidney
damage, GFR
serum Crea indicates
nephron damage, GFR
Nursing implications: Assess kidney function and check Input and Output.
* Mr. E. T. L. as indicated in his blood chemistry is having a normal renal function.
STOOL EXAM 05-06-12
Macroscopic
Examination:
Color:
Consistency:
Gross Evidence of:
>WBC
>RBC
Remarks:
Light Brown
Soft
0-3/HPF
0-2/HPF
No intestinal
Parasites seen
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URINALYSIS 05-06-12
Component Result Interpretation
MACROSCOPIC EXAM:
Color
Transparency
Sugar
Protein
pH
S.G.
MICROSCOPIC EXAM:
WBC
RBC
Epithelial Cells
Crystals
Bacteria
Dark Yellow
Slightly Hazy
N (-)
+2
6.0
1.025
0-2/ HPF
1-3/ HPF
FEW
Amorphous Urates /
Phosphates: Occasional
FEW
Dehydration is the most common condition
that can produce yellow urine.
Normal urine is transparent. Normal turbid
urine includes precipitation of crystals,
mucus, or vaginal discharge. Abnormal causes
of turbidity include the presence of blood
cells, yeast, and bacteria.
Equivalent to 100mg/dl. >2+ in concentrated
or dilute urine indicates significant
proteinuriaNormal pH
Normal S.G.
Normal
Normal
Renal epithelial cells normally appear in
the urine in small numbers.
Normal
Normal
CHEST X-RAY 05-06-12
TYPE: In-patient
Examination:Remarks:
Department of Medicine
General Ward
Chest-Follow up chest x-ray after a
few hours shows complete re-
expansion of the left lung with
no evidence of pneumothorax
-Left sided CTT seen in place.
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Electrocardiogram Test (ECG) MAY 6, 2012
ABNORMAL FINDINGS INTERPRETATION
Poor R progression
ST-T abnormality (Ant, Lat)
Negative T (Inf)
Right axis deviation
QT prolongation
Clockwise rotation
Atrial Fibrillation
-
Noise or baseline drift is present( V1, V6)
Increase the magnitude of the voltage in the
leads from V1 to V4
Ventricular conduction abnormalities and
rhythms originating in the ventricles.
Represents ventricularrepolarizationrhythms
originating in the ventricles.
congenital heart condition wherein the
electrical conduction of the heart is greater
than +105 degrees. Between +90 degrees and
+180 degrees the condition may be termed
Indeterminate Deviation or more often
Extreme Right Axis Deviation. factor for sudden cardiac death, Since
medications can promote or exacerbate the
condition, detection of QT interval
prolongation is important for clinical decision
support.
intraventricular conduction abnormalities
secondary to myocardial degeneration.
cardiac arrhythmia or irregular heart beat. The
ventricles contract irregularly, leading to a
rapid and irregular heartbeat.
Nursing Implications: Explain the purpose of the test and explain that there will be no pain from the
test.
Explain the procedure of the test. The test may be performed when the patient is fully awake, drowsy,
undergoing stimuli, asleep, during sleep deprivation, under sedation, or other situations.
Prepare the patient: Restrict only sedatives and/or stimulants such as caffeine, alcohol, etc. prior to
the test.
Patient Teaching: Be sure to include family in the teaching process. The machine may look frightening
to the patient. Reassure the patient that he will not get a shock from the machine, especially if this is
the first time this patient will have this test. Patients have other misconceptions and fears about the
test.
Report to the physician if the patient is taking any medications. Some drugs (legal or otherwise) may
affect the results of the test. Report if the patient is unusually anxious or upset before the test.
The patient will be carefully observed during the test. Ask the patient to relax and lay still during the
test.
Usually, normal activity may resume after the test.
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LIVER ENZYMES 05-07-12 11:06 PM
Component S.I. Result Normal Value Interpretation
AST (SGOT)
ALT (SGPT)
41u/L
37u/L
15-37 u/L
30-65 u/L
Increased
Normal
AST is normally found
in red blood cells, liver,
heart muscle tissue,
pancreas, and kidneys.
AST may involve
prolonged intake of
several medication,
alcoholism, or due to
hyperthyroidism
Arterial Blood Gas 05-08-12 3:40PM
Component Result Normal Value Interpretation
PH :
pCO2:
pO2
HCO3:
B.E
Sat O2
Total CO2:
7.455
30.2 mm/Hg
97.5 mm/Hg
22.9 mmol/L
1.9 mmol/L
97.8 %
21.7 mmol/L
7.350-7.450
35.00-45.00
80.00-100.00
22 26 mEq/L
+3 to -3 mEq/L
95-100
23-30mmol/L
Normal
Decreased
Normal
Normal
Normal
Normal
Decreased
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CHAPTER 8: COURSE IN THE WARD
May 07, 2012
6am-2pm shiftTime Data Action Response
6:00 am -received pt. in high
fowlers position,
conscious and coherent
- with O2 support via
nasal cannula at 4LPM
- With IV contraption on
R metacarpal infusing
PNSS 1L x 40cc/min
-with CTT to thoraco
bottle on L lower lateral
chest wall at 300 water
peak level. Initial H2O in
CTT: 200
-maintain pt. in high
fowlers position.
-maintain o2 support
via nasal cannula at
4lpm
-monitored IV rate
-monitored placement
and patency of CTT
6:30 am Paputol-putol yung
tulog ko dito kasi
maingay at maya-maya
ginigising ako.
>Dark circles around
the eyes
> Weakness and
restlessness.
>Naps wheneverpossible
>Yawning
>Assessed sleep pattern
disturbances associated
with the environment.
>Observed and obtain
feedbacks regarding on
the usual sleeping
pattern, bedtime
routine and the usual
number of hours ofsleep and rest.
>Did as much care as
possible without waking
up the client and do as
much care as possible
while the client is still
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awake.
>Explained necessity of
disturbances for
monitoring Vital Signs
and care when
hospitalized.
7:00 am -v/s taken and recorded
-chest tube tubings,
dressing and patencywas checked
-medication given:
methimazole 20mg
1tab PO after breakfast
-Temp : 36.8c
RR: 27 cpm
PR: 105 bpm
BP: 130/80 mmHg
-chest tube are patent,
tubings are hang instraight line from
mattress to the drainage
bottle
7:14am -clinical chemistry done
-chest tube tubings,
dressing and patency
was checked
-Chest tube is patent,
tubings are hanged in a
straight line from
mattress to the drainage
bottle
7: 30am Nahihirapan akong
huminga
Parang hinihingal ako.
RR 27cpm
>Auscultated breath
sounds
>evaluated respiratory
function.
>Maintained the
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>(+) facial grimace
>(+) difficulty of
breathing
>(+) dry cough
>(+)chest wall
retraction
>(+) use of accessory
muscles
>(+) shallow breathing
>Diminished breath
sounds.
clients position (High
Fowlers)
>Encouraged client to
do deep breathing
exercises and effective
coughing.
>Monitored bottle for
fluctuation
>Maintained O2
therapy @ 4lpm
>Administered
Salbutamol +
Ipratropium through
nebulization
8:00 am Monitored BP before
and after meds.
-meds given:Furosemide 20mg
1tab PO/ODx 3 days
Enalapril 5mg 1tab
PO/OD
-Daily O2 Saturation
and CBG taken
BP within normal ranges.
-O2 sat. 96%
-CBG: 109 mg/ dL
8:30 am Mas nakakahinga na
ko ng maayos.
RR- 20cpm
-Client has established
an effective respiratory
pattern
-Client has shown
improved ventilation
9:00 am Masakit yung sa gilid
ng dibdib ko, parang
tinutusok tusok.
(+) facial grimace
(+) guarding at the
affected area
- Pain on the Left lateral
chest
P Exacerbates when
coughing and moving.
Q- Stabbing pain
S- 6/10
--assessed pt.
-v/s taken & recorded
-medication given:
Tramadol 50mg TIV
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R Radiates to the left
shoulder
T 5-10 sec
nanghihina ako,
hinahapo pa ako tuwing
bumabangon ako.
>(+) fatigue
>Evaluated medications
the client is taking to see if
they could be causingactivity intolerance.
>Assessed nutritional
needs associated with
activity intolerance.
>Monitored vitals before
and after any activity,
noting any abnormal
changes.
> Assessed for pain before
activity.
> Instructed client in
energy-conserving
techniques (e.g. carrying
out activities at a slower
pace).
9:30am mga 3 nalang ang
score kumpara kanina.
-client verbalized a
decrease in the level of
pain from 6/10 to 3/10
10:00am -bed side care done
-health teaching on
chest tube drainage
system provided
-pt. verbalized
understanding on chest
tube system precaution
12:00 nn - v/s taken and
recorded
-input & output
measured
-meds given:
Ceftriaxone 2g TIV
(loading dose)
- Temp: 36.9c
RR: 23 cpm
PR: 103 bpm
BP: 130/70 mmHg
- Input Oral: 500 cc
IV: 80cc
Total: 580 cc
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-encouraged
ambulation
- urine output: 430 cc
-Chest tube drainage
output: 40cc
Total: 470cc
-BM: 0
2:00 pm -Endorsed patient to
the next shift
May 08, 2012
6am-2pm shift
Time Data Action Response
6:00 am -received pt. sitting on
bed, conscious and
responsive
-continuous with O2
support via nasal
cannula at 4LPM
- With IV contraption
on R metacarpal
infusing PNSS 1L x KVO
-with CTT to thoraco
bottle on L lower
lateral chest wall at
-maintained pt. on
sitting position
-maintained o2
therapy
-monitored IV rate
-maintained patency
-pt. verbalized increased
comfort
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300water peak level.
Initial H2O in CTT: 200
of CTT
6:30am mas okay tulog ko
kumapara kahapon.
>Patient displayed
improvements in sleeping
pattern.
7:00 am -v/s taken and
recorded
- medication given:
methimazole 20mg
1tab PO afterbreakfast
-Temp : 36.9 c
RR: 23 cpm
PR: 100bpm
BP: 130/80 mmHg
8:00 am -Monitored BP before
and after meds
- meds given:Furosemide 20mg 1tab
PO/ODx 3days
Enalapril 5mg 1tab
PO/OD
-meds given:
Ceftriaxone 500mg q
8 hours
BP: 110/70mmHg
9:00 am
From time to time
may inaabot ako sa
mesa.
Makukulit mga
kamag-anak ko dito sa
pwesto ko.
-DailyO2 Saturation
and CBG taken
>Instructed to refrain
from lying or pulling on
tubing.
>Monitored changes and
situations like change in
sound of bubbling,
-O2 sat. 97%
-CBG: 116 mg/ dL
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>CTT bottle not
secured under the
bed.
sudden air hunger and
chest pain, and
disconnection of
equipment.
10:00am Madalas wala dito
ang asawa pag
natutulog ako.>With left side rails
down while client is in
semi-fowlers position.
>Caregiver is absent.
>Limited ROM
>(+) Body weakness
>Ensured patients
safety by raising the
side rails
>Advised client not to
rise abruptly from a
supine position
>Provided emotional
support to client
10:30am May dugong nalabas
sa tubo.
Madalas akongnaihi.
>Noted signs and
symptoms of
dehydration such as dry
mucous membranes, and
thirst.
>Measured intake and
output accurately.
12:00 nn - v/s taken and
recorded
-input & output
measured
-meds given:
Ceftriaxone 500mg q
8 hours
- Temp: 36.9c
RR: 23 cpm
PR: 99 bpm
BP: 120/80 mmHg
- Input Oral: 300 cc
IV: 320cc
Total: 620 cc
- urine output: 480 cc
CTT output: 30cc
Total: 510cc
-BM: 0
2:00 pm -Endorsed patient to
the next shift
-The client was free from
injury and falls throughout
the 8 hour nursing shift.
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CHAPTER 9: ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM
Respiration is essential to all living things because all of the living cells in the body need adequate
oxygenation and produces carbon dioxide. Respiratory System, in anatomy and physiology, comprises of
organs that deliver oxyg en to the c irc ulat ory syst em for tra nspor t to al l body cel ls .
Oxygen is essential for cells, which use this vital substance to liberate the energy needed for cellular
activities. T h e r e s p i r a t o r y s y s t e m b r i n g s o x y g en t hr o u g h t h e a i r w ay s of lu n g s i n to
th e a l v eo l i , wh ere i t d i f fu ses i n to th e b l ood for t ran sp ort to th e t i s su e; th i s p roc ess i s
so vital that difficult inbreathing is expected as a threat to life in self. The respiratory system allows
oxygen from the air to enter the blood and carbon dioxide to leave the blood and enter the air. The
cardiovascular system transport oxygen from the lungs to the cells of the body and carbon dioxide. Without
healthy respiratory and cardiovascular system, the capacity to carry out normal activity is reduced,
and without adequate respirat ory and cardiovascular system fr ic t ion, l i fe itself is
possible.
A. Nasal Passages
The nose, the uppermost portion of the human respiratory system, is a hollow air passage that functions in
breathing and in the sense of smell. Wh il e tr an sp or ti ng ai r to th e ph ar yn x, th e na sa l pa ss ag e
is v i ta l because i tp l a y s t w o c r i t i c a l r o l e s : t h e y f i l t e r t h e a i r t o r e m o v e poten t ia l l
y d i sease-c au s i n g p art i c l es ; an d th ey moi s ten an d w arm th e a i r to p rotec t th e
stru c tu res i n th e resp i ratory sys tem.
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B. Pharynx
A i r leaves the nasal passages and f lows to the pharynx, a short , funnel -shaped tube
about 13 cm (5 in) long that transports air to the larynx. Like the nasal passages, the p h a r y n x i s
l i n e d w i t h a p r o t e c t i v e m u c o u s m e m b r a n e a n d c i l i a t e d c e l l s t h a t
remov e i mp u r i t i es f rom th e a i r . Wh en th e ad en oi d s are swol l en , th ey b l oc k th e f l ow
of a i r f rom t he nas al passa ges t o the pharynx, and a person must br eathe through the
mouth.
C. Larynx
A i r m o v e s f r o m t h e p h a r y n x t o t h e l a r y n x , a s t r u c t u r e a b o u t 5 c m ( 2 i n )
l o n g located approximately in the middle of the neck. Several layers of cartilage, a tough and f l e x i b l e
t i s s u e , c o m p r i s e m o s t o f t h e l a r y n x . While the primary role of the larynx is to transportair to the trachea, it also serves ot he r fun cti ons . It pla ys a pri ma ry ro le in pr odu cin g so und ;
i t p rev en ts food an d f l u i d f rom en ter i n g th e a i r p assage to c au se c h ok i n g; an d i t s
mu c ou s memb ran es an d c i l i a - b ear i n g c e l l s h e l p f i l ter a i r .
D. Trachea, Bronchi, and Bronchioles
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Air passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6in) long located just below
the larynx. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy cartilage rings hold the
trachea open, enabling air to pass freely at all times. The open part of the C-shaped cartilage lies at the back
of the trachea, and the ends of the C are connected by muscle tissue. The base of the trachea is located a
little below where the neck meets the trunk of th e bo dy . He re th e t ra ch ea br an ch es in to tw o
tu b es , th e l e f t an d r i gh t b ron c h i , wh i c h d e l i v er a i r to th e l e f t an d r i gh t
lun gs, re spe ct ive ly. Wi thi n th e lun gs , the bro nch i br anc h into smaller tubes called
bronchioles. The trachea, bronchi, and the first few bronchioles contribute to the cleansing function of the
respiratory system, for they, too, are lined with mucous membranes and ciliated cells that move mucus
upward to the pharynx.
E. Alveoli
The bronchioles divide many more times in the lungs to create an impressive tree wi th smal ler andsmal l er b ran c h es , some n o l a rger th an 0 . 5 mm ( 0 . 02 i n ) i n d i ameter . T h ese b ran c h es
d ead -en d i n to t i n y a i r sac s c a l l ed a l v eo l i . T h e a l v eo l i d e l i v er oxygen to th e c i rc u l atory
system and rem ove carbo n diox ide. Intersper sed am ong the a lveol i a re numerous
macrophages, large white blood cells that patrol the alveoli and remove foreign su bstance s that h av e
n ot b een f i l tered ou t ear l i er . T h e mac rop h ages are th e l as t l i n e
of d e f e n s e o f t h e r e s p i r a t o r y s y s t e m ; t h e i r p r e s e n c e h e l p s e n s u r e t h a t t
h e a l v e o l i a r e protected from infection so that they can carry out their vital role.
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CHAPTER 10: DIFFERENTIAL DIAGNOSIS
SIGNS AND
SYMPTOMS
PNEUMOTHORAX PLEURAL EFFUSIONPULMONARY
EDEMAProductive cough Absent Present Present
Absent or
diminished breath
sounds on the
affected side
Evident Evident Not evident
Tachypnea Present Present Present
Dyspnea Present Present Present
Difficulty of
breathing
Present Present Present
Absent or
diminished tactile
fremitus on the
affected side
Evident Evident Not evident
Dullness on the
affected side when
percussed
Absent Present Absent
Asymmetrical chest
expansion
Evident Evident Not evident
Sharp chest pain
exacerbated when
coughing
Present Present Absent
Orthopnea Present Present Present
Lateral CXR: Opaque
densities on the
lower lobe, blunting
of the costophrenic
angle
Absent Present Absent
Posteroanterior
CXR:
Air in the pneumo
region shown ismuch darker than
the air within the
actual lung in the
affected part
There is an area of
whiteness in theaffected area
Kerley lines: thin
linear pulmonaryopacities:
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CHAPTER 11: PATHOPHYSIOLOGY
Weight: 54.4kg
BMI: 18.2
(Underweight)
Asthma
Smoking
MODIFIABLE:NON-MODIFIABLE:
Age: 36 yrs. Old
Sex: M
Height: 172.72 cm
Idiopathic causes
Genetic Factors
High lung volume
Decrease in
elasticity of lung
Alveoli expands
Damage to lungs
Increased intrathoracic pressure
Rupture of the blebs under superficial lung
surface due to changes in pressure
Formation of air-filled blebs
Air escapes from the lungs
PNEUMOTHORAX
(Accumulation of air in the pleural space)
Air enters the pleural space
Lung deflates
Parietal pleura is breached
Thinning of
alveolar walls
Decrease in elastin
and collagen
Pleural space exposed to
positive pressure
Air muffles flow of sound
and vibration
Decreased breath sounds onaffected lung
Decreased tactile fremitus
Hyper resonant when
percussed
Communication between lung
alveoli and pleural space
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Diminished vacuum or
negative pressure
Irritation of sensory nerves in
the parietal pleura during
deep inspiration.
Pleuritic chest pain
Equilibrium between elastic
recoil forces of the lung &
chest wall disrupted
Decreased lung expansion
on the affected site
Assymetrical chest
expansion
Increased rate of breathing
Tachypnea
Decreased volume of
oxygen inspired on
affected lung
Decreased tissue
oxygenation
Increase pressure on lungs
when lying down
Stimulation of SNS
Orthopnea
Increased Cardiac
contractility
Dyspnea
Atelectasis of
affected area
Peripheral chemoreceptors
respond to changes in PO2
Increase in heart rate
Tachycardia
Increase in
cardiac output
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CHAPTER 12: NURSING CARE PLANS
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Assessment Diagnosis Inference Planning Nursing Intervention Rationale Evaluation
S:
Nahihirapan
akong huminga
O:
> conscious and
coherent
> V/S:
RR 27cpm
>(+) facial grimace>(+) difficulty of
breathing
>(+) dry cough
>(+)chest wall
retraction
>(+) use of
accessory muscles
>(+) Shallow
respirations
>Diminished
breath sounds.
>With under
water seal Chest
tube on the Left
lung, 5th ICS, LMA
line.
Ineffective
breathing
pattern
related to
decreased
lung
expansion.
Air accumulation in
the pleural space
Increase pressure
around the lungs
Decreased lung
expansion
Inspiration/expiration
doesnt provide
adequate ventilation
Ineffective breathing
pattern
After 1 hour
of nursing
intervention,
the Client
will establish
an effective
respiratory
pattern with
a normal
respiratory
rate of 16-
20cpm.
Independent:
1. Auscultate breath sounds
and evaluate respiratory
function, noting
rapid/shallow
respirations,
dyspnea,reports of air
hunger, development of
cyanosis, changes in v/s
2. Maintain the clientsposition (High Fowlers)
3. Encourage client to do
deep breathing exercises
and effective coughing
4. Monitor bottle for
fluctuation
5. Monitor Chest tube
drainage output.
6. Position chest tube
drainage below the bed.
Dependent:
1. Maintain O2 therapy @
4lpm
2. Administer Salbutamol +
Ipratropium .
Collaborative:
1. Monitor Chest x-rays
Independent:
1. Regularly scheduled
evaluation provides a
baseline to evaluate
resolution of pneumothorax
.Respiratory distress and
changes in v/s occur as a
result of physiologic distress
and pain, or may indicate
development of shock due to
hypoxia/ hemorrhage.2. Allows gravity to assist in
lowering the diaphragm, and
provides greater chest
expansion.
3. To establish a normal
breathing pattern
4. To check for chest tube
patency.
5. To determine if patient is
bleeding from a vessel that
was not cauterized during
closure of chest or a
ruptured graft.
6. To avoid kinking, damaging
and any instances that will
affect the drainage system.Dependent:
1. Oxygenation provides more
o2 supply.
2. This medication dilates the
bronchi and creates a better
airway.
Collaborative:
1. To monitor the progress of
resolving pneumothorax and
re-expansion of lungs.
After 1 hour
of nursing
intervention
the Client
has
established
an effective
respiratory
pattern as
evidenced
by
respiratory
rate of
20cpm.
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Assessment Diagnosis Inference Planning Nursing Intervention Rationale Evaluation
S:
Parang hinihingal
ako.
O:
conscious and
coherent
> V/S:
RR 27cpm
PR 105bpm
>(+) difficulty of
breathing
>(+) dry cough
>(+)chest wall
retraction
>(+) use of
accessory muscles
>Diminished
breath sounds.
>With underwater seal Chest
tube on the Left
lung, 5th
ICS, LMA
line.
Impaired Gas
exchange
related to
decreased
lung
expansion
secondary to
air
accumulation
in the pleural
space.
Air accumulation in
the pleural space
Increase pressure
around the lungs
Decreased lung
expansion
Decreased surface
area for oxygen and
carbon dioxide to
exchange
Impaired Gas
Exchange
After 1 hour
of nursing
intervention,
the Client
will have
improved
ventilation
and
adequate
oxygenation
Independent:
1. Maintain patency of nasal
cannula.
2. Monitor ABG results
3. Maintain clients HighFowlers position.
4. Have patient practice
pursed lip breathing.
5. Encourage client to stop
smoking
Dependent:
1. Maintain O2 at 4 Lpm
Collaborative:
1. Monitor ABG and Chest
X-ray results.
Independent:
1. Clearing airways of
secretions improves
ventilationperfusion
relationship.
2. ABG results provide
integral information to
determine deficits in
capacity and effect of
oxygen delivery.3. To facilitate chest
expansion
4. Promotes alveolar open
5. To decrease risk and
prevent further decline in
lung function
Dependent:
1. To provide O2 to the
clients body and balance
ABG.
Collaborative:
1. To monitor the progress
of the clients condition
After 1 hour
of nursing
intervention
the Client
has
improved
ventilation
and
adequate
oxygenation
and
respiratory
rate of 20
cpm
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Assessment Diagnosis Inference Planning Nursing Intervention Rationale Evaluation
S:
Masakit ang
dibdib ko, parang
tinutusok tusok.
O:
> conscious and
coherent
> V/S:
RR 27cpm>(+) facial grimace
>Guarding at the
affected area
>Pain at the Left
thoracic region.
P Exacerbates
when coughing
and moving.
Q- Stabbing pain
S- 6/10
R Radiates to
the left shoulder
T 5-10 sec
Acute Pain
related to
impaired
pleural
integrity
Tissue damage
Peripheral
neurotransmitters
released
Free nerve endings
(nociceptors)
triggered
Signals travel to
spinal cord
Signals rerouted to
appropriate area of
brain
Brain interprets
quality and intensity
of pain present
After 30
minutes of
nursing
intervention,
the client will
verbalize a
decrease of
level of pain
from a score
of 6/10 to a3/10
Independent:
1. Monitor pain. Let the
client describe the pain
he feels.
2. Assist client on splinting
the painful area when
coughing and deep
breathing.
3. Provide a calm, quietenvironment.
4. Monitor vital signs.
5. Monitor the sleeprest
pattern.
6. Maintain stability chest
tube.
7. Explain and
demonstrated the
proper breathing
exercise to the pt
8. explain and
demonstrated
cutaneous stimulation to
Independent:
1. Pain is subjective in
nature, and only the
patient can fully describe
it.
2. Splinting the affected
area may lessen the pain
that the client feels.
3. Promotes action andeffect of medication by
providing decreased
stimuli.
4. To detect changes that
might indicate pain or a
complication of pain.
5. Fatigue may contribute
to an increased pain
response, or pain can
contribute to interrupted
sleep.
6. To reduce pull or drag on
latex connector tubing
which could add up to
the pain.
7. Enhances sense of
control and may improve
coping abilities.
8. Reduces muscle tension
and anxiety associated
with pain.
After 30
minutes of
nursing
intervention
the client
has
verbalized a
decrease of
level of pain
from a scoreof 6/10 to a
3/10
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the pt
9. Explain the ways and
benefits of diversional
activities to alleviate the
pain of the pt
Dependent:
1. Administer Tramadol
50mg TIV
9. Enhances sense of well-
being and helps forget
the thought of pain.
Dependent:
1.Analgesics given TIV reach
the pain centers
immediately, providing
more effective relief with
small doses of medication.
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Assessment: Nursing diagnosis: Inference: Planning: Intervention: Rationale: Evaluation:
Subjective:
Paputol-putol
yung tulog ko
dito kasi
maingay at
maya-maya
ginigising ako.
Objective:
>Dark circles
around the eyes
> Weakness and
restlessness.
>Naps whenever
possible.
>Yawning
Disturbed Sleep
Pattern related to
interruptions for
therapeutics,
monitoring and
other generated
awakening and
excessive
stimulation (noiseand lighting).
External noises
and interruptions
Excessive
environmental
stimulation
Disruption of
relaxation
Reduced
initiation of the
body to induce
sleep
Patient is unable
to obtain
adequate sleep
Disturbed sleep
pattern
After 1 day of
nursing
intervention the
patient will
display
improvements
in sleeping
pattern.
Independent:
1. Assess sleep pattern
disturbances that are
associated with the
environment.
2. Observe and obtain
feedbacks regarding
on the usual sleeping
pattern, bedtime
routine and the usualnumber of hours of
sleep and rest.
3. Do as much care as
possible without
waking up the client
and do as much care
as possible while the
client is still awake.
4. Explain necessity of
disturbances for
monitoring Vital Signs
and care when
hospitalized.
5. Provide information
about relaxationtechniques (such as
instrumental music
and meditation).
Dependent:
1. Administer sedatives
as indicated
Independent:
1. High percentage of
sleep disturbances can
affect the recovery of
the patient.
2. To determine usual
sleeping pattern and to
compare if there are any
improvements on the
sleeping pattern of thepatient.
3. To avoid disturbances
during sleep, and also to
maximize the sleep and
rest of the client.
4. For the patient to have
an understanding of the
importance of care
being done to her and
to minimize the
complaints.
5. For the client tocondition his body for
sleeping.
Dependent:
1. Timely medication can
enhance rest or sleep.
After 1 day of
nursing
intervention
the patient
was able to
display
improvements
in sleeping
pattern.
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Assessment Nursing diagnosis Inference Planning Intervention Rationale Evaluation
Subjective:
nanghihina ako,
hinahapo pa ako
tuwing
bumabangon
ako.
Objective:
>RR- 27cpm
>Weak in
appearance
>(+) fatigue
>thin in
appearance
>(+) DOB
Activity
intolerance r/t
generalized
weakness and
fatigue
Generalized
weakness
Insufficient
physical or
psychological
energy to endureor perform desired
activities
Activity intolerance
After 2 hours of
nursing
intervention, the
patient will be
able to identify
techniques in
enhancing activity
tolerance.
Independent:
1. Evaluate medications the
client is taking to see if
they could be causing
activity intolerance.
2. Assess nutritional needs
associated with activity
intolerance.
3. Monitor vitals before and
after any activity, noting
any abnormal changes.
4. Assess for pain before
activity.
5. Instruct client in energy-
conserving techniques (e.g.
carrying out activities at a
slower pace).
Collaborative:
1. Administer analgesics as
indicated
Independent:
1. Medications such as
beta-blockers, lipid-
lowering agents, which
can damage muscle
tissue, and some
antihypertensive can
result in decreased
functioning.
2. The decline in body mass,
with physical weakness,
inhibits mobility,
increasing liability to
deep vein thrombosis,
and pressure ulcers.
3. This can be caused by a
temporary insufficiency
of blood supply
4. Pain restricts the client
from achieving a
maximal activity level
and is often exacerbated
by movement.
5. Energy-saving technique
reduces the energy
expenditure, thereby
assisting in equalization
of oxygen supply and
demand.
Collaborative:
1. Relief of pain can help
increase tolerance to
activities
After 2 hours of
nursing
intervention, th
patient was able
to identify
techniques in
enhancing
activity
tolerance
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Assessment Diagnosis Inference Planning Nursing Intervention Rationale Evaluation
S:
From time to
time may inaabot
ako sa mesa.
Makukulit mga
kamag-anak ko
dito sa pwesto
ko.
O:
> With under
water seal Chest
tube on the Left
lung, 5th
ICS, LMA
line.
>CTT bottle is not
secured under
the bed
>Patient is
restless
Risk for injury
related to
dependence on
Chest tube
Drainage system
Chest tube
insertion
Chest tube
Drainage system
dependence
CTT bottle is not
secured under the
bed
Visitors constantly
moving around the
bed
Risk for injury
Client will be
free from injury
throughout the
8 hour nursing
shift
Independent:
1. Instruct client to refrain
from lying or pulling on
tubing.
2. Monitor changes and
situations like change in
sound of bubbling, sudden
air hunger and chest
pain, and disconnection of
equipment.
3. Provide safetransportation when client
is sent off unit for
diagnostic purposes.
4. Anchor thoracic catheter
to chest wall and provide
extra length of tubing
before turning or moving
client.
5. Monitor thoracic insertion
site, noting condition of
skin and presence and
characteristics of drainage
from around the catheter.
Change and reapply sterile
occlusive dressing asneeded.
6. Observe for signs of
respiratory distress if
thoracic catheter is
disconnected/ dislodged.
Independent:
1. Reduces risk of obstructing
drainage or inadvertently
disconnecting the tubing.
2. Timely intervention may
prevent serious
complications.
3. Promotes continuation of
optimal evacuation of fluid
or air during transport.
4. Prevents thoracic catheter
dislodgment or tubing
disconnection and reduces
pain and discomfort
associated with pulling or
jarring of tubing.
5. Provides for early
recognition and treatment
of developing skin or tissue
erosion or infection.
6. Pneumothorax may recur/
worsen, compromising
respiratory function and
requiring emergency
intervention
Client was fr
from injury
throughout
8 hour nursi
shift
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ASSESSMENT NURSING DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
Madalas wala
dito ang asawa
pag natutulog
ako.
Objective:
>With left side
rails down while
client is in semi-
fowlers position.
>Caregiver is
absent.
>Limited ROM
>(+) Body
weakness
Risk for falls related
to generalized
weakness
Body weakness
Decreased
muscle strength
Lowered side
rails
Patient is left
unattended by
the significant
other
Risk for falls
Within the 8
hour nursing
shift, the client
will be free from
falls
Independent:
1. Assess patients
general condition
2. Ensure patients
safety by raising the
side rails
3. Monitor vital signs
4. Advise client not to
rise abruptly from
a supine position
5. Provide emotional
support to client
6. Create an
individualized
exercise program
for the client
Collaborative:
1. Consult with
dietician for
proper diet and
nutrition
Independent:
1. To determine the patients
status
2. To keep the patient from
falling of f the bed when moving
3. To obtain baseline data
4. Abrupt change ofposition can lead to
orthostatic
hypotension
5. To decrease anxiety.
6. Engaging in regular
exercise and activity
will strengthen
muscles, improve
balance, and increase
bone density.
Collaborative:
1. Proper nutrition and
diet promotes body
strength and bone
density.
Within the 8
hour nursing
shift, the client
was free from
falls
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Assessment Diagnosis Inference Planning Nursing Intervention Rationale Evaluation
S:
May dugong
nalabas sa tubo.
Madalas akong
naihi.
O:
> With under
water seal Chest
tube on the Left
lung, 5th
ICS, LMA
line.
> With ongoing
IVF, PNSS 1L x
40cc/ min
attached to
patients right
metacarpal vein.
> Client is also
undermedication of
Furosemide
20mg, 1 tab OD x
3 days
Risk for deficient
fluid volume
related to
treatment
regimen
Treatment regimen
(chest tube drainage
system and
Furosemide
medication)
Collection of blood
and air from the
chest tube.
Furosemide creates
diuresis
Decreased fluid in
the body
Risk for deficient
fluid volume
Throughout
the 8 hour
nursing
intervention,
the client will
be able to
maintain a
near balancebetween intake
and output.
Independent:
1. Measure I&O accurately.
Weight daily. Calculate
insensible fluid losses.
2. Encourage enough fluid
intake as necessary. Provide
allowed fluids throughout 24
hour period.
3. Monitor BP, noting postural
changes and heart rate
4. Note signs and symptoms of
dehydration such as dry
mucous membranes, thirst,
dulled sensorium and
peripheral vasoconstriction
5. Control environmental
temperature, limit bed linens
as indicated.
Collaborative:
1. monitor labs studies such as
sodium
Independent:
1. Helps estimate fluid
replacement needs.
2. To replace needed fluids by
the body.
3. orthostatic hypotension and
tachycardia suggest
hypovolemia
4. For immediate prevention of
severe dehydration.
5. may reduce diaphoresis
which contributes to overall
fluid losses.
Collaborative:
1. To gain a more accurate
assessment of the patients
condition
Throughou
the 8 hour
nursing
intervention
the client w
able to
maintain a
near balancbetween
intake and
output
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ASSESSMENT NURSING DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
Di ako masyado
nakakagalaw-
galaw.
Objective:
>Client is
conscious and
coherent
>Limited ROM
>(+) Body
malaise
Risk for
constipation related
to changes in level
of activity
Body weakness
and lack of
privacy
Decrease in level
of activity
Decreased
stimulation of
the smooth
muscles of the
G.I tract.
Decrease in
peristalsis
Risk for
constipation
After 1 hour of
nursing
intervention, the
Client will
verbalize
understanding of
ways in
improving bowel
elimination
patterns an
effective
respiratory
pattern.
Independent:
1. Ascertain usual
bowel pattern and
aids used.
Compare with
current routine.
2. Provide diet high in
fiber bulk in the
form of whole-
grain cereals,
breads, and fresh
fruits.
3. Encourage
increased fluid
intake.
4. Institute an
individualized
program of
exercise, rest, and
diet.
5. Provide emotional
support to client
Dependent:
1. Administermedications as
indicated (e.g.
bulk providers
and stool
softeners)
Independent:
1. Determines extent of
problem and indicates
types of interventions
appropriate.
2. Improves stool
consistency, promotes
evacuation
3. Promotes normal stool
consistency.
4. Increase in activities
and movement
increases peristalsis.
5. Decreases feelings of
embarrassment and
frustration.
Dependent:1. Promotes regularity by
increasing bulk or
improving consistency.
After 1 hour of
nursing
intervention, the
Client has
verbalized
understanding of
ways in
improving bowel
elimination
patterns an
effective
respiratory
pattern
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ASSESSMENT NURSING DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
Mahirap tumigil
sa pagyoyosi
eh.
OBJECTIVE:
>Request for
Information
about the
disease process.
>Inaccurate
follow through
of instructions.
> Demonstrates
nonacceptance
of health status
change.
Risk for
Prone health
behavior
related to
lack of
knowledge
about the
disease
Lack of
knowledge
about the
disease process
Reduced
motivation to
modify lifestyle
Reduced
interest in self-
care
Risk for prone
health behavior
After 4 hours
of nursing
interventions,
the patient will
demonstrate
increase in
interest and
participation in
self-care
INDEPENDENT:
1. Establish rapport
2. Assess patients
general condition.
3. Assist the patient
in identifying
modifiable risk
factors like diet high
in sodium, saturated
fats and cholesterol,
smoking, and
drinking.
4. Reinforce the
importance of
adhering to
treatment regimen
and keeping follow
up appointments.
5. Identify with the
client past and
present significant
support systems
(family, church,groups and
organizations).
6. Identify possible
cultural beliefs /
values influencing
clients response to
change.
7. Acknowledge
clients efforts to
INDEPENDENT:
1. To prevent patient
anxiety and establish
cooperation
2. To determine patients
status.
3. These risk factors have
been shown to
contribute to the
development of several
types of diseases.
4. Provides basis for
understanding of the
condition. Lack of
cooperation may lead to
failure of therapy.
5. Identifies helpful
resources that may be
needed in current
situation.
6. Different cultures deal
with change of health
issues.
7. Avoids feelings of
After 4 hours
of nursing
interventions,
the patient will
demonstrate
increase in
interest and
participation in
self-care
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adjust: You have
done your best.
Collaborative:
1. Refer to spiritual
adviser in necessary
blame / guilt and
defensive response.
Collaborative:
1. For the client to be
given spiritual
counseling.
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CHAPTER 13: DRUG STUDY
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DRUG NAME CLASSIFICATION MECHANISM OF
ACTION
INDICATION DOSAGE/ROUTE/FREQUENCY NURSING
CONSIDERATIONS
EVALUATION
BRAND NAME:
Reglan
GENERIC:
Metoclopramide
Antiemetic,
Dopaminergic
blocker, GI
stimulant
Stimulates
motility of upper
GI tract without
stimulating
gastric, biliary or
pancreatic
secretions.
Sensitizes tissues
to action of
acetylcholine
Relaxes pyloric
sphincter, which
when combined
with effects of
motility
Accelerates
gastric emptying
and intestinal
transit; little
effect on
gallbladder or
colon motility
Increases
esophageal
sphincter
pressure, has
sedative
properties
Induces release
of prolactin.
-Relief of
symptoms of
acute and
recurrent
gastroparesis.
-Stimulation of
gastric
emptying and
intestinal
transit ofbarium.
10 mg/ TIV/ now then PRN
for nausea & vomiting.
-Assess for allergy
to
metoclopramide,
GI hemorrhage,
mechanical
obstruction or
perforation,
epilepsy.
-Assess the
patients
orientation,reflexes, VS,
bowel sounds,
normal output,
EEG.
-Monitor BP
carefully during IV
administration.
-Monitor for
extrapyramidal
reactions, and
notify physician if
they occur.
-Report
involuntary
movement of theface, eyes, limbs,
severe depression
& severe
diarrhea.
-The patients
VS were
monitored, in
normal ranges
during IV
administration.
-Nausea and
vomiting was
prevented.
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DRUG NAME CLASSIFICATION MECHANISM
OF ACTION
INDICATION DOSAGE/ROUTE/FREQUENCY NURSING
CONSIDERATIONS
EVALUATION
BRAND NAME:
Propyl-Thyracil
GENERIC:
Propylthiouracil
Antithyroid drug Inhibits the
synthesis of
thyroid
hormones
Partially
inhibits the
peripheralconversion of
T4 to T3 the
more potent
form of thyroid
hormone.
Hyperthyroidism 50 mg / 1 tab per orem/ q6 -Asses for allergy
to antithyroid
drugs.
-Assess the
patients skin
color, lesions,
pigmentations,
orientation,
reflexes.-Administer drug
in three equally
divided doses at 8
hour intervals,
schedule to
maintain patients
sleep pattern.
-Arrange for
regular, periodic
blood tests to
monitor bone
marrow
depression and
bleeding
tendencies.-Report fever,
sore throat,
unusual bleeding
or bruising.
Headache &
general malaise.
-The clients
thyroid
hormones are
within normal
levels.
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DRUG NAME CLASSIFICATION MECHANISM OF
ACTION
INDICATION DOSAGE/ROUTE/FREQUENCY NURSING
CONSIDERATIONS
EVALUATION
BRAND
NAME:
Vasotec
GENERIC:
Enalapril
ACE inhibitor,
Antihypertensive
Renin released
into circulation
Acts on a plasma
precursor to
produce
angiotensin I
Converted by ACE
to angiotensin II
Increases BP.
Blocks the
conversion of
angiotensin I to
angiotensin II
Decreases BP and
aldosterone
secretion, slightly
increases serum
K+ levels and
causing Na+ and
fluid loss.
Treatment of
hypertension
5 mg/ 1 tab Per Orem/ OD -Assess for allergy
to enalapril,
impaired renal
function, salt or
volume depletion.
-Assess patients
skin color, lesions,
turgor, orientation,
reflexes, peripheral
sensations, VS,
mucous
membranes, bowelsounds and liver
evaluation.
-Monitor patient on
diuretic therapy for
excessive
hypotension after
the first few doses
of enalapril.
-Monitor patient
closely in any
situation that may
lead to a drop in BP
secondary to
reduced fluid
volume (excessive
perspiration, anddehydration,
vomiting and
diarrhea).
-Patient was
monitored
closely for any
situation that
might lead to a
drop in BP.
-Patients blood
pressure is
within normal
ranges.
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DRUG NAME CLASSIFICATION MECHANISM OF
ACTION
INDICATION DOSAGE/ROUTE/FREQUENCY NURSING
CONSIDERATIONS
EVALUATION
BRAND NAME:
Apo-Furosemide
GENERIC:
Furosemide
Loop diuretic Action at the
proximal and
distal tubules
and ascending
limb of the loop
of Henle
Inhibition of
reabsorption ofsodium and
chloride
Leads to a
sodium-rich
diuresis.
For mild to
moderate
hypertension
20 mg/ 1 tab Per Orem/ OD x
3 days
-Assess allergy to
medication.
-Assess the
patients skin color,
lesions.
-Reduce dosage if
given with
antihypertensive
drugs , readjust
dosage gradually as
BP responds.
-Give early in the
day so that
increased urination
will not disturb
sleep.
-Avoid IV use if oral
use is at all possible.
-Measure and
record weight to
monitor fluid
changes.
-Arrange to monitor
serum electrolytes,
hydration, liver and
renal function.
-Arrange forpotassium rich
diet or
supplemental
potassium as
needed.
-Patients sleep
pattern was not
disturbed.
-Patients blood
pressure is within
normal ranges.
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DRUG NAME CLASSIFICATION MECHANISM OF
ACTION
INDICATION DOSAGE/ROUTE/FRE
QUENCY
NURSING
CONSIDERATIONS
EVALUATION
BRAND NAME:
InnoPran XL
GENERIC:
Propranolol
Antianginal,
antiarrhythmic.
Antihypertensive,
Beta-adrenergic
blocker (non
selective)
Completely
blocks beta-
adrenergic
receptors in the
heart and
juxtoglomerular
apparatus
Decreases the
influence ofsympathetic
nervous system
on these tissues,
the excitability of
the heart, cardiac
workload and O2
consumption, and
the release of
renin and
lowering BP.
For adult
hypertension
20 mg/ 1 tab Per
Orem/ q8
-Assess allergy to beta-
blocking agents, sinus
bradycardia, second or
third degree heart block,
cardiogenic shock,
peripheral vascular
diseases.
-Assess the patients
weight, skin color, lesions,
edema, reflexes.-Provide continuous
cardiac and regular BP
monitoring with IV form.
-Give oral drug with food
to facilitate absorption.
-Report difficulty of
breathing, night cough,
swelling of extremities,
slow pulse, confusion,
depression, rash fever,
sore throat.
Patients cardiac
status and BP
were maintained
within the
normal range.
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DRUG NAME CLASSIFICATION MECHANISM OF
ACTION
INDICATION DOSAGE/ROUTE/FREQUENCY NURSING
CONSIDERATIONS
EVALUATION
BRAND NAME:
Tapazole
GENERIC:
Methimazole
Antithyroid drug Inhibits the
synthesis of
thyroid
hormone.
Treatment of
hyperthyroidism.
Methimazole 20mg 1 tabPer Orem after breakfastMethimazole 5mg/ tab 2Per Orem tab after dinner
-Assess allergy to
antithyroid
products.
-Assess for skin
color, lesions,
pigmentation,
orientation.
Reflexes.
-Give drug in three
equally divided
doses at 8-hr
interval.
-Establish a
schedule that fits
the patients
routine.
-Advise the patient
that taking this drug
could increase the
risk of bleeding
problems.
-Report fever, sore
throat, unusual
bleeding or
bruising, headache
and general
malaise.-Obtain regular,
periodic blood tests
to monitor bone
marrow depression
and bleeding
tendencies.
-Thyroid storm
was prevented.
-Patient did not
develop any
allergies to the
medication
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DRUG NAME CLASSIFICATION MECHANISM OF
ACTION
INDICATION DOSAGE/ROUTE/FR
EQUENCY
NURSING
CONSIDERATIONS
EVALUATION
BRAND NAME:
Titradose
GENERIC:
Isosorbide
Dinitrate
Vasodilator Relaxes vascular
smooth muscle
with a resultant
decrease in
venous return
Decrease in
arterial BP
Reduces leftventricular
workload
Decreases
myocardial
oxygen
consumption
Treatment and
prevention of
angina
pectoris/ chest
pain
5mg/tab/ 1 tab OD
for chest pain
-Assess for any allergy to
nitrates, severe anemia, GI
hypermobility.
-Assess for skin color,
lesions, orientation,
reflexes.
-Monitor effectiveness of
drug in relieving angina.
-Headaches tend to
decrease in intensity andfrequency with continued
therapy but may require
administration of analgesic
and reduction in dosage.
-Make position changes
slowly, particularly from
recumbent to upright
posture, and dangle feet
and ankles before walking.
-Keep a record of angina
attacks and the number of
sublingual tablets required
to provide relief.
Patient was
monitored
closely and
chest pain was
relieved.
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DRUG NAME CLASSIFICATION MECHANISM OF
ACTION
INDICATION DOSAGE/ROUTE/FR
EQUENCY
NURSING
CONSIDERATIONS
EVALUATION
BRAND NAME:
DuoNeb
GENERIC:
Salbutamol +Ipatropium
Antiasthmatic &
COPD
preparations
IPATROPIUM:
Anticholinergic
agent inhibits
vagally-mediated
reflexes by
antagonizing the
action of
acetylcholine.
Prevents the
increase in
intracellular
concentration of
cyclic guanosine
monophosphate
w/c are brought
about by
interaction of
acetylcholine with
the muscarinic
receptors on
bronchial smooth
muscle.
SALBUTAMOL:
Direct acting
Beta2-adrenergic
agent.
Acts on the
airway smooth
muscle resulting
in
bronchodilation.
Provides
inhalation for
DOB.
1 nebule Q6 PRN for
DOB
-Monitor respiratory
status; Auscultate lungs
before and after
inhalation.
-Report treatment failure
(exacerbation of
respiratory symptoms) to
physician.-Do not allow the solution
to enter the eyes.
-Allow 30-60 seconds
between puffs for
optimum results.
-Advice patient to wait for
5 mins between this and
other inhaled medications.
-Let the patient rinse
mouth after medication
puffs to reduce bitter
taste.
Patients DOB
was managed
and relieved.
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DRUG NAME CLASSIFICATION ACTION INDICATIONDOSAGE/ROUTE/FREQ
UENCY
NURSING
CONSIDERATIONS
EVALUATION
BRAND NAME:
Tramadine
GENERIC
NAME:
Tramadol
Analgesics
(opioid)
Inhibits
reuptake of
norepinephrine,
serotonin and
enhances
serotonin
release.
Inhibits
reuptake of
norepinephrine,
serotonin and
enhances
serotonin
release.
Decreased pain
Indicated for the
management of
moderate to
moderately
severe pain.
50mg TIV p.r.n. q6 -Assess type, location,
and intensity of pain
before and 2-3 hr
(peak) a
top related