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SAINT LOUIS UNIVERSITY

COLLEGE OF NURSING
BAGUIO CITY

NCP
(CASE STUDY)

SUBMITTED BY:
FERRER, Tristan
GALINATO, Michael
RABARA, Romuel
ALMEROL, Bernalyn
BLANCO, Catherine
BOADO, Andrienne
DAMASCO TY, Mikaella
LAGUINDAY, Michelle
MEJIA, Camille
PARAS, Mary Margarette
SARMIENTO, Ellaine Joyce
URAYENZA, Aira Joyce

SUBMITTED TO:
Ma’am Shiela Adversalo
I. Demographic Data

Full Name: Jesus Carlota Tan Jr.


Age: 59 years old
Birthdate: August 18, 1950
Birthplace: Cebu City
Address: 214 Naguilian Road, Baguio City
Civil Status: Married
Religion: Roman Catholic
Nationality: Filipino
Highest Educational Attainment: Military Graduate
Occupation: Retired military officer (Major)
Date Admitted: August 25, 2009
Time of Admission: 4:30 pm
Chief Complaint: Right flank pain
Impression Diagnosis:Massive pleural effusion right parapneumonic vs. malignant pleural effusion

II. History of Present Illness

2 weeks prior to admission, patient has difficulty of breathing with associated cough and chest pains. No head ache, no fever and no nausea and vomiting.
No medical consultations were done.
1 week prior to admission, after lifting a heavy object, client felt right flank pain described as shooting in character. No fever, head ache or nausea and
vomiting noted. The patient sought consult to his private physician and was given Arcoxia and Myonal affording slight relief. The patient’s right flank pain persisted
in the next few days even having Arcoxia and Myonal. The patient had DOB when sleeping and lying flat on bed.
He was relieved when he was doing right lateral decubitus position. Patient’s flank pain persisted despite the medications and when the pain was already
severe, the patient was brought to the institution for further management and evaluation; hence, admission.

III.Past Medical History

Patient has no known allergies to food and drugs. No major operations were done and no trauma noted. Immunizations were unrecalled.
The patient has been diagnosed with CVD, RMCA on 2006 and his last admission was July 2009 due to removal of boil. The patient was a known
hypertensive and diabetic. Maintenance drugs include Norises, Lifezar, Aspilet, Metformin and Plavix with good compliance.
IV. Family History

The patient claims to have a history of heredofamilial diseases such as DM and HPN and denied any history of CAD, asthma, cancer, CVD, goiter and
kidney diseases.

V. A. Course of Confinement

This is the case of Jesus Tan, a 59 yr old male, married, Filipino, Roman Catholic, born in Cebu City on September 18, 1950, currently residing at 214
Naguilian Road Baguio City. He was admitted for the 2nd time in this institution on August 25, 2009, with a chief complaint of right flank pain. He was given an
IVF of Plain NSS upon admission.

VI. B. Diagnostics

August 27, 2009

Results Normal Values


WBC 10.0 10e9/L 5.00-10.00
58.6% N 45.0-70.0% N
30..0 % L 20.0-40.00 % L
8.61 % M 0.00-12.00 % M
1.68 % E 0..00-8.00 % E
1.13 % B 0.00-2.00 % B
RBC 4.95 10e12/L 4.50-6.00
HGB 140 g/L 120-170

HCT 0.421 L/L 0.40-0.54


8.51 fL

MCV 76.0-96.0
MCH 331 g/L 320-360
Platelet: adequate
Comments: Normocytic, normochromic
RBCs
MCHC 27.0-32.0
28.2 pg

Interpretation:

This test is used to aid in diagnosing anemia and other blood disorders and certain cancers of the blood; to monitor blood loss and infection; to monitor a patient's
response to cancer therapy, such as chemotherapy and radiation. It is also used to diagnose and/or monitor bleeding and clotting disorders through platelet count and
to evaluate bleeding and clotting disorders and to monitor anticoagulation (anti-clotting) therapies through prothrombin time.This test was done to determine the
existence of an infection and to determine if blood components are within normal levels. An increase in the WBCs in indicative of infection whereas a decrease in
the HGB or HCT indicates the possibility that the blood may not be able to adequately supply body’s demands for oxygen. All findings in the examination are
within the normal range.

X-Ray Report

August 25, 2009

Chest PA and Thoracolumbar Vertebrae

Chest

There is homogeneous opacity seen in the right lung field. Observing the right hemidiaphragm and costophrenic angle.
The tracheal air column and mediastinal structures are directed to the right.
Cardiac shadow cannot be evaluated. Atherosclerotic aortic knob. Intact left hemidiaphragm and costrophrenic angle.
• Massive pleural effusion, right
• Atherosclerotic aortic knob
Thoracic and Lumbar

Osteophytic lippings are seen in the articulatory margins of the thoracic and lumbar spine
No evident fracture or listhesis
Line of gravity is physiologic
Intact pedicle and disc spaces
Lumbarized S1 vertebral body
Atherosclerotic abdominal aorta
• Degenerative disease of the thoracic and lumbar spine
• Lumbarized S1

Interpretation:

X-rays are especially useful in the detection of pathology of the skeletal system, but are also useful for detecting some disease processes in soft tissue.Client has
been given an impression diagnosis of massive pleural effusion. In order to confirm the diagnosis, a chest x-ray has been performed. Results convey that there is
massive pleural effusion at the right lung pleura and reveals atherosclerosis of the abdominal aorta which means that there are increased cholesterol deposits at the
wall of the abdominal aorta which may obstruct blood flow.

X-Ray Report

August 26, 2009

Follow up chest study since August 25, 2009 reveals minimal clearing of the previously seen right sided pleural effusion.
The left lung field is still unremarkable
The tracheal air column and mediastinal structure now appear midline
Cardiac shadow still could not be evaluated properly
A CTT tube is seen in the right peripheral hemithorax
No interval change noted

Interpretation:
X-rays are especially useful in the detection of pathology of the skeletal system, but are also useful for detecting some disease processes in soft tissue.After the
insertion of a CTT to drain pleural fluid, x-ray reveals minimal clearing of the right pleural effusion which means that there is minimal decrease in the pleural
volume found at the right lung.. This x-ray has been done as a follow up to the previous x-ray in order to determine the progress of the condition and to check the
placement of the CTT at the same time.

X-Ray Report
August 27, 2009

Follow up study since 08-26-09 shows further clearing of the previously seen right sided pleural effusion.
The lung is still unremarkable
No internal changes noted

Interpretation:

X-rays are especially useful in the detection of pathology of the skeletal system, but are also useful for detecting some disease processes in soft tissue.This x-ray is
done as a follow up of the recent x-ray. This is to determine whether the pleural fluid has been reduced. The result reveals further clearing of the right pleural
effusion which means that the CTT is effective in draining pleural secretions.

Hematology
August 25, 2009

Blood Type: “O”

Rhesus Factor: positive (+)

Bleeding Time: 3 minutes Normal Value: 1-7 minutes


Clotting Time: 7 minutes Normal Value: 5-15 minutes

Interpretation:

A complete blood cell count is a measurement of size, number, and maturity of the different blood cells in a specific volume of blood. A complete blood cell count
can be used to determine many abnormalities with either the production or destruction of blood cells. Variations from the normal number, size, or maturity of the
blood cells can be used to indicate an infection or disease process. Often with an infection, the number of white blood cells will be elevated. The use of this test is
To aid in diagnosing anemia and other blood disorders and certain cancers of the blood; to monitor blood loss and infection; to monitor a patient's response to cancer
therapy, such as chemotherapy and radiation. Since the patient is a diabetic and needs to undergo an invasive procedure, his clotting and bleeding time should be
known in order to determine whether the procedure can be pursued. It is also important to determine the patient’s blood type and Rh factor to prepare for Blood
transfusion if in case bleeding persists and is uncontrolled during the procedure.

Pleural Fluid Examination


August 25, 2009

Physical Description

Pleural fluid submitted for study

Volume: 22 mL
Apperance: turbid
Color: red

Microscopic Description
Smears
- Few atypical cells with medium-sized to large oval nuclei, occasionally with prominent nucleoli, scanty to moderate amount of cytoplasm seen singly
in small clusters
- Few lymphocytes and occasional macrophages
- Few mesothelial cells
- Some erythrocytes

Interpretation:

The test is performed to determine the cause of fluid accumulation in the pleural space (pleural effusion), or when cancer is suspected. In an abnormal test,
malignant (cancerous) cells are present and may indicate a cancerous tumor. This test most often detects breast cancer, lung cancer, and lymphoma. Pleural fluid
from the CTT drain has to be examines in order to determine whether there is a presence of infection at the pleural area. The result reveals the presence of atypical
cells with few lymphocytes and occasional macrophages indicating the presence of an infectious process; with the body’s defenses trying to combat infection by the
release of phagocytic cells.

Plasma Examination

September 2, 2009

Source of Specimen: citrated plasma


Examination Desired: Prothrombin time and activity
Results:

Patient’s plasma: 12.3 seconds


Control plasma: 11.5 seconds
Reference Value: 9.8-12.7 seconds
Prothrombin Activity: 97.1%
I.N.R.: 1.07

Interpretation:

The prothrombin time is the time it takes plasma to clot after addition of tissue factor (obtained from animals). This measures the quality of the extrinsic pathway (as
well as the common pathway) of coagulation. The prothrombin time is the time it takes plasma to clot after addition of tissue factor (obtained from animals). This
measures the quality of the extrinsic pathway (as well as the common pathway) of coagulation. This test has been performed to determine effectiveness of client’s
clotting capacity. Prothrombin is converted to thrombin during clotting. The prothrombin value is quite high indicating that the patient has good clotting capacity.

Creatinine G
September 4, 2009

1.2 mg/dL
Normal Value: 0.6-1.3 mg/dL

Interpretation:
Creatinine tests measure the level of the waste product creatinine in your blood and urine. These tests tell how well your kidneys are working. The substance
creatine is formed when food is changed into energy through a process called metabolism. Creatine is broken down into another substance called creatinine, which
is taken out of your blood by the kidneys and then passed out of your body in urine. Creatinine is made at a steady rate and is not affected by diet or by normal
physical activities. If your kidneys are damaged and cannot work normally, the amount of creatinine in your urine goes down while its level in your blood goes up.
Normal levels of creatinine in the blood are approximately 0.6 to 1.2 milligrams (mg) per deciliter (dl) in adult males and 0.5 to 1.1 milligrams per deciliter in adult
females. The most common causes of longstanding kidney disease in adults are high blood pressure and diabetes mellitus. The cretainine level of the patient is 1.2
mg/dL which revealed that kidneys are not damaged or deficient and did not lead to sudden rise in the blood levels.

CBG (September 4, 2009)

12:00AM – 199 4:50PM – 83

4:00AM - 162 6:20PM - 108

8:00AM - 117 6:00AM – 153

11:30 AM – 137

Interpretation:

CBG consisting in measuring the glucose (sugar) content in the blood is done on a regular basis in diabetes patients to determine their glucose level (Normal = 90 -
120). It consists in making a pinprick with a sterile throwaway lancet in a fingertop, collecting a blooddrop (capillary blood) on a chemical strip, which is introduced
in a glucosemeter. The result appears in a LED.The purpose is to find out if the dosis of medecine which the patient is taking is correct and if his diet is right or if
corrections should be made. It is done in general from one to various times a week.

VII. Drug Study


Generic Name: Losartan Potassium

Brand Name: Lifezar

General Classification: Anti-hypertensive, Angiotensin II Antagonist

Indication: HPN

Mechanism of Action: Blocks the strong BP raising effect of angiotensin II by competing with angiotensin II for tissue binding sites and prevent angiotensin II
from combining with its receptors in the body tissues. It blocks the Angiotensin II AT1 receptors and decreases arterial BP by decreasing vasoconstriction and
systemic vascular resistance.

Contraindications: Hypersensitivity, symptomatic hypotension, hepatic impairment, renal artery stenosis

Side Effects: Facial edema, Fever, angina pectoris, 2nd degree AV block, arrhythmia, diarrhea, dry mouth, anemia, gout, muscle cramps, arthritis, anxiety disorder,
migraine, nervousness

Interactions: Co-administration of losartan and cimetidine led to an increase of about 18% in AUC of losartan but did not affect the pharmacokinetics of its active
metabolite. Losartan and phenobarbital, when used concomitantly led to a reduction of about 20% in the AUC of losartan and that of its active metabolite. Losartan
did not affect the pharmacokinetics and pharmacodynamics of warfarin, oral or IV digoxin, and ketoconazole.

Nursing Considerations: Check BP before each dose. Observe for interactions when administering other drugs that may decrease the drug’s effect such as
adrenergics. Instruct to report if any adverse effects are experienced. Instruct to take drug regularly

Generic Name: Metformin HCl

Brand Name: Neoform


General Classification: Metabolic/Endocrine Drug, Alpha-Glucosidase Inhibitor

Indications: NIDDS Type 2, inadequately controlled by proper dietary management and exercise especially in obese diabetic patients, patients no longer
responding to sulphonylureas, either alone or in combination with other drugs

Mechanism of Action: Inhibits alpha-glucosidase enzymes (sucrose, maltase, amylase) in the GI tract and thereby delay digestion of complex carbohydrates into
glucose and other simple sugars. As a result, glucose absorption is delayed and there is small increase in blood glucose levels following a meal. It is metabolized in
the GI by digestive enzymes and intestinal bacteria. Some of the metabolites are absorbed systemically and excreted in the urine; plasma concentrations are
increased in the presence of renal impairment.

Contraindications: Cardiac failure, ketoacidosis, chronic liver disease, recent MI, acute or chronic alcoholism, conditions likely to predispose to lactic acidosis

Side Effects: Diarrhea, lactic acidosis, anorexia, abdominal pain, nausea and metallic taste

Interactions: Reduction in metformin HCl dosage may be required in patients receiving metformin HCl and cimetidine concomitantly to reduce the risk of lactic
acidosis.

Nursing Considerations: Assess changes in blood sugar levels (400 mg/100ml is dangerous). Ideally administer at the beginning of a meal so the drug will be
present at the GIT with food and be able to block the digestion of CHOs. Instruct to report any side effects

Generic Name: Etoricoxib

Brand Name: Arcoxia

General Classification: Analgesic-Antipyretic, Muscle Relaxant, cox-2 Inhibitor

Indications: rheumatoid arthritis, psoriatic arthritis, osteoarthritis, ankylosing spondylitis, chronic low back pain, acute pain, gout
Mechanism of Action: Inhibits isoform 2 of cyclo-oxigenase enzyme (COX-2). This reduces the generation of prostaglandins (PGs) from arachidonic acid. Among
the different functions exerted by PGs, their role in the inflammation cascade should be highlighted. COX-2 selective inhibitor (aka "COXIB") showed less marked
activity on type 1 cycloxigenase compared to traditional non-steroidal anti-inflammatory drugs (NSAID). This reduced activity is the cause of reduced
gastrointestinal toxicity, as demonstrated in several large clinical trials performed with different COXIB

Contraindications: Hypersensivity, acute peptic ulceration, or active GI bleeding, bronchospasm, acute rhinitis, nasal polyps, angioneurotic oedema, urticaria

Side Effects: Immune system disorders, nervous system disorders, cardiac disorders, respiratory and thoracic mediastinal disorders

Nursing Responsibilities: Administer with full glass of fluid during or after meals to decrease gastric irritation. Observe for decrease in the severity of pain.
Instruct client to report any untoward effects

Generic Name: Eperisone

Brand Name: Myonal

General Classification: Antispasmodic, Skeletal Muscle Relaxant

Indications: Spastic paralysis in conditions such as cerebrovascular disease, spastic spinal paralysis, cervical spondylosis, postoperative sequelae (including from
cerebrospinal tumour), sequelae to trauma (e.g. spinal trauma or head injury), amyotrophic lateral sclerosis, cerebral palsy, spinocerebellar degeneration, spinal
vascular diseases and other encephalomyelopathies, improvement of muscular hypertonic symptoms in conditions such as cervical syndrome, periarthritis of the
shoulder, and lumbago

Mechanism of Action: Eperisone acts by relaxing both skeletal muscles and vascular smooth muscles, and demonstrates a variety of effects such as reduction of
myotonia, improvement of circulation, and suppression of the pain reflex. The drug inhibits the vicious cycle of myotonia by decreasing pain, ischaemia, and
hypertonia in skeletal muscles, thus alleviating stiffness and spasticity, and facilitating muscle

Contraindications: Eperisone is contraindicated in patients with known hypersensitivity to the drug


Side Effects: Shock and Anaphylactoid reactions: In the event of symptoms such as redness, itching, urticaria, oedema of the face and other parts of the body,
dyspnoea etc, treatment should be discontinued and appropriate measues taken. Oculo-muco-cutaneous syndrome (Stevens Johnson Syndrome) and Toxic
Epidermal Necrolysis: Serious dermatopathy such as oculo-muco-cutaneous syndrome (Stevens-Johnson syndrome) or toxic epidermal necrolysis may occur.
Patients should be carefully observed, treatment discontinued and appropriate measures taken, in the event of symptoms such as fever, erythema, blistering, itching,
ocular congestion or stomatitis, etc. CNS side effects: Depletion of Myelin Sheath of Nerves. Other side effects: anaemia, rash, pruritus, sleepiness, insomnia,
headache, nausea ang vomiting, anorexia, abdominal pain, diarrhoea, constipation, urinary retention or incontinence.

Nursing Considerations: Caution the patient on the possible side effects of the drug. Monitor for signs of psychological hypofunction during treatment. Administer
the drug after meals to decrease gastric irritation

Generic Name: Bisacodyl

Brand Name: Dulcolax

General Classification: Laxative—stimulant

Indications: Treatment of constipation, particularly when associated with prolonged bed rest, evacuation of the bowel prior to radiologic studies or surgery

Mode of Action: Stimulates peristalsis, alters fluid and electrolyte transport producing fluid accumulation in the colon.

Contraindication: Hypersensitivity, abdominal pain, obstruction, nausea or vomiting, especially when associated with fever or other signs of an acute abdomen

A/R and S/E: Nausea, abdominal cramps

Interactions: Antacids may remove enteric coating of tablets. May decrease the absorption of other orally administered drugs because of increased motility and
decreased transit time.

Nursing Implication: Assess patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Assess color, consistency, and
amount of stool produced.
Generic Name: Paracetamol

Brand Name: Alaxan

General Classification: Analgesic Antipyretic

Indications: Mild and moderate pain and fever

Mode of Action: Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces antipyresis by inhibiting the hypothalamic
heat-regulating centre. Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.

Contraindication: Renal or hepatic impairment; alcohol-dependent patients; G6PD deficiency.

Side Effects: Nausea, allergic reactions, skin rashes, acute renal tubular necrosis.

Interactions: Reduced absorption of cholestyramine within 1 hr of admin. Accelerated absorption with metoclopramide. Decreased effect with barbiturates,
carbamazepine, hydantoins, rifampicin and sulfinpyrazone. Paracetamol may increase effect of warfarin.

Nursing Implications: Assess patient for signs and symptoms of infection. Assess patients pain characteristics.

Generic Name: Cefotaxime Na

Brand Name: Zefocent

General Classification: Cephalosporins


Indications: Serious & life-threatening infections due to susceptible gm+ve & gm-ve bacteria. Pneumonia, resp infections, UTI, septicemia, bacterial endocarditis,
meningitis. Osteomyelitis, septic arthritis, cellulitis, peritonitis, cholangitis, cholecystitis, tonsillitis. Post-injury, burns, wound & post-op infections, adnexitis,
prostitis, gonorrhea, endometritis, parametritis.

Mode of Action: Inhibits protein synthesis of the bacteria

Contraindications: Hypersensitivity to cephalosporins, penicillins & local anesth eg lidocaine (in IM use

Side Effects: Shock, hypersensitivity reactions, hematologic, renal & hepatic disturbances. Digestive & resp effects. Vit deficiencies & alteration in bacterial flora.

Interactions: Aminoglycosides & diuretics eg furosemide.

Nursing Implications: Assess patient for infection. Obtain specimen for culture and sensitivity. Monitor intake and output and daily weight to assess hydration
status and renal function

Generic Name: Diazepam

Brand Name:

General Classifications: Anxiolytics, Anti convulsants

Indications: Short term treatment for anxiety, insomia, sleepwalking, seizures, muscle spasms,

Mode of Action: Diazepam is a long-acting benzodiazepine with anticonvulsant, anxiolytic, sedative, muscle relaxant and amnestic properties. It increases neuronal
membrane permeability to chloride ions by binding to stereospecific benzodiazepine receptors on the postsynaptic GABA neuron within the CNS and enhancing the
GABA inhibitory effects resulting in hyperpolarisation and stabilisation.

Contraindications: Hypersensitivity; preexisting CNS depression or coma, respiratory depression; acute pulmonary insufficiency or sleep apnoea; severe hepatic
impairment; acute narrow angle glaucoma; children < 6 mth; pregnancy and lactation.
Side Effects: Psychological and physical dependence with withdrawal syndrome; fatigue, drowsiness, sedation, ataxia, vertigo, confusion, depression, GI
disturbances, changes in salivation, amnesia, jaundice, paradoxical excitation, elevated liver enzyme values; muscle weakness, visual disturbances, headache,
slurring of speech and dysarthria; mental changes; incontinence, constipation; hypotension, tachycardia; changes in libido; pain and thrombophloebitis at Inj site
(IV).

Interactions: Increased clearance of diazepam when used with phenytoin, carbamazepine and phenobarbital. Reversible deterioration of parkinsonism may occur
when given together with levodopa. Combination with lithium may produce hypothermia.

Nursing Implications: Assess patients general status. Caution the patient on the possible side effects of the drug. Monitor for signs of psychological hypofunction
during treatment.

Generic Name: Glimepiride

Brand Name: Norizec

General Classification: Antidiabetic

Indications: Adjunct to diet and exercise to lower blood glucose in patients with type 2 diabetes mellitus as monotherapy and in combination with metformin or
insulin when diet and exercise plus the single agent do not result in adequate glycemic control.

Mode of Action: Oral hypoglycemic agent. Glimepiride is a sulfonylurea antidiabetic agent. It lowers blood glucose primarily by stimulating the release of insulin
from functioning pancreatic β-cells. Glimepiride also provides overall glycemic control by increasing sensitivity of peripheral tissues to insulin.

Contraindications: Known hypersensitivity to glimepiride. Diabetic ketoacidosis with or without coma. Treat this condition with insulin.

Side Effects: Hypoglycemia (blood glucose values <60 mg/dL): 0.9-1.7%


Adverse events occurring in >1% of glimepiride patients: Dizziness: 1.7%; asthenia: 1.6%; headache: 1.5%; nausea: 1.1%. Vomiting, gastrointestinal pain and
diarrhea (<1%); rarely, increase in liver enzymes. Allergic skin reactions eg, pruritus, erythema, urticaria, maculopapular reactions (<1%). Leukopenia,
agranulocytosis, thrombocytopenia, hemolytic anemia, aplastic anemia and pancytopenia have been reported with sulfonylureas.

Interactions: Nonsteroidal anti-inflammatory drugs (NSAIDs), sulfonamides and highly protein-bound drugs eg, salicylates, chloramphenicol, coumarins,
probenecid, monoamine oxidase inhibitors and β-blockers can potentiate the hypoglycemic action of glimepiride and sulfonylureas. Thiazides and other diuretics,
corticosteroids, phenothiazines, thyroid products, estrogen, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics and isoniazid tend to produce
hyperglycemia and may lead to loss of glycemic control. Closely observe the patient on glimepiride for loss of glycemic control when these drugs are co-
administered. Co-administration of aspirin (1 g 3 times a day) and glimepiride leads to a 34% decrease in the mean AUC and 4% decrease in the mean Cmax of
glimepiride. However, there is no evidence of clinically significant adverse interactions with uncontrolled concurrent administration of aspirin and other salicylates.

Concomitant administration of propranolol (40 mg 3 times a day) and glimepiride significantly increases Cmax, AUC and t½ of glimepiride by 23%, 22% and 15%,
respectively. Potential interactions between oral miconazole and oral hypoglycemic agents have been reported. Potential interactions of glimepiride with other drugs
metabolized by cytochrome P-450 2C9 also include phenytoin, diclofenac, ibuprofen, naproxen and mefenamic acid.

Nursing Implications: Assess patient for signs and symptoms of hypoglycemia. Assess patient for any change in blood glucose.

Generic Name: Ketorolac

Brand Name: Ketomed

General Classification: NSAIDS

Indications: Short term management of moderate to severe pain

Mode of Action: Ketorolac inhibits prostaglandin synthesis by decreasing the activity of the cyclooxygenase enzyme.

Contraindications: Hypersensitivity to aspirin or other NSAIDs, asthma. Hypovolaemia or dehydration. Do not give postoperatively to patients with high risk of
haemorrhage. History of peptic ulcer or coagulation disorders. Nasal polyps, angioedema, bronchospasm. Labour. Moderate to severe renal impairment. GI
bleeding, cerebrovascular bleeding. As prophylactic analgesic before surgery. Pregnancy, lactation.
Side Effects: GI ulcer, bleeding and perforation, drowsiness, rash, bronchospasm, hypotension, psychosis, dry mouth, fever, bradycardia, chest pain, dizziness,
headache, sweating, oedema, pallor, liver function changes. Transient stinging and local irritation (ophthalmic).

Interactions: May reduce effects of antihypertensives (e.g. ACE inhibitors or angiotensin II receptor antagonists). Increased risk of renal toxicity with ACE
inhibitors, diuretics. Increased adverse effects with aspirin or other NSAIDs. Hallucinations may occur when used with fluoxetine, thiothixene, alprazolam.

Nursing Implications: Assess patient’s pain, signs of dizziness, nervousness and GI disturbances. Medicine should be taken after meals.

Generic Name: Nalbuphine

Brand Name: Nalphine

General Classifications: Analgesic

Indications: Management of Pain

Mode of Action: Nalbuphine is a phenanthrene derivative opioid analgesic with mixed opioid agonist and antagonist activity. It inhibits the ascending pain
pathways, altering the perception of and response to pain by binding to opiate receptors in the CNS. It also produces generalised CNS depression.

Contraindications: May impair ability to drive or operate machinery. Emotionally unstable patients or patients with history of opiate abuse; closely monitor these
patients during long-term therapy. Impaired respiration due to other drugs, uraemia, bronchial asthma, severe infection, cyanosis, respiratory obstruction. MI
patients who exhibit nausea and vomiting and in those about to undergo biliary tract surgery. Head injury, intracranial lesions or pre-existing increased intracranial
pressure. Renal or hepatic impairment. Elderly and debilitated patients. Pregnancy and lactation.

Side Effects: Sedation, dizziness, vertigo, miosis, headache; nausea, vomiting, dry mouth; itching, burning, urticaria. Respiratory depression, dyspnoea, asthma;
speech difficulty, urinary urgency, blurred vision, flushing, warmth; clamminess.

Interactions: Additive CNS depressant effects may occur with other CNS depressants e.g. alcohol, anaesthetics, anxiolytics, hypnotics, TCAs and antipsychotics
Nursing Implications: Assess pain characteristics. Assess for signs of dizziness, headache, nausea and vomiting.

Generic Name: Celecoxib

Brand Name: Celcoxx

General Classification: NSAID

Indications: For the relief of the signs and symptoms of osteoarthritis and rheumatoid arthritis in adults. Management of acute pain in adults especially in
postoperative pain. Reduce the number of adenomatous colorectal polyps in familial adenomatous polyposis (FAP), as an adjunct to usual care (eg, endoscopic
surveillance surgery). Treatment of dysmenorrhea.

Mode of Action: Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that exhibits anti-inflammatory, analgesic and antipyretic activities. The mechanism
of action of celecoxib is believed to be due to inhibition of prostaglandin synthesis, primarily via inhibition of cyclooxygenase-2 (COX-2), and at therapeutic
concentrations in humans, celecoxib does not inhibit the cyclooxygenase-1 (COX-1) isoenzyme.

Contraindications: Patients with known hypersensitivity to celecoxib and those who have demonstrated allergic-type reactions to sulfonamide. Patients who have
experienced asthma, urticaria, or allergic-type reactions after taking acetyl salicylic acid (ASA) or other NSAIDs including other COX-2 specific inhibitors. Severe,
rarely fatal, anaphylactic-like reactions to NSAIDs have been reported in such patients. Patients with renal impairment associated with creatinine clearance of <30
mL/min. Patients with severe hepatic impairment (Child-Pugh Class C), heart failure and inflammatory bowel disease. Patients who have previously had a
myocardial infarction (MI) or stroke and in the peri-operative period undergoing cardiac or major vascular surgery.

Side Effects: Abdominal pain, diarrhea, dyspepsia, flatulence, nausea.

Interactions: Celecoxib metabolism is predominantly mediated via cytochrome P-450 2C9 in the liver . Co-administration of celecoxib with drugs that are known
to inhibit 2C9 should be done with caution. Patients who are known or suspected to be P-450 2C9 poor metabolizers based on a previous history should be
administered celecoxib with caution as they may have abnormally high plasma levels due to reduced metabolic clearance.

Nursing Implications: Assess patient’s pain, signs of dizziness, nervousness and GI disturbances. Medicine should be taken after meals.
Generic Name: Pregabalin

Brand Name: Lyrica

General Classification: Anticonvulsants

Indications: Treatment of neuropathic pain in adults.

Mode of Action: Alpha2-delta ligand modulator (Anti-neuropathic pain/Anticonvulsant/Antiepileptics). In vitro studies show that pregabalin binds to an auxiliary
subunit (α2-δ protein) of voltage-gated calcium channels in the central nervous system, potently displacing [3H]-gabapentin. Two lines of evidence indicate that
binding pregabalin to the α2-δ site is required for analgesic and anticonvulsant activity in animal models: (1) Studies with the inactive R-enantiomer and other
structural derivatives of pregabalin and (2) Studies of pregabalin in mutant mice with defective drug binding to the α2-δ protein. In addition, pregabalin reduces the
release of several neurotransmitters, including glutamate, noradrenaline and substance P. The significance of these effects for the clinical pharmacology of
pregabalin is not known.

Contraindications: Hypersensitivity to pregabalin or to any of the excipients of Lyrica.

Side Effects: Increased appetite, Dizziness, somnolence, vertigo, Blurred vision, diplopia, Dry mouth, constipation, vomiting, flatulence

Interactions: Since pregabalin is predominantly excreted unchanged in the urine, undergoes negligible metabolism in humans (<2% of a dose recovered in urine as
metabolites), does not inhibit drug metabolism in vitro, and is not bound to plasma proteins, pregabalin is unlikely to produce, or be subject to, pharmacokinetic
interactions.

Accordingly in in vivo studies no clinically relevant pharmacokinetic interactions were observed between pregabalin and phenytoin, carbamazepine, valproic acid,
lamotrigine, gabapentin, lorazepam, oxycodone or ethanol. In addition, population pharmacokinetic analysis indicated that the commonly used drug classes, oral
antidiabetics, diuretics and insulin, and the commonly used antiepileptic drugs, phenytoin, carbamazepine, valproic acid, lamotrigine, phenobarbital, tiagabine and
topiramate, had no clinically significant effect on pregabalin clearance. Similarly, these analysis indicated that pregabalin had no clinically significant effect on

Nursing Implications: Assess patients general status. Caution the patient on the possible side effects of the drug. Monitor for signs of psychological hypofunction
during treatment.
Generic Name: Clopidogrel

Brand Name: Norvasc

General Classification: Anticoagulants, Antiplatelets & Fibrinolytics (Thrombolytics)

Indications: Prevention of atherothrombotic events in: Patients suffering from myocardial infarction (from a few days until <35 days), ischemic stroke (from 7 days
until <6 months) or established peripheral arterial disease. Patients suffering from acute coronary Non-ST segment elevation acute coronary syndrome (unstable
angina or non-Q-wave myocardial infarction) including patients undergoing a stent placement following percutaneous coronary intervention, in combination with
ASA; ST segment elevation acute myocardial infarction, in combination with ASA in medically treated patients eligible for thrombolytic therapy. (See
Pharmacology under Actions.)

Mode of Action: Platelet aggregation inhibitors excluding heparin. ATC Code: BO1AC/04. Pharmacodynamics: Clopidogrel selectively inhibits the binding of
adenosine diphosphate (ADP) to its platelet receptor, and the subsequent ADP-mediated activation of the GPIIb/IIIa complex, thereby inhibiting platelet
aggregation. Biotransformation of clopidogrel is necessary to produce inhibition of platelet aggregation. Clopidogrel also inhibits platelet aggregation induced by
other agonists by blocking the amplification of platelet activation by released ADP. Clopidogrel acts by irreversibly modifying the platelet ADP receptor.
Consequently, platelets exposed to clopidogrel are affected for the remainder of their lifespan and recovery of normal platelet function occurs at a rate consistent
with platelet turnover

Contraindications: Hypersensitivity to clopidogrel or any component of Plavix. Severe liver impairment. Active pathological bleeding eg, peptic ulcer or
intracranial hemorrhage.

Side Effects: GI bleeding, Diarrhea, abdominal pain, dyspepsia

Interactions: Warfarin: The concomitant administration of clopidogrel with warfarin is not recommended since it may increase the intensity of bleedings.
Glycoprotein IIb/IIIa Inhibitors: Clopidogrel should be used with caution in patients who may be at risk of increased bleeding from trauma, surgery or other
pathological conditions that receive concomitant glycoprotein IIb/IIIa inhibitors
Nursing Implications: Assess for signs of GI bleeding. Assess for abdominal distention. Assess vital signs especially the cardiac rate.

V. Physical Examination

a. Health-Perception-Health-Management Pattern

Whenever the patient or anyone in the family gets sick, home management is done initially. In the case of fever, self-medication of Paracetamol is done to
decrease body temperature. Whenever the patient experiences sore throat, gargling with bactidol, orahex or warm water with salt is done.
If in case the condition is not relieved by home management, the patient seeks for medical assistance. The patient doesn’t take in antibiotics or any other
drug that has not been prescribed by the physician; except for Paracetamol.
The patient has regular goes for regular monthly check ups to his private doctor for the management of his DM. He complies strictly with his therapeutic
regimen and takes all drugs prescribed by the doctor.
At present, he is at risk of infection related to traumatized tissue secondary to the CTT insertion and the VATS he underwent on September 4.
Patient is awake, conscious and oriented to time, place and persons. There are no tremors, nystagmus or ataxia observed.
Patient’s pupillary size and reaction to light are normal on both eyes. Hearing is slightly impaired on his left ear but he does not use a hearing aid. There are
no discharges from the ears. There is no nasal congestion and the patient has a patent airway. His taste sensation is normal but tongue movement is slightly altered
due to the mild stroke he experienced in 2006. There are no masses on his neck and no palpable lymph nodes. Chest expansion is symmetrical with no adventitious
lung sounds but with decreased breath sounds on the right lung.
He has a cardiac rate of 80 bpm and has been diagnosed to have adynamic pericardium. There is no tenderness noted on his abdominal area. He has no
edematous extremities and skeletal deformities and has good capillary refill of 2 seconds. He does not feel any numbness or tingling sensation at present.
He has a positive perception of his health and believes that his condition will go back to normal after hospitalization.

b. Nutritional-Metabolic Pattern

Patient eats a balanced diet. His preference is fish with a few vegetables and avoids meat. He loves condiments especially bagoong but has avoided such
since he has suffered mild stroke in 2006. At home, common dishes include ginataang kalabasa, labong and pinakbet. His average water intake at home ranges
from 6-8 glasses a day. He drinks milk, coffee and coke zero occasionally.
At the hospital, the patient has an input of approximately 420 cc during the 7-3 shift.
Since patient has experienced flank pain 1 week prior to admission, eating pattern has been affected because of the pain he feels when assuming a sitting
position during meals. He has refrained from taking in rice and viand and preferred eating bread with ham and egg; that he can eat even on a supine position.
At the hospital, he was given a diabetic diet with low cholesterol and low saturated fat. He has no known allergies to food and drugs and was able to return to
his usual eating pattern at the hospital. He was initially on NPO before the VATS has been performed but was informed that he can resume his usual and regular diet
after the surgery as long as tolerated.

c. Elimination Pattern

Patient has normal bowel sounds with no abdominal tenderness. He has undergone hemorrhoidectomy in 2004 and does not experience any difficulty in
voiding and defecating at home or at the hospital. He voids approximately 6 times per day with yellow to dark yellow urine. His usual bowel movement is once a
day with semi-solid to hard stools of usually brown color. He did not pass stools during the 7-3 shift and urinated 1 during the shift. He has a CTT tube placed on
the right chest draining a dark red discharge. His total output is approximately 455 cc with 315 cc from bladder and 140 cc from the pleural fluid.

d. Activity-Exercise Pattern

His usual activities at home include reading the newspaper, watching TV and sweeping the backyard occasionally. He does not perform gross mechanical
activities at home and was placed on CBR without BRPs since admission in this institution. He does not climb the stairs going to the second floor of their house but
believes that he can do so. He does not perform any physical exercise at home and has a sedentary lifestyle in general.
He has been a smoker since 15 years old consuming 5 packs per day. He also used to be a chronic alcohol beverage drinker but has stopped smoking and
drinking 9 years ago.
Since he has felt right flank pain a week before admission, he has preferred lateral decubitus postion and has experienced difficulty in changing bed position
and standing on his own. His condition persisted even during the first days of his stay at the hospital.
He has experienced DOB with associated cough and chest pains 2 weeks PTA but has normal diaphragmatic breathing at present. He has an RR of 20 cycles
per minute a day before the surgery and 16 cycles per minute when he was brought back to the surgical ward after the VATS.
He has limited ROM with stooping noted when walking. He is able to perform ADLs without assistance and no longer experiences any difficulty in changing
bed positions and is able to tolerate standing, sitting and supine positions.
He is also able to perform DBE on his own to relieve pain and facilitate breathing.

e. Sleep-Rest Pattern

Patient sleeps approximately 6-8 hours at night and takes a nap for about 2 hours in the afternoon. He is able to go back to sleep immediately whenever he
wakes up to void at night. He did not experience any sleeping problems before he complained for flank pain.
At the hospital, he experienced sleep disturbances due to the pain he feels secondary to the insertion of the CTT. Since he was given Arcoxia, he has
resumed his usual sleep pattern.
Some of his relaxation techniques at home include watching TV and reading newspapers.

f. Cognitive-Perceptual Pattern

He is oriented to time, place and persons. He is alert but irritable at times due to the pain that he feels at the site of the CTT insertion. The pain was rated as
5/10, characterized as pricking and non-radiating. It is felt whenever he wakes up in the morning and whenever he changes bed positions. Pain has however been
relieved when Arcoxia has been administered.
He is coherent and knowledgeable about his condition and is able to comprehend and understand the treatment and invasive diagnostic procedures that he
needs to undergo.
After the surgery, patient rated post-operative pain as 7/10, characterized as pricking, radiating to the entire right chest up to the right hypochondriac region,
exacerbated when changing bed positions and performing gross movements. Facial grimacing and guarding behaviors have been observed. No diaphoresis has been
observed. Patient has narrowed focus accompanied with reduced interaction with people and is not conversant. Verbal messages are very minimal.
There are no signs of confusion, disorientation or disturbed thought processes.

g. Self-Perception-Self-Concept Pattern

Patient is a retired military officer and projects a good self image. He is however, irritable at times. He feels a sense of superiority over the others including
his wife and HWs. He voice becomes louder whenever he insists on a point which he believes is right.
He denies any anxiety in relation to the upcoming invasive procedures to be done to him. He does not experience any body image disturbance or sense of
powerlessness even after his stroke.

h. Role-Relationship Pattern

Patient is irritable at times and his interaction with others including his wife and HW is affected. Because of the sense of superiority that he feels for himself,
his wife is very submissive to his opinions and ideals. Despite this, his marital relationship with his wife is still intact. He manifests obstinacy towards health care
providers as manifested by his attempts to remove the oxygen mask placed on him after the VAST.
Their family is intact. His 3 children, James 30 y/o, Angelo 29 y/o and Augusto 27 y/o, are currently living with them; and their youngest, Teresa 17 y/o
stays in Manila for her College education.
He denies any impact of the change of his health condition to his role and relationship pattern. The wife verbalized that he has no social activities and does
not go to church. His verbal communication is affected by his altered speech pattern caused by his stroke. Despite this, he is still able to communicate his feelings
and concerns in a manner that can be understood by others.

i. Sexuality-Reproductive

He has no history of prostate problems but does not undergo regular prostate exams. He has no history of penile bleeding or any other sexual problems or
STDs of any kind.
The patient has 4 children and has intact marital status with his wife, Elizabeth Tan. He has no alterations in terms of desired sex role and there are no
conflicts with regards to his sexual orientation and variant preferences. There are no concerns, conflicts and problems with regards to the patient’s sexuality. He is
masculine in appearance, grooming and action.

j. Coping-Stress-Tolerance Pattern

Patient copes well to his condition primarily due to the effectiveness of his support systems and his positive outlook and viewpoint of his present condition.
He is not anxious about the invasive procedures to be done to him.
Whenever their family is faced with problems requiring major decisions, he acts as the head of the family and the primary decision maker.
He is brave and outgoing. He does not experience any fear, anxiety, hopelessness, powerlessness, sadness or depression is relation to this hospitalization.

k. Value-Belief Pattern

The patient is a Roman Catholic but does not go to church. He believes in the existence of supernatural beings but does not believe that these can affect his
health. He does not believe is usog, barang, kulam etc. He does not consider going to an albularyo as a substitute for medical assistance. He believes that the health
team is the only reliable source of treatment. He believes that all diseases are results of pathogenic invasion or part of the degenerative/aging process that everyone
undergoes in life.

He does not believe that being a smoker since he was 15 years old has any relation to his current respiratory problems.

List of Identified Problems

o Impaired Gas Exchange r/t accumulation of fluids at the pleural cavity secondary to pleural effusion
-This is an overt problem and is of primary importance in accordance to the concept of ABC( Airway, Breathing, Circulation). In the case of our
patient, he experienced DOB 2 weeks PTA. One week PTA, he felt flank pain which is associated to accumulation of fluids in the pleural cavity therefore
interefering lung expansion resulting in decreased oxygen inhalation. If the patient's airway is blocked, breathing will not be possible, and oxygen cannot
reach the lungs and be transported around the body in the blood, which will result in hypoxia and cardiac arrest

o Acute pain r/t tissue trauma secondary to VATS


- It has been rated as 7/10 by the patient and needs to be attended to in order to prevent pain from interfering with the client’s rest and relaxation. It should
also be monitored since post operative pain is also a concern for the HW.

o Impaired tissue integrity r/t tissue trauma secondary to VATS and CTT insertion
- This is an overt problem and is of tertiary importance since the break in the skin caused by the procedures done to the patient may result to complications
such as infection.

o Sleep deprivation r/t discomfort secondary to post-operative pain


- Sleep and rest are essential elements for the recovery of a post-operative patient. This problem is 4th in rank since it has lesser bearing than the previously
identified problems and can be managed by performing independent nursing interventions
o Impaired physical mobility r/t post-operative pain secondary to VATS
- This problem is ranked 5th because gross movements are avoided in the case of the client since these movements can aggravate pain. This is of lesser
importance compared to the previously identified problems since the client’s physical mobility will most probably go back to normal once the pain is
relieved and once the wound heals

o Deficient diversional activity r/t situational problem secondary to stroke


- Since the husband suffered stroke in 2006, he has refrained from going out on family outings and no longer goes to church. Since then, the client has not
engaged in any leisure or recreational activities. This problem if not managed may result to social problems since recreational activities are also helpful in
increasing the client’s social interaction and providing a sense of enjoyment and satisfaction. Failure to engage in recreational activities may result to a
feeling of boredom, lack of interest and enjoyment or dissatisfaction in life. Compared to the previously identified problems, this problem does not pose a
threat to life and is thus ranked as 6th.

o Impaired verbal communication r/t speech problems secondary to stroke


- Verbal communications play an essential role in every individual’s day-to-day living. A problem concerning verbal communication may lead to further
problems such as inability to convey message in an understandable way or inability to interact with other people effectively. In the case of the client, this
problem is not yet of major importance since he is still capable of verbalizing his concerns in a manner that can be understood by others. Also, it does not
pose a risk to his life and is therefore ranked as 7th.

o Impaired social interaction r/t communication barrier secondary to stroke


- This problem rose as a result of the 7th problem. In his case, capacity to verbalize is still superior over ability to effectively interact with people; hence this
problem is of lesser bearing than the 7th. Also, if the 7th problem is attended to, this problem may also be resolved.

o Risk for infection r/t traumatized tissue secondary to VATS


- All post-operative clients are at risk for infection. This problem is of lesser bearing compared to the previously identified problems since it is only a risk
factor which has not yet taken place. Also, the client has been given prophylactic doses to prevent infection therefore; this problem may or may not take
place.

o Risk for imbalanced fluid volume r/t accumulation of secretions secondary to pleural effusion
- The client’s problem with regards to the accumulation of fluid has already been addressed by the insertion of the CTT. This problem is of least importance
since it may only take place if management has not been effective in reducing/draining accumulated fluid. This however is least likely to take place since the
client has significant volumes of CTT drains.
NCP PROPER

P > Impaired gas exchange related to accumulation of fluids at the pleural cavity secondary to pleural effusion
S > ”Nahihirapan akong huminga lalo na kapag nakahiga ako ng diretso. Dapat nakatagilid ako parati.” as verbalized by the patient.
 “May ubo pa rin siya pero wala naming plema” as verbalized by the wife

O > Vital signs are as follows:


Temperature: 35.8 °C via axilla
Pulse Rate: 80 beats per minute regular, +2 amplitude
Respiratory Rate: 16 cycles per minute regular
Blood Pressure: 130/90 mmHg at the right arm
 Capillary refill of 1-2 seconds

 Difficulty in breathing

 Irritable at times

 Needs assistance in performing ADLs

 Dry cough noted

 With crackles heard on right lower lobe

 With intact and patent CTT draining dark-red discharges to a one-way bottle

 Restlessness noted
Goal: After 3 days of nursing interventions, the patient will have an adequate oxygenation and absence of respiratory distress

STO: After a day of nursing interventions, the patient will be able to:
a. Verbalizes information about smoking correctly, risks of continuing, benefits of quitting, techniques to optimize cessation efforts

b. Practices and uses pursed lip and diaphragmatic breathing

c. Paces self to avoid fatigue and dyspnea

d. Maintains acceptable activity level

e. Understands the rationale for activities and medications

Explanation of the problem:


Impaired Gas Exchange is the excess or deficit in oxygenation or CO2 elimination at the alveoli-capillary membrane. Injuries to the chest are often life-threatening
and result in one or more of the following pathologic conditions:
Hypoxemia for disruption of the airway, injury to the lung parenchyma, rib cage, and respiratory musculature; massive hemorrhage; collapse and pneumothorax
Ventilation is the flow of gas in and out of the lungs, and perfusion is the filling of pulmonary capillaries with blood. Adequate Gas Exchange depends on an
adequate ventilation-perfusion ratio. Ventilation and perfusion imbalance causes shunting of blood, resulting in hypoxia. A pneumothorax is a collection of gas in
the pleural space that result in collapse of the lung/s. Pleural Effusion, a collection of fluids 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 – 15 ml). In certain disorders, fluid may accumulate in the fluid space to
a point where it becomes clinically evident. This almost always has a pathologic significance. The effusion can be composed of a relatively clear fluid, or it can be
bloody of pulurent. An effusion of clear fluid may be a transudate or exudates. A transudate occurs when factors influencing the formation and reabsorption of
pleural fluid are altered, usually by imbalances in hydrostatic or oncotic pressures. The finding of a transudative effusion generally implies that the pleural
membrane are not diseased. The most common cause of a transudative effusion is heart failure. An exudates, usually results from inflammation by bacterial products
or tumors involving the pleural space.

NURSING RATIONALE CRITERIA OF THE EVALUATION


INTERVENTION EVALUATION
Dx:
 Monitor vital signs  Tachypnea , Tachychardia  Goal is fully met if the
and Dyspnea may indicate patient will attain the
Pnuemothorax optimal gas exchange by
being able to breathe
 Auscultate chest for  Crackles indicate normally without any
breath sounds pulmonary congestion; signs of respiratory
decreased or absent breath distress. He will be able
sounds may indicate to correctly adopt
pneumothorax or practicing pursed lip and
hemothorax diaphragmatic breathing
 Review laboratory and every day. He will be
diagnostic results  It aids in diagnosis of able to verbalize
microscopic and molecular willingness / interest to
abnormalities not detected gradually decrease the
by plain assessment number of cigarettes per
day. The client will be
able to participate in
 Assess for changes in  Restlessness is an early every intervention done.
behavior and mentation sign of hypoxia. Chronic
hypoxemia may result in
cognitive changes such as
memory changes

 Monitored CTT  To make sure that the tube


patency is intact and continuously
flowing
Tx:
 Keep the patient in an  Semi-fowler’s position  Goal is partially met if
upright/semi-fowler’s allows for a better much of the patient will be able
position ventilation and perfusion, to breathe normally but
and therefore may actually with a little respiratory
improve oxygenation difficulties. He will be
able to correctly practice
 Assist in performing  Aids in keeping airway pursed lip breathing and
the correct technique patent, preventing diaphragmatic breathing
for BDE and pursed lip atelectasis, and facilitating but not daily. He will be
breathing lung expansion and ideally able to verbalize
improve gas exchange willingness to minimize
 Pace activities and  Even simple activities such cigarette smoking but
schedule rest periods to as bathing can cause with a little doubt.
prevent fatigue fatigue and increase oxygen
consumption
 Ensure that the  Kinking, looping, or
drainage tubing does pressure on the drainage
not kink, loop, or tubing can produce back-
interfere with the pressure, which may force
patient’s movement fluid back into the pleural
space or impede its
drainage

Edx:
 Explain the need to  To decrease oxygen  Goal not met if no
restrict and pace consumption improvement or
activities willingness occurred.
 Teach the patient  To facilitate adequate air His condition will stay
appropriate breathing exchange and secretion the same. He will do
techniques clearance pursed lip and
diaphragmatic breathing
 Limit visitors as  Reduces likelihood of incorrectly or will
indicated exposure to other infectious totally not adopt the
pathogens exercise taught. He will
not participate from any
nursing intervention
 Educate regarding  Smoking causes permanent done.
hazards of smoking damage to the lung and
diminishes the lungs’
protective mechanisms

 Encourage patient the  Oral gratification reduces


use of oral substitutes the urge to smoke
for smoking like
sugarless gum

P: Acute pain r/t tissue trauma secondary to CTT insertion

S: “Masakit dito,” pointing to incision site at the right chest.

O:

 pain rated as 7/10 (1 as the lowest and 10 as the highest), characterized as pricking, radiating to the entire right chest up to the right hypochondriac region
 pain is exacerbated when changing bed positions and performing gross movements
 no diaphoresis noted
 elevated BP of 160/80 mmHg and normal T=35.8 degrees Celsius, PR=80 bpm and RR=16 cycles per minute
 facial grimacing noted
 guarding behavior observed
 no teeth clenching noted
 narrowed focus accompanied with reduced interaction with people
 not conversant

LTO: After 3 days of nursing interventions, the client will report a significant decrease (2 pts or more) in the severity of pain.

STO: After 1 day of nursing interventions, the patient will:

1. Adhere strictly to pharmacologic regimen.


2. Perform deep breathing exercises without assistance.
3. Obtain adequate rest and sleep.
4. Rate pain as less than 6/10.

Explanation of the Problem

Incision during the CTT insertion creates a break in the skin tissue of the chest wall. This tissue trauma is sensed by the neurons which transmits pain
signals passing through the spinal cord to the brain. Injury activates two kinds of nociceptors namely the A-delta fibers and the C-fibers. The A-delta fibers are
responsible for immediate yet short-lived pain perceived as pricking at the site of injury. On the other hand, the C-fibers are activated after the A-delta fibers which
transmits a vague, throbbing and persistent pain. This is the pain that is continuously perceived by the patient. Neurons transmit the impulses to the brain and the
brain in response, generates a feedback to the site of injury. The feedback consists of reflexive involuntary muscle contractions perceived as pain. Other feedbacks
may also manifest in the form of increased temperature and diaphoresis.

INTERVENTIONS RATIONALE CRITERIA FOR EVALUATION


EVALUATION

*Dx > Monitor v/s and note for * Increase in temperature may
changes indicate progress of infection. Goal fully met if the client
Monitoring vital signs and reports a significant decrease in
noting for changes serves as the severity of pain. He is able
baseline data for evaluating to report a noticeable decrease
effectiveness of interventions. in the severity of pain. He will
Any abnormal changes implies take all the drugs prescribed by
abnormality and problem.
When client perceives pain, this the physician. He is able to
may serve as a sympathetic perform DBE correctly without
stimulus that may increase the assistance. He obtains adequate
body’s vital functions such as rest and sleep. If the client rates
an increase in PR and RR. the pain as 5 or less

> Assess PQRST of pain *Presence of known/unknown


complication may make the
pain more severe.
* Proper assessment of pain
will help to determine proper
interventions to perform to
address the problem

>Observed non-verbal cues * Observation may/ may not be


congruent with verbal reports
indicating needs for further
evaluation

>Assess insertion site for *This indicate for possible


swelling, bleeding and infection
dislocation of the tube

*Tx> Provide comfort *This will help in non-


measures pharmacological pain Goal is partially met if the
management like relaxation client takes some of the drugs
prescribed by the physician. If
>Place in a semi-fowler’s *A semi-fowler’s position the client needs assistance in
position permits residual air in the
pleural space rise to upper performing DBE. If the client
portion of pleural space and be is able to obtain rest for a
removed via the upper chest while. If the client rates the
catheter. pain as 6.

> Administer analgesics as


prescribed * Medication orders will ensure
that the client receives the
adequate doses of medicine for
more effective pain
management.

> Periodically position the


patient (flat position) * Flat position may relieve the
pressure exerted in the
abdominal area.

*Ed
>Encourage divertional *Helps the patient divert his
activities attention thus reduce tension Goal not met if no decrease
and relaxation promotion in the severity of pain is
reported. If the client
refuses to take all the
> Encourage verbalization * Verbalization of feelings will drugs prescribed by the
physician. If the client
of feelings about pain help validates the objective
refuses to perform DBE
data gathered and to know the with/without the nurse’s
proper intervention to address assistance. If the client is
the problem not able to rest at all. If the
client still rates the pain as
7 out of 10
> Encourage the client to take * Rest allows the body time to
adequate rest period heal itself and prevent the
increase in the severity of the
condition

> Teach client to perform Deep *Deep breathing provides good


Breathing Exercises. oxygenation to the body
making it more relaxed.