CASE PRESENTATION: Lung Adenocarcinoma

Submitted by: Mariz Mae S. Boligao Elaine Therese M. Cabacang Maridee P. Dimagna-ong Julie C. Hubilla Phea Lenny C. Nambatac Carl Stephen B. Perez Charlene Marie A. Raya BSN-RUBY

PATIENTS DATA
Personal Data:

Patients Name: Age: Gender: Birth date: Address: Nationality: Religion [Domination]: Civil Status: Educational Attainment: Occupation: Weight: Clinical/ Admitting Data: Date of admission: Time of admission: Hospital:

Beachin Barato 65 years old Female December 11, 1942 Davao City Filipino Christianity [Roman Catholic] Married High School Graduate Retired High School Teacher for 10 years 62 kilograms

July 2, 2009 9:30 am Davao Medical School Foundation Davao City

[1604730] Ward [Room & Bed H244 Numbers]: Attending Physician: Dr. Allan P. Arreola Chief complaint: Difficulty breathing Admitting and Final Left Massive Pleural Effusion secondary to Lung Diagnosis: Vital signs admission: Temperature: Pulse Rate: Respiratory Rate: Blood pressure:
Chest Tube Thoracostomy

CA on
36C Degrees Celsius

87 Beats per Minute 23 Cycles per Minute 130/ 90 mmHg

2|Page

Surgical Done:

Procedure
*Pre-operation Diagnosis: Massive left pleural effusion secondary to lung cancer *Surgeon: Dr. Lei *Anesthesiologist: Dr. Barinaga

Source information:

of Patient; Patients daughter-in-law; Husband

FAMILY BACKGROUND AND HEALTH HISTORY

HEALTH BACKGROUND A. Family Background Beachin Barato (not her real name), 65 years old was born in Misamis Occidental, on December 11, 1942. She spent majority of her childhood there but was separated with her family during the PhilippineJapanese war. In fact, she does not know who her real parents and siblings are. She acquired formal education up to high school while living in an orphanage. She met her current husband, Mr. Optimus Prime (engineer), who is from Davao, in Misamis. Optimus Prime was working as an engineer in Misamis when they met. The couple decided to marry in Davao, where the family of Optimus Prime can witness the wedding and provide support to the couple, who are still starting out as a young family.

3|Page

The couple has three children, all of which are boys. Their sons got formal education in Davao City National High School. Moreover, all are college graduates in different universities and colleges. Mr. Optimus Prime had a stable job working as an engineer and was their main source of income. Beachin Barato was a devout Catholic, joining church organizations and becoming an active member in their mission of enriching their faith, while recruiting others along the way, as Beachin Barato remarked. This provided her good experience to be a teacher of Religion in Davao City National High School for 10 years. Beachin Barato has nine grandchildren, three for each sons. She only has two granddaughters. Beachin Baratos sons have become successful in their chosen professions, thus they had the means to afford good education for their children. Her eldest son, Bumble Bee, is a manager at a telecommunications company. He has two sons in college while her youngest daughter is still in high school. Her second son, Ironhide, is now working in Pampanga as an engineer for the DPWH. His three sons are still in high school. The third son, Jetfire is currently working as a manager at an oil company. He has two sons and a daughter. The eldest is in high school while the younger children are in grade school.

B. History of Past Illness The past illnesses that the patient has encountered in the past were not significant. Only common minor illnesses such as fever, flu, and

4|Page

hyperacidity were experienced by the patient in her lifetime. She did not experience severe, yet common diseases such as dengue and measles. Also, she has no diabetes mellitus. She has no history of food and drug allergies or hypersensitivities. She and the entire family, according to her, do not smoke. Also, consuming alcoholic beverages was something she did not do. A notable health condition that she experienced is bronchial asthma. She coped with asthma by finding a comfortable position during asthma attacks and she did not take any medications because those were not available yet. Her asthma subsided when she was about 40 years old. A significant disease that she encountered (and is still encountering) later on in her life is hypertension. She was diagnosed after getting her routine blood pressure checkup. The doctor advised her to avoid salty and fatty foods and she was also given medicine, specifically amlodipine besylate- Norvasc. Medications she took in her lifetime were not numerous, according to her. In fact, she said she hardly ever took medications. Paracetamol was always her first choice whenever she encounters fever and colds. She also took some Neozep and mefenamic acid in her lifetime. Also, the patient noted that she had to comply with taking Norvasc for her hypertension.

C. Present Health History The patients hypertension is now held at bay by doing follow-up visits to the doctor, asking for advices and of course, compliance with medications. She also minimized eating her favorite food, which is pork, for the sake of 5|Page

improving her hypertensive state. She is currently in a pre-hypertensive state with a blood pressure of 130/90 mmHg. The doctors first impression with her hypertension was that she was in Stage 2, thus we can say that her condition has significantly improved. The patients lung cancer was diagnosed when she was having an onset of difficulty of breathing for three days when she was on a vacation in Pampanga last May 2009. As the days went by, she noticed a progression of dyspnea. Initially, she thought that her asthma had recurred, which prompted her to seek consultation on June 2009. After a series of diagnostic procedures, she was then diagnosed of having lung cancer. The cancer was classified as adenocarcinoma, or a cancer originating in the mucus producing glands in the lungs. It is known to be the most common cancer in lifelong non-smokers. On July 2, 2009, upon receiving the chest x-ray result, her physician, Dr. Arreola, ordered a STAT chest tube thoracostomy. Dr. Lei performed the procedure with the help of Dr. Barinaga as the anesthesiologist.

DEFINITION DIAGNOSIS

OF

COMPLETE

MASSIVE PLEURAL EFFUSION secondary to LUNG CANCER

6|Page

Pleural effusion, a collection of fluid in the pleural space, is rarely a primary disease process but is usually secondary to other diseases. Normally, the pleural space contains a small amount of fluid (5 to 15 ml), which acts as a lubricant that allows the pleural surfaces to move without friction... Bronchogenic Carcinoma is the most common malignancy associated with pleural effusion. Lung cancer arises from a single transformed epithelial cell in the tracheobronchial airway. A carcinogen binds to cells DNA and damage it. This damage results to cellular changes, abnormal cell growth, and eventually a malignant cell. As damage DNA passed on to the daughter cells, the DNA undergoes further changes and becomes unstable. With accumulation of genetic changes, the pulmonary epithelium undergoes malignant

transformation from normal epithelium to eventual invasive carcinoma. (Kelly, 1997) Cited on medical-surgical nursing vol. 1 (2000) By: Suzanne C. Smeltzer and Brenda G. Bare

PHSYICAL ASSESSMENT
Date of Assessment: July 4, 2009 Time of Assessment: 5:25 pm Location of Assessment: Davao Medical School Foundation Hospital

Vital Signs

7|Page

Temperature : Pulse Rate: Respiratory Rate: Blood Pressure:

36 degrees Celsius 87 Beats per Minute 23 Cycles per Minute--Rapid 130/90 Mercury Millimeter per

General Survey During assessment, the patient was eating on bed. There is a chest tube connected to a chest tube drainage installed on the surgical site located at the 6 th and 7th intercostal space of the left lung. Patient is awake, conscious, coherent, and oriented to time, place, person and reason for admission. She is calm and responsive. The patient has an endomorph type of body; with a height of 158.49 centimeters or 62.4 inches and with a weight of 62 kilograms or 136.4 pounds. Patient had already done her general and oral hygiene and was dressed appropriately for the occasion. Skin Her skin color is normal, appears thin and translucent, dry and flaky over the extremities. Skin lost its elasticity and takes longer to return to its natural shape after being tented between the thumb and finger. The palms and the soles are calloused. Wrinkles appear on the skin of the face and neck. Freckles are also noted on the back of the hand. Incision site is 2 cm on the lateral thorax on the 6 th and 7th intercostal space of the left lung and the compact dressing appears to be fixed. Hair is black, thin and fine textured but not evenly distributed on the scalp. No infection or dandruff noted. Scalp is free of lesions. The hair of the eyebrows is coarse. Nails are pink, firm with capillary refill of 2 seconds and without lesions or clubbing.

8|Page

Head Head is symmetrical, rounded normocephalic with smooth skull contour positioned at midline and erect with no lumps or ridges. Facial movements are symmetrical and patient is able to perform different kinds of facial expression effortlessly and without any obstructions.

Eyes Patient uses corrective lenses when reading. Eyebrows are symmetrically aligned and with equal movement with no presence of flakes, scars, or lesions. Darkened skin around the orbit of the eye is noted. Skin folds of the upper lids are more prominent, and the lower lids sag. Eyes are dry and lusterless and iris appears pale with brown discolorations. Conjunctivas of the eye are also pale. Pupil reaction to light and accommodation is normally symmetrically equal, 2mm in size diameter. Both eyes are coordinated; move in unison and with parallel alignment.

Ears The color of patients ears is the same as her facial skin. The left and the right pinna are symmetrical and are aligned with the inner canthus of the eye. There is no foul smelling serous or purulent discharges noted. External canal is normally clear with minimal dry cerumen. The earlobe is elongated and the skin of the ear is dry and less resilient. Upon palpation, auricles are mobile, and nontender; pinna recoils after it is folded. The patient was able to hear normal voice tones and is able to hear ticking in both ears, as whispered same words on both ears with correct responses. Nose

9|Page

The nose is symmetric, straight, and uniform in color and no discharges or flaring noted. Air moves freely as the patient breathes through the nares. Nasal mucosa is pink, clear and no lesions noted. Nasal septum is intact and in midline. Upon palpation, no tenderness noted.

Mouth Lips are dry, cracked and pale in color and with symmetry in contour. Patient is wearing dentures and has an incomplete set of teeth. Gums are pinkish in color, dry and firm with yellow discoloration of the enamel and dental carries was noted on both lower right and lower left of the teeth. The tongue is normally in midline and was able to move freely, and the base has prominent veins. The patient is able to swallow with no difficulty.

Pharynx The patients uvula was located along the midline. The mucosa was pinkish in color and no lesions or ulcerations noted. The tonsils were pink and smooth, no discharges or inflammation noted.

Neck Neck can perform any range of motion without discomfort and with equal muscle strength as the patient turns his head from left to right; up and down; and circular motion. Trachea was located centrally in the midline of the neck, spaces are equal on both sides, and no deviation noted on any part. No lymph nodes noted on any of the areas of the neck. Thyroid gland is not visible upon inspection. No lymph nodes palpated

10 | P a g e

Chest and Lungs The patients thoracic curvature is accentuated , her chest was not symmetrical due to the surgical site and the spine was vertically aligned from the neck to the buttocks. There was a full and symmetric chest expansion. The anteroposterior diameter of the chest widens because of barrel-chested

appearance. Upon auscultation, no adventitious sounds can be heard.

Heart The patients precordial area is flat; there was no lift or heaves. The point of maximal impulse was located at the fifth left intercostals spaces or along the breast line in line with the nipples. During palpation, the patients carotid artery produces full pulsations with thrusting quality.

Breast and Axilla Patients breasts were even. Skin was smooth and uniform in color with the abdomen. During palpation, there were no tenderness, masses or nodules noted with the patients axillary, subclavicular and supraclavicular lymph nodes. There were also no discharges in the patients nipples. Breast is noted to be saggy in contour and in shape as a sign of breastfeeding and child birth.

Abdomen

11 | P a g e

Patients abdomen is round, with silver white striae, symmetric contour, and no evidence of enlargement of liver or spleen. Abdominal wall is slacker and thinner. The patients abdominal girth measures 34 inches or 74.8 centimeters. Skin returns quickly to its original shape when picked up between two fingers and released. Growling sounds noted with fifteen (15) bowel sounds per minute. No areas of tenderness or palpable organs noted upon palpation. Patient defecates once a day, every morning.

Genitor-Urinary The patient declined to assess her genitals. However, according to the client there were no discharges and pain during urination.

Back and Extremities Patients peripheral pulses were symmetrical, strong, within normal rate, regular in rhythm at 24 beats per minute. The patients nails took 2 seconds for the capillary refill. The nails were pinkish in color. Edema was not noted on the patients upper extremity and lower extremities. There are bilateral warmth on both arms and legs of the client. The patient was able to perform range of motion without any discomfort, swelling, deformity, or nodule on her upper and lower quadrants and on both upper and lower extremities. Weakness and pain were noted at the upper left extremity of the patient near the incision or surgical part. There is no missing finger or bone enlargement on the hands and wrists. The back is also symmetrical with the spinal cord aligning from the neck down to the buttocks. There were no deformities or abnormalities on the bone such

12 | P a g e

as scoliosis, osteoporosis and alike to be noted. There are also no lesions and the like noted on the back. Skin color at the back and the extremities are similar with the rest of the body. Hip joints and thighs can perform range of motion without any discomfort.

ANATOMY AND PHYSIOLOGY

The lungs are a pair of cone-shaped breathing organs in the chest. The lungs bring oxygen into the body as you breathe in. They release carbon dioxide, a waste product of the bodys cells, as you breathe out.

Each lung lobes. The left lung while the right lung is has three lobes. Two bronchi, lead from the to the right and left bronchi are

has sections called has two lobes,

slightly larger and tubes called

trachea (windpipe) lungs. sometimes These also

involved in lung cancer disease process.

13 | P a g e

Tiny air sacs called alveoli and small tubes called bronchioles make up the inside of the lungs. A thin membrane called the pleura covers the outside of each lung and lines the inside wall of the chest cavity. This creates a sac called the pleural cavity. The pleural cavity normally contains a small amount of fluid that helps the lungs move smoothly in the chest when you breathe.

Lung Cancer Cancer of the lung, like all cancers, results from an abnormality in the body's basic unit of life, the cell. Normally, the body maintains a system of checks and balances on cell growth so that cells divide to produce new cells only when needed.

There

are

two

main

types of lung cancer, nonsmall cell lung cancer and small cell lung cancer. First is the Non-small Cell Lung Cancer. NSCLC accounts for about 80% of lung cancers.

There are different types of NSCLC, including 1. Squamous cell carcinoma (also called epidermoid carcinoma). This is the most common type of NSCLC. It forms in the lining of the bronchial tubes and is the most common type of lung cancer in men. 2. Adenocarcinoma. This cancer is found in the glands of the lungs that produce mucus. This is the most common type of lung cancer in women and also among people who have not smoked. 3. Bronchioalveolar carcinoma. This is a rare

14 | P a g e

subset of adenocarcinoma. It forms near the lungs' air sacs. Recent clinical research has shown that this type of cancer responds more effectively to the newer targeted therapies, and 4. Large-cell undifferentiated carcinoma . This cancer forms near the surface, or outer edges, of the lungs. It can grow rapidly. The second type of lung cancer is the Small cell Lung Cancer. SCLC accounts for about 20% of all lung cancers. Although the cells are small, they multiply quickly and form large tumors that can spread throughout the body. Smoking is almost always the cause of SCLC.

Adenocarcinoma Like other cancers, adenocarcinoma is the growth of abnormal cells. These cancerous cells multiply out of control and form a tumor. As the tumor grows, it destroys parts of the lung. Eventually, the tumor's abnormal cells can spread (metastasize) to other parts of the body, including the local lymph nodes in the chest and the central portion of the chest, called the mediastinum; the liver; the bones; the adrenal glands; and other organs, including the brain.

15 | P a g e

When lung cancer metastasizes, the tumor in the lung is called the primary tumor, and the tumors in other parts of the body are called secondary tumors or metastatic tumors. Tumors are dangerous because they take oxygen, nutrients, and space from healthy cells, thus leading to the destruction of the healthy and normalfunctioning cells in our body

16 | P a g e

17 | P a g e

DIAGNOSTIC EXAM
COMPLETE BLOOD COUNT WITH PLATELET COUNT Date Exam Normal Value Result Rationale The test that measures the amount of hemoglobin per liter of blood of Patient 122 g/dL Clinical Significance Normal Nursing Responsibilities
1. Discuss and explain the procedure and purpose of the test. 2. Inform the patient that no fasting is needed. 3. Assess the patient for any factor that

Hemoglobin 120 160 g/dL

18 | P a g e

Date July 2, 2009

Exam Hematocrit

Normal Value M: 4252% F: 3747%

Result Rationale The test measures the percentage of RBC in the total blood volume of Patient 35%

Clinical Significance Normal

Nursing Responsibilities
will probably affect the results of the test. 4. Make sure patient is well hydrated. Dehydration elevates the test results. 5. If patient is connected to IVF, make sure that the blood is not taken from the arm connected to the IVF. Hemodilution causes false decrease of the test results. 6. After the puncture, assess the site for bleeding or bruising.

19 | P a g e

Date

Exam WBC count

Normal Value 0.5-10 X10^9/L

Result Rationale The test measures all leukocytes present in 1 cubic millimeter of blood. of Patient 13.6 X

Clinical Significance HIGH:

Nursing Responsibilities
7. If patient is under treatment from an infection, inform the patient that the test will be repeated to monitor progress. 8. Any abnormality noted will be reported to the physician.

10^9/L Conditions that cause high WBC values include infection, inflammation, damage to body tissues, severe physical or emotional stress (such as a fever, injury, or surgery), burns, kidney failure, lupus, tuberculosis, rheumaoid arthritis, malnutrition, leulemia, and diseases such as cancer.

20 | P a g e

Date

Exam Monocyte

Normal Value 2 10%

Result Rationale Monocytes have phagocytic action. It removes dead or injured cells, cell fragments, and microorganis m. This test is done to diagnose an illness such as inflammatory diseases. of Patient 2%

Clinical Significance Normal

Nursing Responsibilities

21 | P a g e

Date

Exam

Normal Value

Result Rationale Eosinophils initiate allergic responses and act against of Patient

Clinical Significance

Nursing Responsibilities

Eosinophils

1 8%

parasitic infestation. The test is use to diagnose worm infestation. The test circulating RBCs in 1 cubic millimeter of blood.

2%

Normal

RBC count

4.0-5.0X 10^12/L

4.73X L

Normal

measures the 10^12/

22 | P a g e

Date

Exam

Normal Value

Result Rationale The test measures the of Patient

Clinical Significance

Nursing Responsibilities

Thrombocyt es

150300X 10^9/L

amount of platelets that are important for blood clotting. The test meaures the percentage of

290 X10^9/ L Normal

Lymphocyte s

20-40%

the principal component of the bodys immune system.

20%

Normal

23 | P a g e

PROTHROMBIN TME Date Exam Normal Value Result Rationale The prothrombin time is the time it takes plasma to clot after addition of tissue July 2, 2009 Prothrombi n time 12-15 seconds factor. This measures the quality of the extrinsic pathway (as well as the common pathway) of coagulation. 12.4 second s Normal of Patient Clinical Significanc e 1. Discuss and explain the procedure and purpose of the test. 2. Assess the patient for any factor that will probably affect the results of the test. 3. Check to see if the patient is taking any medications that may affect test results. This precaution is particularly important if the patient is taking warfarin, because there are a number of medications that can interact with warfarin to increase or decrease the PT time. 4. After the procedure,there must be routine care of the area around the puncture mark. Apply moist warm compresses on the area around the puncture mark. Nursing Responsibilities

24 | P a g e

Date

Exam

Normal Value

Result Rationale of Patient

Clinical Significanc e Nursing Responsibilities

The test is to know if there Internation al Normalized Ratio is a high 0.81.2 chance of bleeding or high chance of blood clot. 0.07 Normal

5.Apply pressure for a few seconds and the cover the wound with a bandage. 6. Inform the patient that there might be mild dizziness and the possibility of a bruise or swelling in the area where the blood was drawn.

25 | P a g e

DRUG NAME

ACTION

INDICATION CONTRAINDI- ADVERSE NURSING CATION REACTION RESPONSIBILI TIES

> RELIEF AND PREVENTION OF BRONCHOSP ASM IN PATIENTS WITH REVERSIBLE OBSTRUCTIV E AIRWAY DISEASE OR COPD >INHALATIO N AND TREATMENT OF ACUTE ATTACK OF BRONCHOSP ASM >HYPERSENSITI VITY TO A SALBUTAMOL, ALSO TO ATROPHINE AND ITS DERIVATIVES. >CARDIAC ARRHYTHMIA ASSOCIATED W/ TACHYCARDIA CAUSED BY DIGITALIS INTOXICATION. >FINE >ASSESS CARDIOSKELETAL RESPIRATORY MUSCLE FUNCTION: B/P, TREMOR, LEGHEART RATE AND CRAMPS, RHYTHM AND PALPITATIONS BREATH SOUNDS , >MONITOR FOR TACHYCARDIA EVIDENCE OF , ALLERGIC HYPERTENSIO REACTIONS AND N, HEADACHE,PARADOXICAL NAUSEA, BRONCHOSPASM VOMITING, DIZZINESS, HYPERACTIVIT Y, INSOMNIA,

DATE ORDERED: FEB.13 2011 GENERIC NAME: NEBULIZATON WITH SALBUTAMOL + IPRATROPIUM Q 8 1 AMP. BRAND NAME: ACTIVENT DOSAGE AND FREQUENCY: 1NEB. 1AMP EVERY 8 HOURS. CLASSIFICATIO N: SYMPHATOMIM ETICS

>STIMULATES BETA2 RECEPTORS OF BRONCHIOLES BY INCREASING THE LEVELS OF CAMP WHICH RELAXES SMOOTH MUSCLES TO PRODUCE BRONCHODILATI ON.

26 | P a g e

. DRUG NAME

ACTION

INDICATION CONTRAINDICATIO ADVERSE N REACTION

NURSING RESPONSIBILITIES

Date >Synthetic >Respiratory glucocorticoid diseases Ordered: marked Feb.13 2011 w/ antiGeneric inflammatory effect because Name: of its ability to Dexamethas inhibit one 250 g IV prostaglandin q8 synthesis, inhibit Brand Name: migration of macrophages, Decilone leukocytes Dosage and and Frequency: fibroblasts at of Classificatio sites inflammation, n: phagocytosis and lysosomal Hormones and related enzyme release. It can drugs. also cause the reversal of increased capillary permeability.

>systemic fungal>Thromboembolis > Obtain pt. infection: IMm or fat embolism;history of injection use inthromboplebitis; underlying idiophatic necrotizing condition thrombocytopenic angiitis; cardiacbefore purpura: arrhythmias ortherapy. ECG changes. >Assess for >vertigo possible drug induced > headache adverse >Impared woundreaction. healing >Monitor >visual acuity renal status and function. >thoat irritation >Assess mental status: Affect, mood, behavioral changes. >Assess pts and familys knowledge on drug therapy.

27 | P a g e

DRUG NAME

ACTION

INDICATION

CONTRAINDICATION ADVERSE NURSING REACTION RESPONSIBILITIES of>Assess patients condition before and after drug ortherapy. Monitor peak expiratory flow. >Monitor for evidence of allergic reactions, paradoxic bronchopspasm. >Assess pt and familys knowledge on drug therapy. >Inform pt. that drug is not effective for treatment of acute bronchopspasm >Teach pt. the proper way of drug administration.

Date Ordered:

Chemically relatedAcute Hyper sensitivity toDryness to atropine, itexacerbations soya lecithin or relatedmouth, Feb. 13, 2011 antagonizes theof chronicfood products. Atropinethroat effect of obstructive or any anticholinergicirritation Generic Name: acetylcholine. Itpulmonary derivates. cough. Nebulizaton causes a local anddisease with site specific(COPD). Used salbutamol + bronchodilatation in conjunction betaIPRATROPIUM by preventing thew/ increase in adrenergic q 8 1 amp. intracellular cyclicstimulant for Brand Name: guanosine mono-acute phosphate whichasthmatic Atrovent produced by theattacks. of Classification: interaction acetylcholine w/ Anticholinergic the muscarinic s receptors of the bronchial smooth muscles.

28 | P a g e

29 | P a g e

NURSING CARE PLAN

Patients Name: Beachin Barato Chief Complaint: Difficulty of Breathing Arreola Gender: Female Diagnosis: Massive pleural effusion secondary to lung cancer. Room No.: 4C 444 to 244 Date and Time July 3, 200 9 at 5:00 pm Cues Subjective cues: Verbalized difficulty in breathing. Objective cues: -Rapid breathing Respiratory rate: 23 cycles per minute - O2 saturation of 65% Nursing Diagnosis Impaired gas exchange related to disease process as evidenced by dyspnea. (R) The presence of pleural fluid (a complication of lung cancer wherein pleural fluid collects in the pleural space as a result of irritation or obstruction of the venous drainage by the tumor), may hinder adequate lung expansion, and it causes the pleural membranes (essential for diffusion of gases) to compress thus Need(s ) A C T I V I T Y E X E R C I S E Objective(s) of care Within 3 hours of nursing care, the patient will experience improved gas exchanged as evidenced by: a. Improved oxygenati on (within 88%100% O2 saturation ) and absence of respirator y distress. b. Statemen t of acceptabl Age: 65 years old Attending Physician: Dr. Allan P. Shift: 3-11 Date: July 2, 2009

Interventions

Evaluation July 3, 2009 at 7:30pm GOAL PARTIALLY MET. Within three hours of nursing care, the patient stated acceptable dyspnea. Nakakahinga na ako ng mas maayos kaysa kanina. In addition, the patient participated in treatment regimen, such as breathing exercises. However, the patient still has

Independent: Monitor vital signs. (R)To evaluate degree of compromise. Assess lung sounds, respiratory rate and effort and use of accessory muscles. (R) Respiratory rate less than 12 or more than 24 or use of accessory muscles indicate distress. Diminished lung sounds indicate possible poor air movement and impaired gas exchange. Observe skin and

30 | P a g e

affecting gas exchange.

Source: William, L. Hopper, P. (2007) Understanding Medical Surgical Nursing: Third Edition. Philadelphia: F. A Davis.

e dyspnea. c. Participati on in treatment regimen (breathin g exercises) within the level of ability.

mucous membranes for cyanosis. (R) Cyanosis indicates poor oxygenation. Oral mucous membrane cyanosis indicates serious hypoxia. Monitor for confusion or changes in mental status. (R) A change in mental status indicates impaired gas exchange. Elevate head of bed or help the patient lean on over bed table. (R) Upright position helps promote lung expansion. Encourage adequate rest and limit activities within clients level of tolerance. Promote a calm and restful environment. (R) Helps limit oxygen needs/consumption. Dependent: Monitor for ABG prn. (R) PaO2 < 80 mmHg, PaCO2 > 45mmHg or SaO2 <

respiratory distress and has 02 saturation by 7:30pm of only 73%.

31 | P a g e

may indicate impaired gas exchange. Administer supplemental oxygen as ordered by the physician. (R) Supplemental oxygen decreases hypoxia. Administer medications as needed. (R) To treat underlying Independent: Assess pain level q4h and prn. (R) Good assessment must guide treatment. Assess sedation and respiratory status frequently. (R) Opioids are given carefully because they may reduce respiratory rate and cough reflex, which is vital to achieve normal breathing pattern and clearing the airway. Include nonpharmacological pain interventions (such as distraction and relaxation). (R) It

July 3, 200 9 at 5pm

Subjective: Ayaw itaas ang ulohan nako, kay naga-sakit ang akoang dughan. Objective: -Covers /Protects the painful area -Resistance when it comes to lifting the head part.

Acute pain related to chest tube thoracostomy procedure as evidenced by guarded and expressive behaviour. (R) The effect of anaesthesia can be diminished after the patient has been fully awaked and conscious. The hole made by the incision and insertion of chest tube can be painful, as movements often cause tension and pull to the tube, thus the perceived pain.

C O G N I T I V E P E R C E P T U A L

Within 8 hours of nursing care, the patient will: a. State that her pain is relieved (rating of 3-5 out of 10 in pain scale). b. Verbalize methods that provided relief.

July 3, 2009 at 7:30pm GOAL MET. The patients pain was relieved as evidenced by pain scale of 4 out of 10. And the patient verbalized methods that provided relief such as the pain medications given, distraction techniques by constantly talking to significant others.

32 | P a g e

-Restricted movements . -Pain scale of 6 out of 10.

Source: William, L. Hopper, P. (2007) Understanding Medical Surgical Nursing: Third Edition. Philadelphia: F. A Davis.

will help pain control and reduce the need for opioids. Dependent: Administer analgesics as ordered, on an around- the- clock basis, via a patientcontrolled pump, for the first few days of surgery. (R) The patient who is pain free will be better able to participate in care and take measures to prevent complications such as coughing and ambul

33 | P a g e

Discharge Plans or [METHOD]:

MEDICATION
Take pain medications as needed Inform client to take medications on time, or as directed for the full course of therapy, even if feeling better. Inform the client about the possible side effects of the medication. Encourage the client to report or inform the physician if any of these side effects occur. Inform and explain to the client in simple terms that other drugs, such as over the counter drugs that he or she is taking, will probably have other effects with the medication given. Moreover, emphasize the right timing or taking or the right time intervals of these drugs to maximize its effects and avoid further complications. Provide information for better understanding regarding therapeutic regimen

EXERCISE
Encourage early ambulatory. Patient will be given deep breathing exercises to promote lung expansion. breathing. Use an incentive spirometer to promote deep

TREATMENT
Instruct the client to continue drug therapy as ordered. Inform the client as well as the family the dangers of non compliance to treatment regimen. Discuss to the client the complication of the condition. Inform client to do exercises and stretches. Advise patients to wash their hands before touching incision sites. Instruct the patient to report to the physician promptly about any changes on health condition. Encourage patient to strictly comply with the doctors orders, especially in taking prescribed medications

34 | P a g e

Encourage the patient to have followed up visitations to the physician after discharge.

HEALTH TEACHINGS
The incision area must be kept dry until the wound begins to heal and sponge baths are recommended for the first day or two. Provide meticulous chest tube care, and use aseptic technique for changing dressings around the tube insertion site. If the patient has open drainage through a rib resection of intercostal tube, use hand and dressing precautions. Notify the physician on the following: o o o o fever and chest colds redness, swelling, or bleeding or other drainage from the incision site(s) increased pain around the incision site(s) abdominal pain, cramping, or swelling

OUTPATIENT
Remind client on the arrangements to be made with the physician for follow-up check ups Follow-up check up regularly in order to monitor and properly manage patients illness. Continue medication as ordered. Instruct to have a follow-up check-up or refer to the physician if the patient is uncomfortable Instruct the client and significant others to report for any unusualities. Record the amount, color, and consistency of any tube drainage.

35 | P a g e

The pathology results from patients surgery should be available within one week after your surgery.

Follow-up appointments are generally made before surgery with the physician and a nurse. The dressing will be changed or removed at patients post-operative visit.

DIET
Instruct client may resume his regular diet as soon as he can take fluids after recovering from anesthesia. Encourage eight to 10 glasses of water and non-caffeinated beverages per day, plenty of fruits and vegetables as well as lower fat foods. Encourage to eat high fiber foods such as fruits and vegetables.

36 | P a g e