ALMAAREFA COLLEGE Adult nursing Care practice II Weekly Report Name of Student: Najwa Thawab .

Item Medical diagnosis and Pathophysiology

Day/Date:
Students Notes

1 -

Pleura effusion , breast cancer . Pathophysiology of Pleura effusion : Fluid accumulation in the pleural space .the effusion it can be clear fluid or bloody or purulent , usually results from inflammation by bacteria products or tumors involving the pleura surfaces .

2- Assessment

Decreased breath sound = present Decrease fremitus = Cough = present Fever = absent Physical examination = Chest X-ray , CT scan .

3- Medication

Fluconazole ( antifungal ) , 100mg , oral ,Q12h . Aspirin ,81mg, oral , daily . Docusate (laxative) , 100mg, orally, BID. Captopril ( antihypertensive ) ,12,5 mg . orally .BID.

4- Diagnostic tests

LDH plasma = 352 ( 135-214) Magnesium = 0,62 ( 0.70 1.05 ) mmol\L Billirubin = 2.7 ( 0.0 5.0 ) umol Calcium = 1.57 ( 2.09 2.54 ) mmol\L

5- Needs and diagnosis

1- Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as manifested by tachypnea, presence of crackles on both lung fields and dyspnea 2- Impaired Gas Exchange R/T Alveolar Capillary Membrane Changes and respiratory fatigue Secondary to Pleural Effusion as manifested by tachypnea , Use of accessory muscles . 1-patient would be able to apply techniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress. 2-demonstrate improved ventilation and adequate oxygenation of tissues and absence of symptoms of respiratory distress . 1-Monitor and record vital signs . -Assess breath sounds, respiratory rate, depth and rhythm -Administer prescribed medications as ordered -Encourage adequate rest periods between activities 2-Monitor and record vital signs . -Monitor respiratory rate, depth and rhythm . -Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus -Encourage frequent position changes and deep-breathing exercises . -Administer prescribed medications as ordered . -When coughing, hold a pillow over your chest where the pain is. -Do not smoke, and do not allow others to smoke around patients . -Eat a variety of healthy foods every day. -Drink enough liquids and get plenty of rest

6- Client Goal

7- Nursing interventions

8Discharge plan

9- Procedure

Give medication. Take a vital signs .

Instructor Comments: Students Signature: Signature: Instructor