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    1

    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