Hard Bound

I.
INTRODUCTION
Time and health are two precious assets that we dont recognize and appreciate until
they have been depleted.
-
Denis Waitley
Health is the most precious and the most valuable piece of man, if a man
recognizes that he is free from sickness and any diseases, and then by all means he is
aware of his surroundings. If a man does not take care of his/her health then that person
is vulnerable to acquiring such diseases; which may jeopardize his/her health in the
future. Time and health is a blessing in this world that a man must cherish. Maintaining
your health in full conditions is not always easy. It has problems, too and challenges lies
in maintaining and keeping it in full condition, a man needs courage and patience on
keeping his health wealthy. Difficulties in keeping you in condition will test your
courage, patience and perseverance and true character of a human being. Until you find
out that your health is depleted that is when hardship comes in and would make you a
strong person and ready to change for the better.
A good example would be a condition affecting the lungs. The lungs are very
important in the body because whenever you inhale and exhale, oxygen gets supplied into
and out of your lungs for oxygenation. When the lungs are not functioning well, it not
only hinders you from breathing normally but it will affect your normal daily living until
then you realize that the simplest and the utmost undemanding labors in life is hindered
by the condition you are suffering from, such as Tuberculosis that can lead to
Bronchiectasis.
Tuberculosis (TB) is an infectious disease that primarily affects the lung

parenchyma. It also may be transmitted to other parts of the body, including the
meninges, kidneys, bones, and lymph nodes. The primary infectious agent,
Mycobacterium tuberculosis, is an acid-fast aerobic rod that grows slowly and is sensitive
to heat and ultraviolet light. TB spreads from person to person by airborne transmission.
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An infected person releases droplet nuclei through talking, coughing, sneezing, laughing,
or singing. Larger droplets settle; smaller droplets remain suspended in the air and are
inhaled by a susceptible person. Symptoms are cough of more than two weeks, loss of
weight, fever, chest pain or spiting with blood. A TB patient may infect 10- 15 persons
per year. It is usually an illness of adults but it can also affect children. TB is curable and
preventable (Bare et.al, 2010).
The initial damage to the bronchi may result from a number of different causes;
one of these is Tuberculosis, leading to Bronchiectasis. Bronchiectasis is a disease state
defined by localized, irreversible dilation of part of the bronchial tree caused by
destruction of the muscle and elastic tissue. It is classified as an obstructive lung disease,
involved bronchi are dilated, inflamed, and easily collapsible, resulting in airway
obstruction and impaired clearance of secretions (National Heart, Lungs and Blood
Institute, 2011). According to World Health Organization (WHO), Bronchiectasis is an
abnormal widening of one or more airways. Normally, tiny glands in the lining of the
airways make a small amount of mucus. Mucus keeps the airways moist and traps any
dust and dirt in the inhaled air, but because bronchiectasis creates an abnormal widening
of the airways, extra mucus tends to form and pool in parts of the widened airways. This
condition is more common in adults, although it may originate in childhood. The
common, defining symptom is the frequent coughing up of foul, smelly secretions that
are thick and green or yellow in color and may be blood-flecked. The person suffers from
frequent respiratory infections and is often breathless and unwell. In addition, the person
may be abnormally tired and anemic. The main treatment is the practice of postural
drainage to eliminate the accumulated secretions. Also, surgery to remove a part of the
lung (lobectomy) may be needed and antibiotics to fight infections (Elicano, 2013).
a. Current Trends about the disease condition

A compound from the South African toothbrush tree inactivates a drug target for
tuberculosis in a previously unseen way. Tuberculosis causes more deaths worldwide
than any other bacterial disease. At the same time as rates are increasing, resistance
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strains are emerging due, in part, to non-compliance with the treatment required. Many
current drugs are nearly 50 years old and alternatives are needed to the long, demanding
treatment schedules.
The compound under research, diospyrin, binds to a novel site on a well-known
enzyme, called DNA gyrase, and inactivates the enzyme. DNA gyrase is essential for
bacteria and plants but is not present in animals or humans. It is established as an
effective and safe drug target for antibiotics. "The way that diospyrin works helps to
explain why it is effective against drug-sensitive and drug-resistant strains of
tuberculosis," said Professor Tony Maxwell from the John Innes Centre. In traditional
medicine the antibacterial properties of the tree are used for oral health and to treat
medical complaints such bronchitis, pleurisy and venereal disease. Twigs from the tree
are traditionally used as toothbrushes.
Most antibiotics originate from naturals sources, such as the soil bacteria
Streptomyces. Antibiotics derived from plants are less common, but they are potentially
rich sources of new medicines. "Extracts from plants used in traditional medicine provide
a source for novel compounds that may have antibacterial properties, which may then be
developed as antibiotics," said Professor Maxwell. "This highlights the value of
ethnobotany and the value of maintaining biodiversity to help us address global
problems."
Professor Maxwell is continuing the work on diospyrin and related
naphthoquinone compounds as part of the efforts of a consortium of European
researchers, More Medicines For Tuberculosis (MM4TB). The collaboration between 25
labs across Europe is dedicated to the development of new drugs for TB (Norwich
BioScience Institutes, 2013).
b. Statistics
Tuberculosis is a worldwide public health problem that is closely associated with
poverty, malnutrition, overcrowding, sub-standard housing, and inadequate health care.
Mortality and morbidity rates continue to rise; Mycobacterium tuberculosis infects an
estimated one third of the worlds population and remains the leading cause of death from
infectious disease in the world. According to the WHO, an estimated 1.6 million deaths
resulted from Tuberculosis in 2005 (WHO, 2007). In the Philippines, TB is a major
health problem. It is the sixth leading cause of death and illness. In 2011, WHO estimates
there are 260,000 incident cases in the country, and 28,000 die in a year. Tuberculosis
prevalence is high among the high-risk groups such as the elderly, urban poor, smokers
and those with compromised immune systems such as people living with HIV,
malnutrition and diabetes. It is estimated that 10,600 patients have multi-drug resistant
TB (MDR-TB) in 2011. This situation leads to substantial socio-economic losses to the
country (World Health Organization in Western Pacific, 2013).
c. Reasons For Choosing Case Presentation

To heed about what is less likely to be unknown is to bring a change on the way
we experience and think about things---it would be a quantum shift, not only on a
professional manner but also to gain a higher level of intellectual grounds To seek is to
see and to see, it may be.
- Anonymous
Hence, a case with Pulmonary Tuberculosis as a history, leading to Bronchiectasis

and Fungus Ball, this condition is seldom studied as evidenced by the difficulty of
finding statistical data to directly measure its pertinence, frequency and incidence.
Neither a specific book nor internet site has enough information which is completely
focused, updated and is sufficient to fully quantify its pertinence especially on the local
setting. Almost all the references just include it as an inclusion or more so, an estimated
statistical basis is only done.
With all this in mind and because of the understanding of the possibilities, risks,
and other complications that the condition may bring, the need to study it profoundly had
deemed it relevant for the group to take this condition as their case study. Research in this
area can help shed light into the workings of the disease, the predisposing factors, impact
on the morbidity and mortality rates and the measures taken by the health care team in the
treatment be it in nursing, medical and surgical management and control of the condition.
Furthermore, the analysis and synthesis of both the patient-centered

pathophysiology and that of available literature, as well as the medical management and
nursing management that transpired during the confinement of the patient and the
corresponding progress evaluation of the patients condition are ultimately significant not
only in the field of research but also in the clinical area in that therapeutic management
that is both effective and significant may be identified which can lead to the ruling out of
the less effective measures undertaken and prioritizing on the effectiveness of the other
interventions. Such results can be significant for future management and clinical handling
of the disease.
But personally, the group would want to expand their horizons with this case.
They thought of this as a great deal to challenge their intellectual grounds. More so, it is
really a good subject for their case and a lot of learning may possibly be extracted to it
because appropriate managements were performed to the patient during the entire
hospitalization; with these the group decided to choose this as their case because of the
many learnings; skills and proper approach that they will be gaining during the entire
student nurse and patient interaction.
d. Objectives
General Objectives
After the completion of the study, the student nurse-researchers will be able to:
Acquire knowledge and have a deeper understanding of the development of
disease condition in relation to the modifiable and non-modifiable factors that have
predisposed the client to the occurrence of the disease condition hence, be able to discuss
management and treatment and provide better nursing care and preventive health
teachings through the utilization of the nursing process.
OBJECTIVES
A. Student Nurse Centered Objectives
Short- Term Objectives

After 5 days of nurse-patient interaction, the student nurses shall have:
1.
Familiarized the attitude of the patients family health and obtained the
personal and pertinent family health-illness history of the client and relate it
to the present disease condition;
2.
Identified the statistics and prevalence of the disease condition as well as the
latest trends in the management of the disease condition.
3.
Gathered pertinent information about the patient regarding his personal and
socio-economic histories, cultural beliefs and environmental factors that
may have contributed in the development of the disease condition.
4.
Analyzed the diagnostics and laboratory procedures performed to diagnose

the condition of the patient.
5.
Identified and prioritized appropriate nursing care plans to aid in the

management of the patients condition.
6.
Provided various therapeutic nursing interventions that are suitable with the
presenting problems experienced by the patient.
Long- Term Objectives

After completion of this case study, the student nurses shall have:
1. Discussed Tuberculosis, Bronchiectasis and Fungus Ball, Diabetes Mellitus
Type II and Hypertension, its definition, risk factors, sign and symptoms that
had contributed to the occurrence of the disease condition. As well as
identified the apparent sign and symptoms manifested by the patient in
relation to the mentioned disease condition.
2. Performed
comprehensive
assessment;
physical,
neurological
and
neurovascular assessment as to general condition of the patient; as well as its

effects to the significant other may be it physically, socially, mentally and
spiritually
to
confirm
the
diagnosis
of
Pulmonary
Tuberculosis,
Bronchiectasis, and Fungus ball, Diabetes Mellitus Type 2, Hypertension; or

to identify other possible causes of patients symptoms;
3. Comprehensively analyzed and interpreted the different laboratory and
diagnostic procedures in relation to the clinical manifestations of the disease
condition; and the different nursing interventions that must be done before,
during and after each procedure.
4. Identified nursing problems and appropriate nursing care plan that involves
the patient and the significant others.
5. Specified the various treatments modalities such as medical management and
surgical management as well as current trends in managing Tuberculosis,
Bronchiectasis and Fungus Ball, Diabetes Mellitus Type II and Hypertension.
6. Identified the appropriate nursing diagnosis and make corresponding
interventions and carry them out as the situation permits as to promote patient
wellness.
7. Made daily progress chart to evaluate patients response to medical
management
8. Formulated discharge planning and care of patient at home.
9. Formulated conclusions based on findings and enumerate recommendations
concerning the management of Tuberculosis, Bronchiectasis and Fungus Ball,
Diabetes Mellitus Type II and Hypertension.
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10. Evaluated effectiveness of nursing care and medical interventions rendered
B. Client-Centered Objectives
Short-Term Objectives
After 5 days of nurse-patient interaction, the patient/SO shall have:
1. Established rapport with student nurses and will trust and cooperate with
them;
2. Determined their level of understanding about the disease condition;
3. Understood the purpose of the student nurse purpose for acquiring related
information about the patient with regards to the condition;
4. Cooperated during the interview process and gathering of data thereby sharing
of information that is significant to the present condition of the patient.
5. Willingly answered the questions of the student nurses and shared relevant
information about their health belief and practices. Shared their perceptions
regarding the history of illness their family are experiencing.
6. Demonstrated awareness on the activities necessary to accomplish the case
study
7. Imparted their views in what the possible effects of these health problems are
and what interventions can be done to solve them.
Long-Term objectives
After the completion of the case study the patient and his family shall have:
1. Enumerated the underlying cause of the disease and its occurrence;
2. Participated in the modality of the treatment given to the patient;
3. Obtained pharmacological and non-pharmacological treatment to alleviate
disease condition;
4. Acquired palliative care and management of pain as well as reducing the
occurrence of complication from disease condition;
5. Participated in formulating various nursing care plans with the student nurses
to improve patients condition.
II. NURSING PROCESS

A. ASSESSMENT
1. Personal History
a. Demographic Data
Mr. Baga, who is a 58 years old male, a natural born Filipino, currently residing at
Tarlac, Pampanga. He was born on April 13, 1955 in his hometown in Pampanga. He
was admitted to one of the tertiary hospitals in Angeles City on November 3, 2013,
9:52 am, with an admitting diagnosis of Recurrent Massive Hemoptysis to consider
Tuberculosis Bronchiectasis versus Fungus Ball, Left Upper Lobe.
During the interview the student nurses informant was his second eldest daughter
Alveoli, who was very informative and patient in answering all the student nurses
queries.
The patient was discharged last November 15, 2013 with the Final diagnosis of
Recurrent Massive Hemoptysis Secondary to Tuberculosis Bronchiectasis, Fungus
Ball, Left upper lobe.
b. Socio-Economic and Cultural Factors

b.1. Income and Expenses
Mr. Baga was a farmer, since he was 13 years old up until he was 45 years old.
According to Alveoli, his father earns every four months when they harvest rice. He
also owns the rice field in his hometown. He planted corn crops other than rice and
has mango trees on his farm. He also owns an itikan . According to Alveoli his
father uses chemical pesticides on his farm without proper protective equipment like
mask because according to the patient they are not used of wearing mask, one
example of pesticide they use is the urea 14X14X14. He is also a tricycle driver
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during the time that he is not in his farm.

The familys primary source of income is from the monthly remittances of Mr.
Bagas children, which is Php 30,000 pesos/month. According to Alveoli their profit
from farming depends on their harvest every 4 months, the average net profit is Php
40,000 plus the remittances of Php 30,000 the total income is Php 70,000/month
when it is harvest season, but when it is not harvest season the family will have Php
30,000 as their monthly income. Mrs. Baga budgets the income as follows:
Expenses
Amount
Food (rice/ fish/ pork/ vegetables)

(Php 250.00 x 30 days)
Php 7,500.00
Electricity (lights, appliances & Jetmatic)
Php 1000.00
Water bill
Php 1000.00
Miscellaneous
Groceries- (Php 500 x 2 a month)
Php 1,000.00
Maintenance Drugs (Estimated amount: 1000)
Php 1,000.00
Total Expenditures
Ph 11,500.00
Php 30,000- Php 11,500 = 18,500/ month (during non-harvest season)

Php 70,000 Php 11,500 = Php 58,500 total savings every 4 months
According to NEDA, each member of the family should have at least 2,768.60
pesos to use per month. This is computed by dividing the familys total monthly income
by the number of family members. Computing the adequacy of the familys income, Mr.
Bagas family is categorized to be not poor since the division of the Php 70,000 pesos
monthly income of the family into 5 as the total number of the members of the family
yields an estimation of Php 14,000 pesos.
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b.2. Educational Attainment

Mr. Bagas highest educational attainment is elementary level. According to
Alveoli he wanted to continue his studies but due to financial constraints he stopped
schooling to help with his family and support all his other 8 siblings.
b.3. Religious Affiliation
According to Alveoli her father is the only Iglesia ni Cristo (INC) in their family
since 2007 while the rest of the members of family are Roman Catholic, he is an active
member, he usually attends their church service every Thursdays and Sundays at the
nearby INC church. Alveoli said that when it comes to health beliefs, his father as an INC
member does not have any restrictions on health beliefs.
b.4. Cultural factors affecting health of the family

Alveoli verbalized that the family believed in hilot or herbolarios except for
Mr. Baga who is always consulting his private doctor when his health is compromised.
She also said that her father has a monthly check up on his diabetologist.
Mr. Baga used to be a smoker, he can consume 40 sticks a day, he started

smoking when he was a teenager, 15 years old, he stopped smoking last 2008 when he
was diagnosed of Tuberculosis, 53 years old.Pack years: 40 sticks /day multiply by 38
years of smoking = 76 pack years.
He drinks hard liquor occasionally, such as Emperador approximately 500ml.

According to Alveoli, Mr. Bagas diet prior to diagnosis of Diabetes Mellitus compose of
eating rice every meal, during breakfast, lunch and dinner even his snacks he eats rice
with 1 viand it could be fish, chicken, pork and beef. He became conscious of the food he
eats, avoiding sweet and fatty food when he was diagnosed of DM in 1994.
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c. Environmental Factors
Mr. Bagas family is made up of six members namely Mr. Baga who stands as the
head of the family, with regards to familys health Mr. Baga and his wife shares on
decision making; his wife Mrs. Baga takes care of the household; Bronchi, the eldest
daughter; Alveoli, second oldest daughter; Pleural, his only son and Surfactant his
youngest daughter. Currently all of Mr. Bagas children are overseas Filipino workers.
The familys internal relationship is said to be harmonious, although there are moments,
which seldom occur, that distort this harmony between the members of the family, but
they are able to manage it. Alveoli verbalized that her parents Mr. Baga and Mrs. Baga
lives on a house near their rice fields with their three grandchildren which makes his
family a Skipped type of family. Mr. Bagas house is made up of concrete/wood with 3
bedrooms and 1 bathroom; they have a total of 9 windows as verbalized by Alveoli.
Alveoli stated that their house is well ventilated and lighted although their house is under
renovation. The familys sleeping arrangement composed of bedroom 1 which is being
shared by Mr. and Mrs. Baga, bedroom 2 is for their 3 grandchildren, they also have an
extra bedroom wherein their son and daughters stay when they visit them.
According to Alveoli, Mrs. Baga cooks food for her family everyday where she
goes to the nearest market, being mindful of Mr. Bagas diet, which is suitable for
diabetic, Alveoli said that Mr. Baga usually eats ampalaya and one cup of rice per meal,
he refrains from eating sweets and usually jogs in the morning. As for their left-over
food, they keep it covered with a plate and store it inside their refrigerator. The familys
primary source of water is through the use of Jet matic. They get their drinking water by
buying purified water from nearby water station. Their garbage is stored in a sack, being
disposed at the back of their house where they have a garbage pit and as verbalized by
Alveoli, they have a closed drainage system
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2. Family Health Illness History

Mr. Baga is the 6th oldest in their family with a total of 9 siblings. Four out of the
nine siblings has Diabetes Mellitus, and one of them had a history of kidney failure. Two
of Mr. Bagas oldest siblings are deceased, the cause of the death are kidney failure and
complications of Diabetes, respectively. Mr. Bagas both parents were deceased, the
father died from heart attack and the mother from Alzheimers disease and old age.
As stated by Alveoli, there is no known familial history of Tuberculosis in the
family. According to Alveoli, when Mr. Baga has cough and colds he will immediately
seek for medical care on his private doctor.
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GENOGRAM
PATERNAL
Grandfather
Unknown
MATERNAL
Grandmother
Unknown
Grandfather
Unknown
Father
Heart Attack
Kidney
Failure
Grandmother
Unknown
Mother
Old Age with
Alzheimers
Complication With
of DM
Diabetes
With
Diabetes
With
Diabetes
LEGEND:
Deceased
Female
Deceased
Male
MALE
With Dse
Female
With Dse
Male
FEMALE
Mr. Baga
PTB; BRONCHIECTASIS; DM;

HPN
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3. History of Past Illness
According to Alveoli, in the year 1991, her father Mr. Baga had an accident, which is
being electrocuted through faulty wire on his farm fences while he was trying to fix it. Leaving
lesions on his right hand due to burns.
In the year 2001, Mr. Baga had a self-accident; he was riding a motorcycle when he lost
control and swerved on the road with minor injuries.
As stated by Alveoli, Mr. Baga started to have high blood pressure on April 2013 and
was diagnosed as Secondary Hypertension he takes Amlodipine (calcium channel blocker) 10
mg once a day as his maintenance drug.
4. History of Present Illness
On 1994, Mr. Baga was diagnosed of Diabetes Mellitus Type II; he has a monthly check
up with his diabetologist and has been managing his DM with Diamicron (oral hypoglycemic
agent) twice a day one in morning and at night which he religiously take every day.
According to Alveoli, in the year 2008, Mr. Baga was farming and afterwards complains
of fatigue from work, She stated that while her father is farming he also coughed out blood and
the family rushed him to one of the hospitals in Pampanga. The family did not see any earlier
symptoms prior to vomiting of blood as verbalized by Alveoli. Mr. Baga was diagnosed of
Primary Tuberculosis and they gave him 4 kinds of medication; Rifampicin, Isoniazid,
Pyrazinamide, and Ethambutol (RIPE). Wherein, he completed treatment for more than 6
months. Alveoli verbalized that Mr. Baga was relieved of the signs and symptoms after the
treatment. From 2008-2010 he continued with farming and no other signs for PTB were noted.
In the year 2010, two years after, Mr. Bagas Tuberculosis recurred as verbalized by
Alveoli, she said that her father was farming and experienced the same event, coughing off
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blood; Thus they rushed him to the hospital and recommended to undergo another 2 months of
treatment with the same combination of anti tuberculosis drugs, and after completing the
treatment he was relieved and no signs of TB was experienced up until June of 2013.
The episodes of hemoptysis started again on July 2013 as verbalized by Alveoli,

amounting to almost one glass of blood. He undergone computed tomography scan and x-ray
after that his doctor suggested undergoing surgery, which is lobectomy but Mr. Baga refused to
have one. He was then given another option, which is to have chemical embolization, in which
he agreed upon, it was performed on August 28, 2013 in one of the tertiary hospitals in Tarlac.
Three weeks after the procedure, his episodes of hemoptysis recurred.
On September 29, 2013 Mr. Baga was admitted in one of the tertiary hospitals in Tarlac
due to massive hemoptysis amounting to 2 liters as verbalized by Alveoli and he was then readmitted to same hospital in Tarlac. X-ray result shows Pneumonia, Left Upper Lobe, and Left
ventricular cardiomegaly. He was given a combination drug of RIPE (Fixcom) where he had an
allergic reaction (blisters on upper extremities accompanied by urticaria) after a day of
administration. The drug was immediately stopped and treatment was halted, after which Alveoli
said that his fathers hemoptysis got worse that he fainted and he was confined in the hospital for
6 days. On October 2, 2013 he was diagnosed of Chronic Kidney Disease stage 3 secondary to
Diabetic Nephropathy and he was discharged on October 4, 2013 at 2 pm.
On the same day, October 4, 2013, 9pm, when they went home Mr. Baga had another
episode of hemoptysis, he was rushed again to the same hospital but according to Alveoli no
medical management was given not until they find an allgergologist to check which of the
components of Fixcom he was allergic to. An allergologist was found in one of the tertiary
hospitals in Angeles City, which made them transfer Mr. Baga from Tarlac to Angeles City. On
October 7, 2013 Fiber Optic Bronschoscopy and bronchial washing was done to him with result
shows that there is no microorganism, acid fast Bacilli and fungal elements seen. Rifampicin
challenge was done on October 8, 2013 and was been stopped on October 9, 2013 because of
allergic reaction which then Ethambutol challenge was done and show no allergic reaction to the
Ethambutol. Desensitization was done on October 15, 2013 and was given Dipenhydramine
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(anti-histamine) for his allergies. He was been diagnosed of Pulmonary Tuberculosis,

Hypetension SII, Diabetes Mellitus Type II, Adverse reaction to Rifampicin.
He was then given medical management for Tubercolosis after having an allergologist
performed desensitization, and was admitted on October 20, 2013. Mr. Baga does not want to
have the surgery and was discharged on October 24, 2013 with a final diagnosis of Bleeding
Bronchiectasis secondary to PTB hemoptysis, Hypertension II, DM II and was given home
medications: Unasyn 750mg/tab BID x 7days; Tranexamic Acid 500mg/tab TID for bloody
phlegm, Pantoprazole 40mg/tab OD x 5 days; Levocetirizine 500mg/tab OD for itchiness;
Levopront syrup 1 teaspoon BID X 5days; Losartan 100 mg/tab OD; Amlodipine 10mg/tab OD;
Carvediol 25 mg/tab tab BID; Sinecod Forte 1tab/TID x 5 days; Rifampicin 60 mg/tab 1 tab
after breakfast, Isoniazid 400mg/tab OD; Ethambutol 400mg/tab TID; Mixtard 44 units at 6am,
22 units at 6pm; which Mr. Baga complied religiously taking his home medications.
On November 3, 2013, Mr. Baga had another episode of massive hemoptysis and they
went to a doctor in Angeles City because his fathers condition got worse. He was admitted again
to the same tertiary hospital with the admitting diagnosis of recurrent massive hemoptysis to
consider TB Bronchiectasis versus Fungus Ball on the left upper lobe. The doctor suggested
having a surgery, which is lobectomy on the left upper lobe of the lung, that made Mr. Baga to
agree with his doctor and was scheduled to have it done on November 5, 2013.
5. PHYSICAL ASSESSMENT
November 3, 2013 (Lifted from the chart)
Upon admission : The patient is afebrile, does not have dyspnea, positive recurrent
hemoptysis for 5 days, with body weakness, with Difficulty Of Breathing on exertion, with
Diabetes Mellitus, Hypertension and positive Pulmonary Tuberculosis.
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11:20 pm done by NOD

BP: 120/70 PR: 64bpm RR: 21cpm Temp : 36C
GENERAL APPEARANCE: patient is awake, conscious and coherent, with intravenous

fluid of #1 PNSS1L x 80cc/hr
November 4, 2013 done by nurse on duty
8am- BP: 120/70 PR: 60bpmRR: 20cpm Temp: 36

4pm- BP: 140/70 PR: 60bpm RR: 20cpm Temp: 36
11pm- BP: 120/70 PR: 64 RR: 21 Temp: 36
GENERAL APPEARANCE: patient is awake, afebrile, appears weak, conscious and

coherent, intravenous out
3:05 pm done by NOD (lifted from the chart)

GENERAL APPEARANCE: patient is awake, conscious and coherent, with an ongoing
intravenous fluid of #2 PNSS 1L x 80cc/hr, no signs of infiltration, no signs of
respiratory distress, no complains of pain
November 5, 2013
12 midnight
GENERAL APPEARANCE: patient is on bed, asleep but arousable, with an ongoing

intravenous fluid of #2PNSS 1L x 80cc/hr, without infiltration, no difficulty of breathing,
no chest pain, no nausea and vomiting, afebrile
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6-2pm done by the Nurse on duty (lifted from the chart)
9am- BP: 160/80 PR: 60bpm RR: 21cpmTemp:36
GENERAL APPEARANCE: patient is on moderate high back rest, awake, oriented to

time, place and person, with an ongoing intravenous fluid of #3 PNSS 1L x 80cc/hr
infusing well over left hand, no signs of phlebitis and infiltration, no difficulty of
breathing, no chest pain, no signs of respiratory distress, afebrile, for thoracotomy left
upper lobectomy under General Endotracheal Anesthesia using double lumen
Endotracheal tube.
@9AM endorsed to OR nurses ----------------OPERATING ROOM------------------
10 am done by the NOD (lifted from the chart)

GENERAL SURVEY: received patient from floor via wheelchair, conscious and
coherent, with ongoing intravenous fluid of #4 D5LRS 1L x 80cc/hr
GENERAL APPEARANCE: Patient @ OR table, conscious and coherent, hooked to

O2 inhalation via nasal cannula @3-4Lpm, hooked to cardiac monitor, general anesthesia
started, Foley catheter inserted, patient on side lying position, body and arm straps are
applied, draped aseptically
Operation started at 11:10 am, specimen out at 2:20 pm.
November 6, 2013
GENERAL APPEARANCE: Patient was seen on a high fowlers position, conscious,
coherent and oriented to person, place and time, with intravenous fluid of #7 PNSS 1L x
100cc/hr, dopamine drip at 3mcg/kg/min. with anterior and posterior closed thoracotomy
tube with output level of 70/300cc on anterior and 400/400cc serosanguinous on
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posterior at 1:30pm, with indwelling Foley catheter connected to urine bag, with intake
of 868cc/80cc, with oxygen therapy via nasal cannula at 3-4Lpm.
9am done by Student Nurse (1ST NURSE-PATIENT INTERACTION)
SKIN
The patient has dark complexion noted. Presence of pitting edema on both upper
extremities
HEAD/SCALP
Hair is black and is equally distributed upon inspection. The patient has no
pediculosis, dandruff, scratches or depressions. No abnormal mass and no tenderness
upon palpation of scalp.
EYES
The patient has pink palpebral conjunctiva and anicteric sclera. The eyes are able
to move in cardinal directions no deviation or nystagmus and with normal blinking reflex.
Eyes are symmetrical, no abnormal protrusion noted and with parallel eye movement.
EARS
The patients ears are symmetrical in size and shape upon inspection and no
abnormal discharge was noted. No excess cerumen was observed in the auditory canal
upon inspection. Pain is not felt upon palpation of ears. Patient is able to hear clearly the
voice of the nurse without difficult and able to hear the tickling sound on the watch tick
test.
NOSE
The patient has no nasal deviation. No nasal discharges and deformities noted. No
obstruction and nasal flaring upon inspection. Air moves freely as the patient breathes
through the nares with Oxygen via nasal cannula.
20
FACE
No facial asymmetry or facial deviation, no edema or bruises noted. There is no
tenderness upon palpation. Patient has no difficulty in swallowing.
NECK
No lateral deviation of the neck and has normal range of motion actively done pain
free. No tenderness and no abnormal mass are noted upon palpation.
CHEST AND LUNGS

Patient has asymmetrical chest expansion and no complains of dyspnea. No pain or
tenderness felt upon palpation and normal tactile fremitus.
Crackles heard upon
auscultation. Patient uses accessory muscles when breathing, no chest pain noted.
Presence of Anterior (upper left) and posterior (lower left) closed thoracotomy tube.
HEART
The patients heart rate is of normal rate and regular rhythm.
ABDOMEN
The patient has no distension of abdomen.
6am: with fever T: 38.0

8am: BP: 120/80 mmHg; PR: 84 bpm; RR: 24 bpm; Temp: 37.1 C
9:25am: BP: 140/70 PR:72bpm RR: 24cpm Temp: 37.3
10:20: asleep
11:20: BP: 130/70 PR:64bpm RR:21cpm Temp:37.3
12:20: BP: 130/70 PR: 68 RR: 22 Temp: 37.3
4:10: BP: 110/70 PR: 64 RR: 24 Temp: 36
5:15: BP: 140/70 PR: 66 RR: 24 Temp: 36.2
6:10: BP: 130/70 PR: 60 RR: 22 Temp: 36.2
8:10: BP: 130/70 PR: 62 RR: 22 Temp: 36.6
11:31: BP: 120/80 PR: 64 RR: 22 Temp:36.6
21
1:05: BP: 120/80 PR: 62 RR: 23 Temp: 36

2 am: BP: 140/70 PR: 65 RR: 24 Temp: 36.7
3:35 BP: 120/70 PR: 68 RR: 24 Temp: 36.7
4:35: BP: 130/70 PR: 67 RR: 22 Temp: 36.4
6:20: BP: 140/70 PR: 76 RR: 24 Temp:_36.5
CRANIAL NERVES
Cranial Nerve
Assessment Technique
1. Olfactory
Patient was asked to Patient must be able to Patient was able to
Type: Sensory
close
Fxn: Sense of smell
asked to determine the coffee grounds when of coffee grounds
eyes
and
Normal Response
Actual Response
was identify the scent of identify the scent
scent of the material allowed to smell it.
when allowed to
used which is coffee
smell it.
grounds.
2. Optic
Patient was asked to Patient must see the pen Patient was able to
Type: Sensory
read news paper.
or penlight clearly from see the pen or
Fxn: Sense of vision
a certain distance; must penlight from a
and visual fields
be
able
to
read certain
distance,
newspaper with writings and had difficulty

14 inches away.
of
reading
the
newspaper.
3. Oculomotor
Patient was asked to Eyes must follow the The Patient was
Type: Motor
follow the direction of direction
Fxn:
of
Pupil the penlight and ask to movement
constriction
raising of eyelid
the able to follow the
of
the movement of the
and look straight while light penlight;
penlight
was shone through his In
dimmed his eyes and his
eyes.
lightly
environment, the pupils pupils
were
of the eyes will dilate equally

but
upon
introduction
of
the and
through
rounded
reactive
to
light, light
pupils will constrict.
accommodation.
22
4. Trochlear
The patient was asked The eye must follow the The Patient was
Type: Motor
to follow the tip of the movement of the tip of able to follow the
Downward penlight downward and penlight
Fxn:
eye inward movement.
inward
in
different penlight with his
directions
with eyes
coordination.
movement
without
moving his head.
Corneal Sensitivity test The Patient must elicit The
5. Trigeminal
Type: Sensory and through
the
use
of blinking
cotton wisp.
Motor
Fxn:
touching
reflex
the
upon elicited
movements, chewing
(Corneal
and mastication
Test)
touching
the
Sensitivity cornea.
Use
Type: Motor
follow lateral directions. tip of the penlight and able to follow the
Lateral
movements
of
penlight
upon
6. Abducens
Fxn:
of
blinking
cornea reflex
with the use of cotton.
Jaw
Patient
to Patient must follow the The Patient was
its movements.
tip of the penlight

and
the
its
lateral
direction.
eyes
Use of hard candy to Patient must be able to The Patient was
7. Facial
Type:
Motor
and assess anterior 2/3 of raise eyebrows, show able

taste buds.
Sensory
to
raise
teeth, frown, smile, pout eyebrows,
show
Fxn: Movement of Asked the patient to do and puff out cheeks. teeth frown, smile,
muscles of the face facial expressions
Also, the Patient must pout and puff out
and sense of taste on
also be able to taste the cheeks. Also, the
the
sweetness
anterior
two-
candy.
thirds of the tongue
of
hard Patient was able to

taste the sweetness
of hard candy.
8.
Acoustic Used watch tick test, Patient must be able to The Patient was
(Vestibulocochlear)
watch was place on the hear the tick of the able to hear tick of
Type: Sensory
auditory
Fxn:
hearing
Sense
canal
and watch.
the watch.
of asked the patient is he

can hear it.
23
9. Glossopharyngeal
Type:
Motor
Use of tongue depressor The patient must be able The Patient was
and to elicit gag reflex
were chewed. Also, the food and elicit gag
Sensory
Fxn:
to swallow foods that able to swallow
gag reflex should be reflex.
Pharyngeal
movements
stimulated.
and
swallowing
Sense of taste on the
posterior
one-third
of the tongue
10. Vagus
The patient was asked The patient must be able The Patient was
Type: Motor
to take sips of water
to tolerate sips of water.
able
to
of
tolerate
Fxn: Swallowing and
sips
water
speaking
without difficulty.
11. Accessory
Patient was asked to The patient must able to The Patient was
Type: Motor
raise his shoulders
elevate
his
shoulders able to elevate his
Fxn: Movement of
against
resistance. shoulders against
shoulder muscles
(Sternocleidomastoid
resistance.
and Trapezius muscles

function test)
12. Hypoglossal
The patient was asked The patient must able to The patient was
Type: Motor
to stick his tongue and move his tongue side to able to move his
Fxn: Movement of move it from side to side and protrude his tongue side to side
tongue and strength side
of the tongue
tongue.
and protrude his

tongue.
24
November 7, 2013 (2nd nurse-patient interaction)
8am- BP: 140/70 PR: 64 RR:22 Temp: 36.4

9am: asleep
10am: BP: 140/80 PR: 76 RR: 20 Temp: 36.4
11am: asleep
12nn: BP: 140/70 PR: 62 RR: 21 Temp: 36.2
GENERAL APPEARANCE: patient on bed, with ongoing intravenous fluid on left

hand of #8 PNSS 1L x 100cc/hr, no phlebitis and infiltration, with dopamine drip
3mcg/kg/min, side drip of insulin drip 5u humulin R in 100cc PNSS, with anterior
posterior Closed Tube, with fluctuation,negative bubbling, both closed tubes maintained
on Emerson pump, with indwelling foley catheter connected to urine bag, with intake
and output of 3200L/880cc with O2via nasal cannula at 2-3Lpm.
SKIN, HAIR, NAILS: the patient has dark complexion, warm to touch skin, no signs of
pallor,(-)rashes, skin is relatively dry, with good skin turgor, with black and equally
distributed hair, no pediculosis and dandruff upon inspection, with short and clean
fingernails.
EYES AND EARS: eyes are symmetrical, eyelids covers the quarter top of the iris, with
equally distributed eyelashes. With anicteric sclera, with complains of blurred vision,
patient has difficulty in reading newspaper. Ears are symmetrical in size and shape,
presence of dry cerumen was noted, and no mass and tenderness was noted upon
palpation. Patient reports normal hearing ability.
NOSE, MOUTH, THROAT AND NECK: patients nose is at the center, no swelling
and deformity is noted, no nasal discharge, with minimal nasal flaring, patients lips
was slightly pale and dry, with pinkish tongue, incomplete set of teeth, no swollen lymph
nodes, with pulsations, no neck masses upon palpation.
25
LUNGS: no difficulty of breathing, not using accessory muscles when breathing. Patient
has asymmetrical chest expansion. No pain or tenderness felt upon palpation and normal
tactile fremitus. Crackles heard upon auscultation.
CARDIOVASCULAR: no jugular vein distention, with localized pulsation, with normal

heart rhythm, no chest pain at the moment, no murmurs
ABDOMEN: flat, non-tender to palpation no complains of pain upon palpation, had no

bowel movement for 5 days according to the patient.
EXTREMITIES: no pallor, with regular pulses
NEUROLOGIC EXAM: GCS=15 (E4V5M6)
LEVEL OF CONCIOUSNESS: conscious

MOTOR: 5/5
CRANIAL NERVES
Cranial Nerve
1. Olfactory
Type: Sensory
close
Fxn: Sense of smell
eyes
and
Normal Response
Actual Response
when allowed to
smell it.
grounds.
2. Optic
Patient was asked to Patient must see the pen Patient
Type: Sensory
read newspaper.
or penlight clearly from complains
a certain distance; must blurred
and visual fields
be
able
to
vision
read and has difficulty
newspaper with writings in

14 inches away.
of
reading
newspaper
26
writings
inches
in
14
focal
length.
3. Oculomotor
Type: Motor
of
Fxn:
constriction
of
the movement of the
penlight
raising of eyelid
eyes.
lightly
through
were

but
upon
introduction
the and
of
rounded
reactive
to
light, light
accommodation.
4. Trochlear
Type: Motor
Fxn:
Downward penlight
downward penlight
inward
in
directions
with eyes
coordination.
movement
without
moving his head.
5. Trigeminal
the
use
cotton wisp.
Motor
Fxn:
of blinking
touching
reflex
the
upon elicited
movements, chewing
(Corneal
and mastication
Test)
touching
the
Sensitivity cornea.
Use
Type: Motor
Lateral
movements
of
its movements.
tip of the penlight

and
its
lateral
direction.
eyes
7. Facial
Type:
the
penlight
upon
6. Abducens
Fxn:
of
blinking
cornea reflex
Jaw
Patient
Motor
to
raise
27
taste buds.
Sensory
show
the
sweetness
anterior
two-
of
candy.
taste the sweetness

of hard candy.
8.
(Vestibulocochlear)
Type: Sensory
auditory
Fxn:
Sense
canal
and watch.
the watch.
hearing
can hear it.
9. Glossopharyngeal
Type:
Motor
Sensory
Fxn:
Pharyngeal
movements
stimulated.
and
swallowing
posterior
one-third
of the tongue
10. Vagus
Type: Motor
able
to
of
tolerate
Fxn: Swallowing and
sips
water
speaking
without difficulty.
11. Accessory
Type: Motor
raise his shoulders
elevate
his
Fxn: Movement of
against
shoulder muscles
resistance.

function test)
28
12. Hypoglossal
Type: Motor
tongue.
and protrude his

tongue.
of the tongue

4:10: BP: 120/70 PR: 70 RR: 23 Temp: 38
6:10: BP:130/60 PR: 68 RR: 23 Temp: 36.4
8:10: BP: 140/70 PR: 68 RR: 21 Temp: 37
Patient on bed, with intravenous fluid, with side drip of Nephrosteril 500cc x 12 hrs., side
drip of insulin drip, 100 humulin R in 100cc PNSS at 12 u/hr via soluset, with anterior
posterior closed thoracostomy connected to bottle with fluctuation, negative bubbling,
with anterior level of 80cc/350cc and posterior level of 400cc/600cc, both with
serosanguinuous fluid at 8:45pm, with indwelling foley catheter, with O2 via nasal
cannula at 2-3Lpm, no respiratory distress.

12mn: BP: 120/70 PR: 72 RR: 22 Temp: 36.2
1am: 120/70 PR: 62 RR: 25 Temp: 36.6
Patient on bed, with intravenous fluid of PNSS 1L,#2Dopamine drip at 8mcg/kg/min

16cc/hr, with side drip of insulin drip 100 u humulin R in 100cc PNSS at 10u/hr,
with closed thoracostomy tube connected to emerson pump for 20cc/hr, with indwelling
foley catheter,
no difficulty of breathing and no chest pain, with dry cough, no
complains of pain, afebrile, with stable vital signs.

.
29
November 8, 2013 (6-2 done by NOD)

8am: BP: 140/70 PR: 64 RR: 18Temp: 36.2
9am: BP: 130/70 PR: 56 RR: 20 Temp: 36.1
10am: BP: 130/70 PR: 54 RR: 18 Temp: 36.2
11am: BP: 140/70 PR: 56 RR: 18 Temp: 36.3
12nn: BP: 140/70 PR: 64 RR: 70 Temp: 36.4
GENERAL APPEARANCE: patient on bed, with ongoing intravenous fluid on left

hand of #9 PNSS 1L x 100cc/hr, no phlebitis and infiltration, with dopamine drip
3mcg/kg/min, side drip of insulin drip 100u Humulin R in 100cc PNSS at 8u/hr.,
with anterior posterior closed Tube connected to bottle, with anterior chest tube level of
40cc, posterior chest tube level of 30cc serosanguinous consistency with fluctuation,
negative bubbling, with indwelling foley catheter connected to urine bag, on bladder
training, with intake of 33cc and output of 22cc at 9:50AM, with O2via nasal cannula at
3Lpm. Afebrile.
10:50 am (3rd nurse-patient interaction)
BP: 140/70 PR: 64bpm RR: 18cpm Temp: 36.2C
GENERAL APPEARANCE: received on high fowlers position, oriented to time, place
and person; with ongoing IVF of #9 PNSS 1L x 100cc/hr on right hand, with side drip of
Dopamine drip at 3mcg/kg/min, Side Drip of Insulin drip at 8u/hr, with anterior posterior
closed tube bottle with fluctuations, negative bubbling, with anterior closed tube level of
40cc with moderate bloody consistency, with posterior closed tube level of 30cc with
serosanguinous consistency; with indwelling foley catheter connected to urine bag
draining well to a yellow colored urine received at 400cc level; with O2 inhalation via
nasal cannula at 3Lpm; with complains of pain on closed tube site; with deep regular
rhythm of respirations, with use of accessory muscles, with stabbing pain upon
movement, localized on surgical site, 7/10 severity; pain relieved by rest.
30
pallor, no rashes, skin is relatively dry, with good skin turgor, with black and equally
fingernails.
patient has difficulty in reading. Ears are symmetrical in size and shape, presence of
dry cerumen was noted, and no mass and tenderness was noted upon palpation. Patient
reports normal hearing ability.
and deformity is noted, no nasal discharge, no nasal flaring, patients lips was slightly
pale and dry, with pinkish tongue, incomplete set of teeth, no swollen lymph nodes, with
pulsations, no neck masses upon palpation.
LUNGS: no difficulty of breathing, do not use accessory muscles when breathing.

Patient has asymmetrical chest expansion. No pain or tenderness felt upon palpation and
normal tactile fremitus. Crackles heard upon auscultation.
CARDIOVASCULAR: no jugular vein distention, no decreased cardiac output, with

localized pulsation, with normal heart rhythm, no chest pain at the moment, no murmurs
ABDOMEN: flat, with normal bowel sounds, non-tender to palpation no complains of

pain upon palpation.
EXTREMITIES: with regular pulses

MOTOR: 5/5
31
CRANIAL NERVES
Cranial Nerve
1. Olfactory
Type: Sensory
close
Fxn: Sense of smell
eyes
and
Normal Response
Actual Response
when allowed to
smell it.
grounds.
2. Optic
Type: Sensory
read newpaper.
and visual fields
be
able
to
of
vision

14 inches away.
reading
newspaper
writings
inches
in
14
focal
length.
3. Oculomotor
Type: Motor
of
Fxn:
constriction
raising of eyelid
of
the movement of the
penlight
eyes.
lightly
were

but
upon
introduction
the and
of
through
rounded
reactive
to
light, light
accommodation.
4. Trochlear
Type: Motor
Fxn:
inward
Downward penlight
downward penlight
directions
in

with eyes
without
32
coordination.
movement
moving his head.
5. Trigeminal
the
use
of blinking
cotton wisp.
Motor
Fxn:
reflex
touching
the
upon elicited
movements, chewing
(Corneal
and mastication
Test)
touching
the
Sensitivity cornea.
Use
Type: Motor
Lateral
movements
of
penlight
upon
6. Abducens
Fxn:
of
blinking
cornea reflex
Jaw
Patient
its movements.
tip of the penlight

and
the
its
lateral
direction.
eyes
7. Facial
Type:
Motor

taste buds.
Sensory
to
raise
show
the
sweetness
anterior
two-
candy.
of

taste the sweetness
of hard candy.
8.
(Vestibulocochlear)
Type: Sensory
auditory
Fxn:
Sense
canal
and watch.
the watch.
hearing
can hear it.
9. Glossopharyngeal
Type:
Motor
Sensory
Fxn:
Pharyngeal
movements
and

stimulated.
33
swallowing
posterior
one-third
of the tongue
10. Vagus
Type: Motor
able
to
of
tolerate
Fxn: Swallowing and
sips
water
speaking
without difficulty.
11. Accessory
Type: Motor
raise his shoulders
elevate
his
Fxn: Movement of
against
shoulder muscles
resistance.

function test)
12. Hypoglossal
Type: Motor
tongue.
of the tongue
and protrude his

tongue.

BP: 140/70mmHg
GENERAL APPEARANCE: patient on bed, oriented to time and place; with ongoing
Intravenous fluid of #10 PNSS 1L x 100cc/hr, with side drip of Dopamine at
3mcg/kg/min at approximately 170cc; with closed thoracostomy tube posterior connected
to Emerson pump at 20cc/hr., anterior 300cc clear; posterior @430cc level; IV site
bulged and painful as verbalized by the patient.
34
November 9, 2013 done by NOD (lifted from the chart)
3:00 am
GENERAL APPEARANCE: received patient on bed, with ongoing intravenous fluid of
#10 PNSS 1L x 100cc/hr, side drip of nephrosteril 500cc x 12hrs; no signs of infiltration,
with closed thoracostomy tube dry and intact, anterior containing 350cc level, clear;
posterior at 500cc level with light red fluid, afebrile, no difficulty of breathing, with
complains of pain on incision site.
6:35 am
GENERAL APPEARANCE: received patient on bed, awake and coherent, oriented to
time, place and person, with intravenous fluid of #10 PNSS 1L x 100cc/hr; no infiltration
was noted; with closed thoracostomy tube connected to bottle, anterior bottle at 300cc
level, with moderate bloody fluid, posterior bottle at 350 cc level; with
serosanguinuous fluid, with fluctuations, no bubbling, no difficulty of breathing, no chest
pain; with non-productive cough, afebrile, with pain scale of 7/10, with stable vital
signs.
3:50 pm
GENERAL APPEARANCE patient on high back rest, awake, oriented to time and
place, with ongoing Intravenous fluid of #10 PNSS 1L x 100cc/hr, with side drip of
Nephrosteril 500cc x 12hrs, without signs of infiltrations and phlebitis, with closed
thoracostomy tube output of 400cc at posterior area and 300cc on anterior area,
with fluctuations, negative bubbling, with dry and intact closed thoracostomy tube
dressing, no difficulty of breathing, no chest pain, no respiratory distress, with nonproductive cough, able to expectorate, has the ability to perform deep breathing exercise
yet with slight pain upon inhalation, with stable vital signs.
35
2 am
GENERAL APPEARANCE: patient on bed, awake, with ongoing intravenous fluid of
#10 PNSS 1L x 100cc/hr, afebrile, with stable vital signs; with closed tube anterior @
300cc level, posterior @ 500cc level; no difficulty of breathing and chest pain, no
nausea and vomiting; with intake of 2640cc and output of 2620cc at 4:30am.
7:24 am
GENERAL APPEARANCE: patient on high back rest, awake and oriented to time,
place and person, with an ongoing intravenous fluid of #11 PNSS 1L x 100cc/hr, no signs
of phlebitis and infiltration; with anterior closed tube, with fluctuation, no bubbling,
dressing dry and intact, no difficulty of breathing, no chestpain, not in respiratory
distress.
8 am
GENERAL APPEARANCE: patient on high back rest, awake and oriented to time,
place and person, with an ongoing Intravenous fluid of #12 PNSS 1L x 100cc/hr, no signs
of phlebitis and infiltration; with posterior closed tube output of 150cc, with serous
fluid, closed tube maintained in place, with fluctuation, no bubbling, dressing dry and
intact, no difficulty of breathing, no chest pain, not in respiratory distress.
November 12, 2013 (4th nurse patient interaction)
8:30am
BP: 140/70 PR: 64 RR: 23 Temp: 36.4
GENERAL APPEARANCE: patient on sitting position, with ongoing intravenous fluid
of #14 PLRS 1L x100cc/hr on right hand, no phlebitis and infiltration, with posterior
Closed Tube connected to drainage bottle, draining to a yellow fluid @ 320cc level,
36
with fluctuation, no bubbling, afebrile, needs assistance when changing of position and
activity,
fingernails.
patient has difficulty reading newspaper. Ears are symmetrical in size and shape, and
no mass and tenderness was noted upon palpation. Patient reports normal hearing ability.
and deformity is noted, no nasal discharge, with minimal nasal flaring after activity,
patients lips was slightly pale and dry, with pinkish tongue, no swollen lymph nodes,
with pulsations, no neck masses upon palpation.
LUNGS: no difficulty of breathing at rest, not using accessory muscles when breathing.
Patient has asymmetrical chest expansion. No pain or tenderness felt upon palpation,
crackles heard upon auscultation on both lung fields.

heart rhythm, no chest pain, no murmurs

EXTREMITIES: no pallor, with good muscle strength, with regular pulses
MOTOR: 5/5
37
CRANIAL NERVES
Cranial Nerve
1. Olfactory
Type: Sensory
close
Fxn: Sense of smell
eyes
and
Normal Response
Actual Response
when allowed to
smell it.
grounds.
2. Optic
Type: Sensory
read newspaper.
and visual fields
be
able
to
of
vision

14 inches away.
reading
newspaper
writings
inches
in
14
focal
length.
3. Oculomotor
Type: Motor
of
Fxn:
constriction
raising of eyelid
of
the movement of the
penlight
eyes.
lightly
were

but
upon
introduction
the and
of
through
rounded
reactive
to
light, light
accommodation.
4. Trochlear
Type: Motor
Fxn:
inward
Downward penlight
downward penlight
directions
in

with eyes
without
38
coordination.
movement
moving his head.
5. Trigeminal
the
use
of blinking
cotton wisp.
Motor
Fxn:
reflex
touching
the
upon elicited
movements, chewing
(Corneal
and mastication
Test)
touching
the
Sensitivity cornea.
Use
Type: Motor
Lateral
movements
of
penlight
upon
6. Abducens
Fxn:
of
blinking
cornea reflex
Jaw
Patient
its movements.
tip of the penlight

and
the
its
lateral
direction.
eyes
7. Facial
Type:
Motor

taste buds.
Sensory
to
raise
show
the
sweetness
anterior
two-
candy.
of

taste the sweetness
of hard candy.
8.
(Vestibulocochlear)
Type: Sensory
auditory
Fxn:
Sense
canal
and watch.
the watch.
hearing
can hear it.
9. Glossopharyngeal
Type:
Motor
Sensory
Fxn:
Pharyngeal
movements
and

stimulated.
39
swallowing
posterior
one-third
of the tongue
10. Vagus
Type: Motor
able
to
of
tolerate
Fxn: Swallowing and
sips
water
speaking
without difficulty.
11. Accessory
Type: Motor
raise his shoulders
elevate
his
Fxn: Movement of
against
shoulder muscles
resistance.

function test)
12. Hypoglossal
Type: Motor
tongue.
and protrude his

tongue.
of the tongue
10:50pm done by NOD (lifted from the chart)

With closed tube output of 90cc for 24hrs, with fluctuations negative bubbling, patient
complains of
epigastric pain.
November 13, 2013 (5th nurse patient interaction)
8am
BP: 140/70 PR: 64 RR: 23 Temp: 36.4
GENERAL APPEARANCE: patient on sitting position, with ongoing intravenous fluid
of #15 PLRS 1 L x 100cc/hr infusing well on right hand, no phlebitis and infiltration,
40
with posterior closed Tube connected to drainage bottle at 320cc level,
with
fluctuation, negative bubbling, afebrile.
fingernails.
patient has difficulty reading newspaper. Ears are symmetrical in size and shape, and
no mass and tenderness was noted upon palpation. Patient reports normal hearing ability.
and deformity is noted, no nasal discharge, no nasal flaring, patients lips was slightly
pale and dry, with pinkish tongue, no swollen lymph nodes, with pulsations, no neck
masses upon palpation.
LUNGS: no difficulty of breathing at rest, not using accessory muscles. Patient has
asymmetrical chest expansion. No pain or tenderness felt upon palpation, crackles heard
upon auscultation on both lung fields.

heart rhythm, no chest pain, no murmurs

EXTREMITIES: no pallor, with good muscle strength, with regular pulses
MOTOR: 5/5
41
CRANIAL NERVES
Cranial Nerve
1. Olfactory
Type: Sensory
close
Fxn: Sense of smell
eyes
and
Normal Response
Actual Response
when allowed to
used, which are coffee
smell it.
grounds.
2. Optic
Type: Sensory
read newspaper.
and visual fields
be
able
to
of
vision

14 inches away.
reading
newspaper
writings
inches
in
14
focal
length.
3. Oculomotor
Type: Motor
of
Fxn:
constriction
raising of eyelid
of
the movement of the
penlight
eyes.
lightly
were

but
upon
introduction
the and
of
through
rounded
reactive
to
light, light
accommodation.
4. Trochlear
Type: Motor
Fxn:
inward
Downward penlight
downward penlight
directions
in

with eyes
without
42
coordination.
movement
moving his head.
5. Trigeminal
the
use
of blinking
cotton wisp.
Motor
Fxn:
touching
reflex
the
upon elicited
movements, chewing
(Corneal
and mastication
Test)
touching
the
Sensitivity cornea.
Use
Type: Motor
Lateral
movements
of
penlight
upon
6. Abducens
Fxn:
of
blinking
cornea reflex
Jaw
Patient
its movements.
tip of the penlight

and
the
its
lateral
direction.
eyes
7. Facial
Type:
Motor

taste buds.
Sensory
to
raise
show
the
sweetness
anterior
two-
candy.
of

taste the sweetness
of hard candy.
8.
(Vestibulocochlear)
Type: Sensory
auditory
Fxn:
Sense
canal
and watch.
the watch.
hearing
can hear it.
9. Glossopharyngeal
Type:
Motor
Sensory
Fxn:
Pharyngeal

43
movements
stimulated.
and
swallowing
posterior
one-third
of the tongue
10. Vagus
Type: Motor
able
to
of
tolerate
Fxn: Swallowing and
sips
water
speaking
without difficulty.
11. Accessory
Type: Motor
raise his shoulders
elevate
his
Fxn: Movement of
against
shoulder muscles
resistance.

function test)
12. Hypoglossal
Type: Motor
tongue.
of the tongue
and protrude his

tongue.
3:50pm done by NOD (lifted from the chart)

GENERAL APPEARANCE: patient lying on bed, awake, with an ongoing intravenous
fluid of nephrosteril 500cc x 12 hrs on right hand, mainline off, with closed tube
posterior at 350cc, serosanguinuous, with fluctuation, no bubbling, no difficulty of
breathing and no chest pain, no nausea and vomiting, no headache.
11:30pm
GENERAL APPEARANCE: patient on bed, intravenous out, no difficulty of brathing,
no chest pain, afebrile, with stable initial Vital Signs, with closed thoracostomy
44
tube(posterior) connected to CT bottle at 400cc level connected to bedside, with

fluctuation, negative bubbling, with serous fluid.
Rehooked
Intravenous, infusing well, no signs and symptoms of phlebitis and
infiltration, no difficulty of breathing and chest pain..
3 pm
GENERAL APPEARANCE: patient on bed, awake and coherent, with ongoing
intravenous fluid, no infiltration noted, with posterior closed tube connected to closed
thoracostomy tube bottle at 390cc level, with serous fluid, no difficulty of breathing
and no chest pain no complains of pain on operative site, with dry and intact dressing,
afebrile, with stable Vital Signs.
November 15, 2013
12:30 am
GENERAL APPEARANCE: patient on bed, asleep but arousable, intravenous out,
afebrile, no complains of pain, with dry and intact closed thoracostomy tube dressing on
left anterior posterior thorax.
7:00 am
GENERAL SURVEY: patient on bed, awake, conscious and coherent, intravenous out,
no difficulty of breathing
no chest pain, with stable Vital Signs,
3:05 pm
GENERAL SURVEY: patient on bed, awake and coherent, no contraptions noted, with dry and
intact dressing, no difficulty of breathing and chest pain, no complains of pain, afebrile, with
stable Vital Signs.
45
DIAGNOSTIC AND LABORATORY FINDINGS
Diagnostic/
Date ordered
Laboratory
and date
Procedures
result(s) in
Indication(s) or purpose
Results
Normal value
Analysis and interpretation

of results
A complete blood count (CBC) is

a series of tests used to evaluate
COMPLETE
Date ordered:
BLOOD
11-03-2013
the
COUNT
11-06-2013
concentration
composition
of
the
and
cellular
components of blood. It consists

Date results
of the following tests: red blood
in:
cell (RBC) count, white blood
11-03-2013
cell (WBC) count, and platelet
11-07-2013
count;
measurement
of
hemoglobin and mean red cell

volume; classification of white
blood cell (WBC differential);
and calculation of hematocrit and
red
blood
cell
indices,
(Chernecky and Berger, 2011).
46
CBC is inexpensively, easily and

rapidly performed as a screening
test.
This
is
indicated
to
determine any alteration in Mr.

Bagas blood component since
the patient is coughing up blood,
testing on November 3, 2013. It
focuses on determining the rate of
bleeding
and
any
risk
to
breathing; moreover, it was used

as a preoperative test and cardio
clearance for surgery to ensure
both adequate oxygen carrying
capacity and hemostasis; also to
aid in diagnosing anemia and
other blood diseases, to monitor
blood loss and infection; thus to
identify acute and chronic illness
and/or bleeding tendencies.
47
Hence, on November 5 and 6,

2013 the patient was subjected for
another Complete Blood Count to
check the effect of surgery and
medical
management,
monitor
response of the patients body to

blood loss since his hgb and hct
count since November 3, 2011,
prior to surgery until November
5, 2013 are at low levels thus to
evaluate if he needed a blood
transfusion.
Result
Date ordered:
Hemoglobin
retrieved
on
11-03-2013
The hemoglobin concentration is
November 3, 2013 shows
11-05-2013
a measure of the total amount of
that Hemoglobin count is
11-06-2013
Hgb in the peripheral blood,
below
which then reflects the number of
which means that during this
Date results
RBCs in the blood. Hgb serves as
time,
in:
a vehicle for the patient to check
11-03-2013
his oxygen and carbon dioxide
140.00
128
175.00 g/L
the
there
normal
might
range
be
problem in oxygen supply

and
patient
may
suffer
48
transport (Muchnick, 2010).
anemia due to episode of

massive hemoptysis reported
Since there is affectation in the
prior to admission. However,
patients respiratory system it is
the doctor has cleared the
indicated to the patient to assess
patient for surgery and has
adequacy
tissue
ordered preparation of 4
oxygenation primarily in the heart
units of fresh whole blood
and lungs and other parts of the
type O, 2 units of which to
body. Also, to determine if
be crossmatched and reserve
patient has anemia related to
the other 2 units if blood
reported
transfusion will be necessary
of
his
massive
hemoptysis
and/or poor nutrition. It is done
during
also to check if the patient is fit to
(2012) and Liumbruno et al
undergo
(2009) explains that Blood
surgery
lobectomy of left lung.
which
is
the
surgery.
Hitt
transfusion (BT) is indicated

if
hemoglobin
level
has
reached below 60-70 mg/dL

where in the client had was
128 mg/dL that did not
necessitate the order to be
49
executed.
11-05-2013
107
On November 5, 2013, postoperative Hgb count is below

the normal range indicating a
decreased
in
hemoglobin
which may be caused by

further blood loss due to
surgery, hence, at this point
the
patient
may
have
problems in oxygenation and

is more prone to suffer
anemia.
11-07-2013
112
Further, on November 6,
2013 the patient was then
again subjected to hgb and
hct count to monitor patients
response and compensation
due to blood loss, thus result
50
retrieved on November 7,
2013 reveals that patients
hgb count has increased from
107 to 112 however it is still
below the normal range but
then no signs and symptoms
of possible anemia was noted
during periods of decreased
hemoglobin
levels.
There
was no blood transfusion

ordered and done to Mr.
Baga.
Hematocrit
Date ordered:
This procedure is used to measure
As said, hct is directly
11-03-2013
RBC number and volume. It is
related with hgb. With the
11-05-2013
routinely performed as a part of
below normal results of hgb,
11-06-2013
complete blood count.
hct count also reveal below

normal
results.
It
also
The Hct is a measure of the
indicates that the patients
percentage of total blood volume
body did
not
effectively
51
that is made up by the red blood
compensate well with the
cells. The Hct closely reflects the
problem.
hgb and RBCs values. Therefore,

Date results
in:
it is also made to check for any
0.35 %
alteration with oxygen transport.
0.41 0.50 %
Result
retrieved
on
November 3, 20103 shows

that Hct count is below the
11-03-2013
11-05-2013
It is indicated to the patient to
normal range which means
determine if there is problem with
that during this time, there
vascular volume depletion with
might
hemoconcentration,
prior
oxygen
surgery
appropriate
patient may suffer anemia
management can be done prior or
due to episode of massive
during the surgery, more so to
hemoptysis reported prior to
rule out presence of anemia and
admission. Hence, during the
dehydration related to reported
surgery the patient was given
massive hemoptysis and/or poor
haesteril which is a plasma
nutrition.
volume expander.
so
that
to
Test is done after the surgery to

check effects of the blood loss.
0.31 %
be
problem
supply
and
in
the
On November 5, 2013, postoperative Hct count is below
52
the normal range indicating a

decreased
in
hemoglobin
which may be caused by

further blood loss due to
surgery, hence, at this point
the
patient
may
have
problems in oxygenation and

is more prone to suffer
anemia.
11-07-2013
It was repeated after increase
0.31%
Moreover, on November 6,
PNSS regulation to 100 cc/hr.
2013 the patient was then
This is to check vascular volume
again subjected to hgb and
after increase IVF rate.
hct count to monitor patients

response and compensation
due to blood loss, thus result
retrieved on November 7,
2013 reveals that patients
hcts count remain the same
which
is
0.
31%.
The
53
increase in IVF regulation

from 80 cc to 100 cc of
PNSS maintained vascular
volume thus can prevent
shock.
White Blood Cell
Date ordered:
It determines the number of white
11-03-2013
blood cells microliter a cubic
11-06-2013
millimeter of whole blood.

Due to strenuous exercise, stress
Date results
or digestion, the WBC count may
in:
increase or decrease significantly

with certain diseases but it is
diagnostically useful only when
patients white cell differential
and clinical status are considered.
It is done to determine infection
of inflammation.
It is done to rule out infectious
54
and inflammatory diseases of the

respiratory and other systems of
the patients body. The body is
also in stress due to his condition
the WBC may have an increased
result brought about
by the
surgery.
11-03-2013
Test
is
done
to
determine
presence of infection and prior to

surgery
in
order
to
give
6.48 x 10
9
/L
4.50 11.00
9
/L
WBC count is within the

normal range which indicates
that the patients body has
appropriate management prior the
adequate
said surgery like administration of
disease-fighting cells, viruses
prophylaxis.
and bacteria hence, making

him
less
outside
protection
from
susceptible
infections
to
or
disallowing multiplication of
organisms within the body
which would normally kept
in
check
by
healthy
55
immune system. However,

since the patient was ordered
to undergo surgery he was
given (Cefepime 1g IV q
12hrs).
11-07-2013
12.36 x
On November 7, 2013 WBC
10 9/L
count
relayed
an
above
normal result which may be

due to the patients bodys
response to an infection,
inflammation and stress after
the surgery.
Neutrophils
Neutrophils are the most common
Neutrophils count is within
11-03-2013
Polymorphonuclear
leukocytes
the normal range however it
11-06-2013
(PMN) which is a division of
is slightly increased and falls
WBC in granulocytes, comprising
on the peak normal level
Date results
about 50%-70% of all white
which may indicate that the
in:
blood cells. They are phagocytic,
Date ordered:
0.70
0.18 0.70
patients body is responding
56
11-03-2013
meaning that they can ingest
to infection or inflammation
microorganisms. Neutrophils are
at this time
the first immune cells to arrive at

a site of infection. Neutrophil
11-07-2013
count is indicated to the patient to

determine
acute
Latter neutrophils count is
0.88
bacterial
increased due to effect of
infection.
inflammation after surgery

but this was manage by
giving (Cefepime 1g IV q 12
hrs).
Lymphocytes
Date ordered:
Lymphocytes are WBCs under
Lymphocytes count is within
11-03-2013
the division of agranulocytes that
the normal range, indicating
11-06-2013
is primarily involve is cellular-
that the patient has adequate
type
defenses
immune
reactions
and
hormonal immunity or antibody

Date results
in:
11-03-2013
production.
and
0.13
0.10-0.48
against
viral
bacterial
infections.
However, the lymphocytes

are commonly and more
certain for viral infections.
57
11-07-2013
It is indicated to Mr. Baga to
Relayed lymphocytes count
0.10
determine the ability of his body
on November 7, 2013 is
to fight bacterial infection
within
however
the
normal
it
is
range
slightly
decreased or at its borderline

level.
The
infection
is
possibly caused by bacteria.
Monocytes
Date ordered:
Monocytes are phagocytic cells
11-03-2013
capable
11-06-2013
infection.
of
fighting
bacterial
Date results
in:
11-03-2013
11-07-2013
It was ordered on November 3
0.04
0.00 0.04
Monocytes count results are
and 6, 2013 to determine if there
within normal range thus
is any bacterial microorganism
there
invading his body.
0.02
may
still
be
no
systemic infection at this

point.
58
Eosinophils
Date ordered:
Eosinophil is performed to find
11-03-2013
out if patient has allergic reaction
11-06-2013
or parasitic infections.
Date results
It was performed to the patient as
in:
part of the institutions routine
11-03-2013
analysis and to abet if there is an
0.02
allergic reaction and or parasitic

11-07-2013
infections.
0.00 0.03
Eosinophil count results are

within normal range thus
0.01
indicating absence of allergic

reaction
or
parasitic
infection.
Platelet
Date ordered:
Indicates the amount of platelets
11-03-2013
in a given amount of blood, the
11-06-2013
platelets are the ones responsible

for
blood
clotting
and
stop
bleeding.
59
Date results
It was indicated to the patient to
in:
check platelet count level which
11-03-2013
can be a reason for massive
normal range signifying that
hemoptysis
that
which
172 x10
9
/L
was
150-400
On
November
3,
2013
x10 9/L
platelet count is within the
thromboregulatory
experienced by the patient. More
process of the patient is
so, the patient was subjected to
maintained.
this test to determine risk for

bleeding during and after surgery.
11-07-2013
It was done to the patient to check

risk for possible bleeding after the
surgery.
122 x10
9
/L
On November 7, 2013, Postoperative
abnormally
low
platelet
level
(thrombocytopenia)
may
indicate that the patient has

increased
platelets
destruction
once
they
of
are
produced and released into

the circulating blood.
60
Nursing Responsibilities:
Prior:
Verify doctors order.
Identify the patient.
Explain the procedure to the patient, its purpose and how it is done.
Instruct patient about the schedule of the test.
Tell the patient that no fasting is required.
Assure patient that collecting blood sample take less than 3 min.
Inform patient that the patient will be experiencing pain on the site where the needle was pricked.
Refer to the member of the health care team.
Explain the procedure and purpose to the patient.
Tell the patient that fasting not required.
Instruct patient there are no special measures needed.
During:
Select a vein for venipuncture.
Clean venipuncture site with alcohol; allow area to dry. Use antiseptic technique when obtaining the sample.
Perform venipuncture by entering the skin with needle at approximately a 15 degree angle to the skin, needle bevel up.
After blood is drawn, place cotton ball over site; withdaraw the needle and exert pressure. Apply bandage if needed.
61
After:
Record the date and time of blood collection. Attach a label to each blood tube.
Properly dispose of contaminated materials.
Fill-up the laboratory form properly and send to the laboratory technician.
Check the venipuncture site for bleeding.
Obtain results and secure it to the patients chart.
Refer the result to the physician.
62
BLOOD
Results
Normal value
Analysis and interpretation
CHEMISTRY
Creatinine
of results
Date ordered:
This test measures the amount of
11-06-2013
creatinine in the blood. Creatinine
11-07-2013
is produced by the breakdown of
11-08-2013
creatinine
11-10-2013
muscles by catabolism and is
phosphates
in
the
excreted by the kidney. It is an

end product of muscle energy
metabolism.
\
Date results
It is indicated to the patient to
Results relayed on November
in:
assess renal function that can be
6, 7, and 9, 2013 shows high
affected
11-06-2013
due
to
disease
condition.
3.29
0.79 1.56
mg/dl
mg/dl
creatinine levels. Elevated

creatinine
level
signifies
impaired kidney function due

to persistent high level of hgt
11-07-2013
Hence, further creatinine tests
3.61
and DM thus the patient was
were ordered on November 6, 7, 8
mg/dl
diagnosed of having CKD
and 10, 3013 because there is a
stage 3 secondary to Diabetic
63
11-09-2013
documented decreased patients
Nephropathy.
output compared to his input
kidneys become impaired for
(320/60 ml) on November 6,
any reason, the creatinine
2013,
(3,200/880
November,
7,
(3,300/2000 and
ml)
2013
As
the
on
2.23
level in the blood will rise
and
mg/dl
due to poor clearance of
2,200/500 ml)
creatinine by the kidneys.
on November 8, 2013, this is
Abnormally high levels of
indicative of a problem with the
creatinine
patients
possible
renal
function,
thus
warn
malfunction
failure
Kidney disease (CKD) Stage 3
Furthermore, The patient was
secondary
given Furosemide to help in
Nephropathy.
Diabetic
the
or
moreover, the patient has Chronic
to
of
of
kidneys.
proper elimination of fluids

thru
urination
because
Creatinine is not eliminated

well in the body as evidence
by imbalance in Input and
Output.
64
Management done includes

11-11-2013
This test is done to evaluate also
1.54
orders for the administartion
results of massive hemoptysis,
mg/dl
of Furosemide 20 mg IV stat
bleeding
during
the
surgery,
on November 6, 2013 due to
and
imbalance in patients intake
possible affectation of the kidneys
and output; followed by an
due to DM.
increased in the dosage and
increased
HGT
result
frequency of Furosemide to
40mg IV now then q 8hrs on
November 7 and 8, 2013.

2013 result retrieved shows a
normal level of creatinine of
Mr.Baga,
signifying
that
convertion of oliguric to
nonoliguric
renal
impairment with the use of

Furosemide helped with fluid
and electrolyte management.
65
Blood Urea
Date ordered:
A blood urea nitrogen (BUN) test
Nitrogen
11-07-2013
measures the amount of nitrogen
11-08-2013
in blood that comes from the
11-10-2013
waste product urea. Urea is made

when protein is broken down in
the body. Urea is made in
the liver and passed out off the
body in the urine.
Date results
in:
11-07-2013
A BUN test is done to the patient

to see how well the kidneys and
liver are working.
A BUN test may be done with a
46.27
7.84 20. 17
BUN result on November 7,
mg/dl
mg/dl
9, and 11 2013 reveals high

BUN
blood creatinine test. The level of

11-09-2013
This
may
creatinine in the blood also tells
47.39
indicate that the kidneys are
how well the patients kidneys are
mg/dl
not able to remove urea from

the blood normally, thus the
working-a high creatinine level

11-11-2013
level.
may mean his kidneys are not
39.38
patients kidneys or liver
working properly. Blood urea
mg/dl
may not be working properly
66
nitrogen (BUN) and creatinine
was diagnosed of having
tests can be used together to find
CKD stage 3 secondary to
the
Diabetic Nephropathy. .
BUN-to-creatinine
(BUN:creatinine).
ratio
BUN-to-
creatinine ratio can help doctors

check for problems, such as
dehydration,
that
may
cause
abnormal BUN and creatinine

levels.
Same with creatinine tests, BUN
tests ordered on November 6, 7, 8
and 10, 3013 because there is a
documented decreased patients
output compared to his input
(320/60 ml) on November 6,
2013,
(3,200/880
ml)
on
November, 7, 2013 and (33/2 and

22/50 ml) on November 8, 2013,
this is indicative of a problem
with the patients renal function,
67
moreover, the patient has CKD

but urine with pus and increasing
creatinine was evaluated. This
test is also done to evaluate also
results of massive hemoptysis,
bleeding
during
increased
the
HGT
surgery,
result
and
possible affectation of the kidneys

due to DM.
Sodium
Serum Sodium
is
the
principal
Date ordered:
electrolyte of the extracellular
Serum
11-04-2013
fluid of the blood maintaining
normal range so as with
11-11-2013
osmotic pressure, and is involved
potassium. It indicates that
in acid-base balance and the

Date results
transmission of nerve impulses.
in:
11-04-2013
138
135-150
meq/L
meq/L
sodium
is
within
there is normal sodium-water

balance
which
sodium
excretion
inhibits
and
The test is ordered to monitor
promotes its absorption (with
electrolyte balance, water balance
water) by the renal tubules to
and base balance. The patient had
maintain
massive
shows that extracellular fluid
hemoptysis
on
balance.
Also
68
November 3, 2013 and he was
osmotic
pressure
scheduled
maintained
and
for
on
November 5, 2013. This test was
promote
done to Mr. Baga to determine
function.
extracellular
11-11-2013
surgery
monitor
fluid
osmolality
helps
neuromuscular
and
electrolyte
139.4
Latter testing was done on
balance especially before and
mEq/L
November
after surgery.
and
it
is
revealing
11,
2013
normal
sodium
level. It again indicates that

there is normal sodium-water
balance
which
inhibits
sodium
excretion
and
promotes its absorption by

the renal tubules to maintain
balance. Also shows that
extracellular fluid osmotic
pressure is maintained and it
helps
promote
neuromuscular function.
69
Potassium
is
the
principal
electrolyte of the intracellular
Serum
Date ordered:
Potassium
11-04-2013
fluid,
11-05-2013
concentrations circulating in the
11-06-2013
extracellular fluid.
with
only
low
11-07-2013
11-11-2013
The test determines Mr. Bagas

level of potassium in the body,
Date results
in:
11-04-2013
(7:38AM)
because
again
November
as
said,
on
3, 2013 he had
massive hemoptysis, and he was

scheduled
for
surgery
on
5.13
3.50-5.50
Results relayed on November
mEq/L
mEq/L
4 and 5, 2013 for serum
November 5, 2013. This test was
potassium are within normal
done to Mr. Baga to determine
ranges so as with sodium. It
11-05-2013
intracellular
(9:55AM)
monitor
osmolality
fluid
and
and
electrolyte
5.43
mEq/L
indicates that the cellular

osmotic
equilibrium
and
balance especially before and
regulation of muscle activity,
after surgery.
acid-base
balance
is
maintained.
Potassium
is
necessary
to
70
maintain nerve conduction and

11-06-2013
plays a major role in control of
5.96
However, on November 6 at
(2:00PM)
cardiac output. It is important to
mEq/L
2:00PM the result relayed
(5:12PM)
maintain serum potassium within
5.41
reveals increased potassium
normal ranges, so as not to further
mEq/L
level may indicate a kidney
promote serious arrhythmias.
problem since potassium is

excreted by the kidneys.,
thus D5050 + insulin was
ordered and was given at
5:00PM
to
manage
hyperkalemia.
Insulin
known
move
to
is
the
potassium present in the

blood inside the cells. This
however is only a temporary
measure
because
in
few
hours the potassium will

move back to the blood.
However,
this
technique
helps to procure time until
71
the
excess
excreted
potassium
through
is
kidneys.
Dextrose is also given to

prevent insulin from causing
hypoglycemia (low glucose
levels). Hence, the patient
was again subjected to this
test and result shown normal
potassium level at 5:12PM,
thus
the
patient
was
continously given D5050 +

insulin
11-07-2013
6.03
(8:30am)
mEq/L
until
6pm.
2013
result
shown
is
increased potassium level.

To
manage
episode
of
hyperkalemia the patient was

(5:00PM)
5.16
mEq/L
then again given D5050 +

insulin
and
Calcium
72
Gluconate at 10:20am, thus

the
patient
was
also
submitted to 12-lead ECG

monitoring
to
serious
rule
out
dysrrhythmias
present. Moreover, result at

5:00PM
revealed
normal
level of potassium of 5.16

mEq/L.
11-11-2013
4.41
(6:00AM)
mEq/L
Latter testing was done on

November
11,
2013
revealing normal potassium

level so as with sodium. It
indicates that the cellular
osmotic
equilibrium
and
regulation of muscle activity,

acid-base balance is restored.
Thus,
the
kidneys
are
functioning well that they
73
can able to excrete
and
reabsorb potassium well.
Prior:
Identify the patient.
Explain the procedure to the patient, its purpose and how it is done.
Tell the patient that no fasting is required.
Assure patient that collecting blood sample take less than 3 min.
Inform patient that the patient will be experiencing pain on the site where the needle was pricked.
Refer to the member of the health care team.
Explain the procedure and purpose to the patient.
Tell the patient that fasting not required.
Instruct patient there are no special measures needed.
74
During:
Select a vein for venipuncture.
Clean venipuncture site with alcohol; allow area to dry. Use antiseptic technique when obtaining the sample.
Perform venipuncture by entering the skin with needle at approximately a 15 degree angle to the skin, needle bevel up.
After blood is drawn, place cotton ball over site; withdaraw the needle and exert pressure. Apply bandage if needed.
After:
Record the date and time of blood collection. Attach a label to each blood tube.
Properly dispose of contaminated materials.
Fill-up the laboratory form properly and send to the laboratory technician.
Check the venipuncture site for bleeding.
Obtain results and secure it to the patients chart.
Refer the result to the physician.
75
Diagnostic/
Date ordered
Laboratory
and date
Procedures
result(s) in
Electrocardiography
Date ordered:
11-04-2013
Date results in:

11-04-2013
Results
Analysis and
Normal Value
interpretation
of results
Normal
sinus Patients
representation of the electrical Sinus
rhythm;
with bradycardia and
impulses that the heart generates Bradycardia
normal P -wave, AV block may
during
QRS
ECG
is
the
cardiac
graphical 11-04-2013
cycle. First Degree
Indicated by the physician for AV Block
complex due to the use of
and T- wave.
beta-blocker
cardiopulmonary (CP) clearance
(Carvedilol)
since the patient is for operation.
maintenance
as
drug
for
hypertension.
Carvedilol
works
relaxing
by
blood
vessels
and
slowing
heart
rate to improve
76
blood flow and

decrease
blood
pressure.
12 lead ECG was ordered to 11-05-2013
Normal
sinus The
check the activity of the Heart, Sinus
rhythm;
with bradycardia
in related to the proper pumping Bradycardia
normal P -wave, may due to the
Date results in:
of blood to supply the vital
QRS
11-05-2013
organs of the body (e.g. kidneys)
and T- wave.
Date ordered:
11-05-2013
patients
is
complex use of GETA

which
can
after surgery. Also to check
decrease
heart
GETA and ET tube insertion
rate.
Also
effects post-op.
Dopamine drip
may contribute
in lowering the
heart
rate
because of its
side effect.
Date ordered:
11-05-2013
Normal sinus
The
patients
check the activity of the Heart, Sinus
rhythm; with
bradycardia
is
77
in related to the proper pumping Bradycardia
normal P -wave,
May due to the
Date results in:
of blood to supply the vital
QRS complex
use of GETA
11-05-2013
organs of the body (e.g. kidneys)
and T- wave.
which
can
after surgery. Also to check the
decrease
heart
effect of hyperkalemic episode
rate.
Also
of the patient that may lead to
Dopamine drip
sinus bradycardia. Also to check
may contribute
GETA effects post-op.
in lowering the
heart
rate
because of its
side effect.
The
Date ordered:
patients
Normal sinus
bradycardia
check if the activity of the Heart Sinus
rhythm; with
may due to the
was restored.
normal P -wave,
use
Date results in:
QRS complex
Dopamine drip
11-06-2013
and T- wave.
because of its
11-05-2013
Bradycardia
side
is
of
effect
decrease
of
heart
rate.
78
Patient preparation:
Explain the procedure to the patient.
Tell the patient that no food or fluid restriction is necessary.
Assure the patient that the flow of electric current is from the patient. The patient will feel nothing during the procedure.
Expose only the patients chest and arms. Keep the abdomen and thighs adequately covered.
After:
Remove the electrodes from the patients skin and wipe off the electrode gel.
Indicate on the ECG strip or request slip if the patient has experiencing chest pain during the study. The pain may be correlated
with an arrhythmia on the ECG.
79
Diagnostic/
Date ordered
Results
Analysis and
Laboratory
and date
Normal
interpretation of
Procedures
result(s) in
Value
results
Random Blood
DO: 11-03-13
A blood sample will be taken at
Sugar (RBS)
DR: 11-03-13
a random time. Blood sugar
higher thus the
TR: 6PM
values
in
patient was given
milligrams per deciliter (mg/dL)
insulin of Mixtard
or millimoles per liter (mmol/L).
30 HM 22 units
The patient is a candidate for
(PM
operation; the physician has
manage
ordered a 12hour monitoring of
level in the blood
CBG/HGT to give immediate
prior to surgery
measures
an
and the glucose
elevated or decreased level of
level was checked
glucose in blood. This is done to
again at 6 AM
check if the patient is fit for
November
surgery because patient has DM.
result
are
in
expressed
controlling
345 mg/dL
The
result
dose)
is
to
glucose
was
4
137
mg/dL.
80
DO: 11-04-13
Continuous monitoring for the
DR: 11-04-13
serum glucose of the patient as
slightly increased
TR: 6AM
ordered by the physician.
thus patient was
137 mg/dL
The
result
was
given Mixtard 30
HM 40 units (AM
dose) to maintain
glucose
within
level
normal
range.
DO: 11-04-13
DR: 11-04-13
increased thus the
TR: 8AM
patient was given
240 mg/dL
The
result
was
Mixtard 30 HM
40
units
(PM
dose)
DO: 11-05-13
DR: 11-05-13
TR: 9:20AM
97 mg/dL
The
result
was
low
thus
the
ordered by the physician. The
physician ordered
test was ordered to check CBG
to withhold the
level because patient has to be in
Mixtard
81
NPO prior to surgery.
administration
while patient is on
NPO status (for
OR)
Shifted PNSS to
D5LRS 1L x 80
cc/hr done to
increase
serum
the
glucose
with the use of a

D5
containing
IVF
DO: 11-05-13
This
is
done
to
check
DR: 11-05-13
effectiveness of holding Mixtard
increased thus the
TR: 6PM
and shifting IVF to D5LRS.
patient was given
286 mg/dL
The
result
was
HR 8 units SC
because Mixtard
was hold. But the
CBG result of the
82
patient at 8PM
was
increased
(335 mg/dL)
DO: 11-05-13
This is to check effectiveness of
DR: 11-05-13
giving HR 8 units SC.
335 mg/dL
Patient was given

HR 10 units IV to
TR: 8PM
control increasing
levels of CBG but
still the result at
11
PM
was
increased
(237
mg/dL)
DO: 11-05-13
To check effectiveness after
DR: 11-05-13
giving HR 10 units IV STAT
237 mg/dL
Still
the
result
was above normal
TR: 11PM
level
but
no
management
done or insulin
given.
DO: 11-06-13
DR: 11-06-13
high so the doctor
TR: 6AM
ordered by the physician
ordered
287 mg/dL
The result is sill
D5LRS
83
to consume and
change to PNSS
1L x 80 cc/hr.
D5LRS
was
changed to PNSS
because
D5
containing fluids
are
high
dextrose
in
or
glucose.
Physician ordered
to give Mixtard
20 units SC, now
Mixtard 20 units
SC (AM dose)
Mixtard 20 units
SC (PM dose)
DO: 11-06-13
DR: 11-06-13
high so the doctor
TR: 12PM
ordered by the physician for
ordered to give to
264 mg/dL
The
result
was
84
appropriate
management
for
the patient HR 12
CBG.
units SC and 12
units IV at 5 PM.
It
was
checked
again after and

the result was 199
mg/dL
DO: 11-06-13
The test was ordered to check
DR: 11-06-13
effectiveness of HR 12 units SC
D50/50 1 vial + 10
TR: 5PM
and 12 units IV which was given
units HR FOR 3
to the patient at 12 PM. It is done
DOSES (1). This
also to monitor CBG levels for
is to lower down
appropriate management.
the
194 mg/dL
Patient was given
patients
potassium level of
5.96 meq/L.
Physician ordered
to
halt
administration of
Mixtard
(PM
85
dose) temporarily
and
continue
tomorrows
AM
dose
DO: 11-06-13
This
was
done
to
check
DR: 11-06-13
effectiveness
TR: 6PM
administration of D50/50 1 vial
above
+ 10 units HR and holding of
The patient was
Mixtard.
given D5050 was
of
331 mg/dL
the
The
patients
CBG result was

normal.
given to decrease
the
potassium
level, but due to

this procedure the
pt
HGT
level
increased to 344
mg/dL
DO: 11-06-13
This
was
done
to
check
DR: 11-06-13
effectiveness of administering
D50/50 1 vial + 10
TR: 7PM
d5050 1 vial + 10 units of HR
units HR (3)
344 mg/dL
Patient was given
86
The
result
above
was
normal
level because the

patient has eaten
consisting of rice
porridge and also
given
D5050
insulin to lower
down the K+ level.
DO: 11-06-13
This
was
done
to
check
DR: 11-06-13
effectiveness of administering
above
TR: 8PM
d5050 1 vial + 10 units of HR
level because the
423 mg/dL
The
result
was
normal
patient has eaten

food such as plain
soup,
an
apple
and a fruit drink.

DO: 11-06-13
DR: 11-06-13
TR: 9PM
369 mg/dL
Still
the
was
abnormally
high so the doctor

then
result
ordere
to
87
continue
CBG
monitoring q 1.
Insulin drip 100
units HR in 100cc
PNSS A 10 units/
hr.
Continuous
management
high
for
level
of
result
was
CBG.
DO: 11-06-13
DR: 11-06-13
abnormally high
TR: 10PM
ordered by the physician. To
so
check
ordered for the
also
insulin drip.
effectiveness
of
341 mg/dL
The
the
doctor
patient to have an
insulin drip 100
units HR in 100
cc of PNSS at 10
units/hr
88
DO: 11-06-13
DR: 11-06-13
abnormally high
TR: 11PM
so
check
ordered
also
effectiveness
312 mg/dL
of
insulin drip.
The result is still
the
doctor
continuous
insulin drip 100
units HR in 100
cc of PNSS at 10
units/hr
DO: 11-07-13
DR: 11-07-13
insulin drip 100
TR: 12MN
units HR in 100
254 mg/dL
Patient
has
an
cc of PNSS at 15
units/hr.
The
doctor
also
ordered to repeat
CBG after 1 hour.
DO: 11-07-13
DR: 11-07-13
insulin drip 100
TR: 1AM
units HR in 100
208 mg/dL
Patient
has
an
89
check
also
effectiveness
of
cc of PNSS at 15
increasing the rate of the insulin
units/hr
drip after 1 hour.

DO: 11-07-13
DR: 11-07-13
insulin drip 100
TR: 2AM
units HR in 100
check
cc of PNSS at 15
also
effectiveness
181 mg/dL
of
Patient
has
an
units/hr
drip after 2 hours.

DO: 11-07-13
DR: 11-07-13
hold because the
TR: 3AM
results are almost
check
in normal levels.
also
effectiveness
114 mg/dL
of
Insulin drip was

drip after 3 hours.
DO: 11-07-13
To test the result of holding the
DR: 11-07-13
insulin drip.
TR: 4AM
147 mg/dL
Insulin drip was

hold because the
results are almost
in normal levels
90
DO: 11-07-13
137 mg/dL
DR: 11-07-13
hold because the
TR: 5AM
results are almost
Insulin drip was
in normal levels.
DO: 11-07-13
DR: 11-07-13
again
TR: 6AM
doctor ordered to
226 mg/dL
The CBG went up
resume
so
the
insulin
drip of 100 units

HR in 100 cc of
PNSS
at
has
an
units/hr
DO: 11-07-13
To check the effectiveness of
DR: 11-07-13
resuming insulin drip of 100
insulin drip 100
TR: 7AM
units HR in 100 cc of PNSS at 5
units HR in 100
units/hr.
cc of PNSS at 5
210 mg/dL
Patient
units/hr
DO: 11-07-13
To check the CBG level while on
DR: 11-07-13
insulin drip of 100 units HR in
high so the doctor
TR: 8AM
100 cc of PNSS at 5 units/hr.
ordered
199 mg/dL
The result is still
to
91
increase rate of
insulin drip 100
units HR in 100
cc of PNSS from 5
units/hr
to
12
units/hr
DO: 11-07-13
DR: 11-07-13
increasing the rate of insulin drip
above
TR: 9AM
of 100 units HR in 100 cc of
level of CBG was
PNSS from 5 units/hr to 12
continuous.
165 mg/dL
Management for
normal
units/hr.
DO: 11-07-13
DR: 11-07-13
increasing the rate of insulin drip
insulin drip 100
TR: 10AM
of 100 units HR in 100 cc of
units HR in 100
PNSS from 5 units/hr to 12
cc of PNSS at 12
units/hr.
units/hr and the
144 mg/dL
Patient
doctor
has
an
ordered
d5050 1 vial + HR
10 units x 3 days
1 hour interval to
92
lower down the

levels
of
potassium
with
6.03 meq/L
DO: 11-07-13
Test
was
done
to
check
DR: 11-07-13
effectiveness of insulin drip and
checked again to
TR: 11AM
d50/50 1 vial + HR 10 units x 3
check CBG level.
days 1 hour interval.
The
178 mg/dL
The
result
CBG
was
is
slightly high. The

doctor
ordered
continuous
insulin
drip
of
100 units HR in
100 cc of PNSS at
5 units/hr
DO: 11-07-13
Test
DR: 11-07-13
TR: 12NN
was
done
to
check
182 mg/dL
The
result
was
effectiveness of insulin drip of
still high so
the
100 units HR in 100 cc of PNSS
doctor
at 5 units/hr
continuous
insulin
ordered
drip
of
93
100 units HR in
100 cc of PNSS at
5 units/hr
DO: 11-07-13
DR: 11-07-13
TR: 1PM
212 mg/dL
The
result
was
still high so
the
ordered by the physician and to
doctor
check effectiveness of insulin
continuous
drip.
insulin
ordered
drip
of
100 units HR in
100 cc of PNSS at
5 units/hr
DO: 11-07-13
DR: 11-07-13
TR: 2PM
265 mg/dL
The
result
was
still high so
the
doctor
continuous
drip.
insulin
ordered
drip
of
100 units HR in
100 cc of PNSS at
5 units/hr
94
DO: 11-07-13
DR: 11-07-13
above normal so
TR: 3PM
the
ordered
drip.
increase the rate
185 mg/dL
The
result
was
doctor
to
of the insulin drip

of 100 units HR in
100 cc of PNSS
from 5 units/hr to
13 units/hr
Patient
is
on
Nephrosteril
DO: 11-07-13
DR: 11-07-13
CBG
TR: 4PM
high so the doctor
check
of
ordered
to
continue
insulin
drip from 5 units/hr to 13
drip 100 units HR
units/hr
in 100 cc of PNSS
the
effectiveness
146 mg/dL
The result of the

was
still
at 13 units/hr
95
DO: 11-07-13
DR: 11-07-13
results
TR: 5PM
patient refused to
Patient refused
There
were
no
because
have CBG taking.

Patient
has
an
insulin drip 100

units HR in 100
cc of PNSS at 13
units/hr
DO: 11-07-13
Test was done to determine the
DR: 11-07-13
current CBG level after refusal
decreased to 85
TR: 6PM
of the patient to the previous
mg/dL
CBG taking.
doctor ordered to
85 mg/dL
The
result
so
decrease
the
insulin
to 10 units/hr.
DO: 11-07-13
To test the effectiveness of
DR: 11-07-13
decreasing the rate of the insulin
rapidly but there
TR: 7PM
drip after having a CBG reading
was
of 85 mg/dL.
management
185 mg/dL
Result
elevated
no
extra
given except for
96
the insulin drip

100 units HR in
100 cc of PNSS at
10 units/hr
DO: 11-07-13
DR: 11-07-13
down again so the
TR: 9PM
doctor ordered to
86 mg/dL
The result went
decrease the rate

of the insulin drip
of 100 units HR in
100 cc of PNSS
from 10 units/hr
to 8 units/hr
DO: 11-07-13
To
test
effectiveness
of
DR: 11-07-13
decreasing the rate of the insulin
high rapidly but
TR: 11PM
drip from 10 units per hour to 8
no
units per hour.
management
132 mg/dL
The result went
rendered
extra
except
for the continuous

infusion
of
the
97
insulin
drip
of
100 units HR in
100 cc of PNSS at
8 units/hr
DO: 11-08-13
DR: 11-08-13
slightly
TR: 1AM
but there was no
174 mg/dL
The result went

elevated
extra
management
ordered but the
doctor
ordered
for the continuous

infusion of insulin
drip of 100 units
HR in 100 cc of
PNSS
at
units/hr
DO: 11-08-13
DR: 11-08-13
down
TR: 3AM
ordered by the physician
doctor
145 mg/dL
The result came

and
the
ordered
98
for the continuous

infusion of insulin
drip of 100 units
HR in 100 cc of
PNSS
at
units/hr
DO: 11-08-13
DR: 11-08-13
change thus the
TR: 5AM
doctor
147 mg/dL
The result did not
the
ordered
continuous
infusion of insulin
drip 100 units HR
in 100 cc of PNSS
at 8 units/hr
DO: 11-08-13
DR: 11-08-13
CBG
TR: 7AM
dropped but no
99 mg/dL
The result of the

suddenly
extra
management
99
except
for
the
continuous
infusion
of
the
insulin
drip
of
100 units HR in
100 cc of PNSS at
8 units/hr
DO: 11-08-13
DR: 11-08-13
decreased to 78
TR: 9AM
mg/dL
71 mg/dL
The
result
so
the
doctor ordered to
hold insulin drip
temporarily
to
feed
and
patient
then repeat CBG

after 30 minutes.
DO: 11-08-13
DR: 11-08-13
holding insulin drip temporarily
CBG
TR: 11AM
because of the decreased CBG
rapidly but still
level of 71 mg/dL as of 9AM
insulin drip was
145 mg/dL
The
result
of
increased
100
result on November 08 2013.
hold temporarily
as ordered by the
doctor.
DO: 11-08-13
DR: 11-08-13
CBG is increased
TR: 1PM
yet the doctor did
199 mg/dL
The result of the
not
order
resume
to
insulin
drip.
DO: 11-08-13
DR: 11-08-13
CBG is increased
TR: 3PM
so
200 mg/dL
The result of the
the
ordered
doctor
HR
units SC STAT to
decrease the CBG
levels. After 15
mins, the doctor
ordered another 3
units of HR to be
given SQ.
101
DO: 11-08-13
DR: 11-08-13
giving HR 3 units SC STAT and
CBG
TR: 5PM
another HR 3 units SC to
increased so the
manage Hgt result of 200 mg/dL
doctor
213 mg/dL
The result of the

is
still
ordered
HR 8 units SC
now to decrease
the CBG levels.
DO: 11-08-13
DR: 11-08-13
giving HR 8 units SC now to
CBG
TR: 7PM
manage Hgt result of 213 mg/dL
decreased so the
152 mg/dL
The result of the
doctor
was
did
not
order any insulin

injection to lessen
the CBG level of
the patient.
DO: 11-08-13
DR: 11-08-13
CBG increased so
TR: 8PM
the
181 mg/dL
The result of the
doctor
ordered to give
Mixtard 22 units
102
SC at 8PM then
Mixtard 44 units
SC at 8AM
DO: 11-09-13
To see the effectiveness of
113 mg/dL
DR: 11-09-13
giving Mixtard 22 units SC at
CBG
TR: 12MN
8PM
decreased so the
The result of the
doctor
was
did
not
order any insulin

injection to lessen
the CBG level of
the patient.
DO: 11-09-13
92 mg/dL
DR: 11-09-13
CBG
TR: 4AM
decreased to 92
The result of the

was
mg/dL thus the

doctor
did
not
order any insulin

injection to lessen
the CBG level of
the patient.
103
DO: 11-09-13
114 mg/dL
DR: 11-09-13
CBG
TR: 8AM
increased slightly
The result of the

was
to 114 mg/dL and

the
doctor
ordered
on
11/08/13 at 8PM
to give Mixtard
44 units SC at
8AM.
DO: 11-09-13
DR: 11-09-13
giving Mixtard 44 units at 8AM
CBG
TR: 12PM
in attempting to lower down
increased to 207
CBG level of 114 mg/dL
mg/dL
207 mg/dL
The result of the

was
so
the
doctor ordered to
give HR 5 units
SC now
DO: 11-09-13
DR: 11-09-13
giving HR 5 units SC now in
CBG
TR: 4PM
attempting to lower down CBG
increased to 216
216 mg/dL
The result of the

was
104
level of 207 mg/dL
mg/dL
so
the
doctor ordered to
increase HR to 6
units SC now
DO: 11-09-13
DR: 11-09-13
CBG
TR: 8PM
attempting to lower down CBG
high so the doctor
level of 216 mg/dL
ordered to give
187 mg/dL
The result of the

was
still
Mixtard 22 units
SC now
DO: 11-10-13
DR: 11-10-13
giving Mixtard 22 units SC now
CBG was elevated
TR: 12MN
in attempting to lower down
but the doctor did
CBG level of 187 mg/dL
not
208 mg/dL
The result of the
made
orders
any
in
decreasing
the
elevated levels of
CBG
of
208
mg.dL
105
DO: 11-10-13
114 mg/dL
DR: 11-10-13
CBG
TR: 4AM
from 208mg/dL to
The result of the

lowered
114 mg/dL thus

the doctor did not
made any orders
of
lessening
it
further.
The doctor made

an
order
decrease
to
Hgt
Monitoring to q
6
DO: 11-10-13
DR: 11-10-13
CBG was elevated
TR: 12NN
so
223 mg/dL
The result of the
the
doctor
ordered to give
HR 6 units IV
now and HR 6
106
units SC now
DO: 11-10-13
To monitor the effectiveness of
DR: 11-10-13
giving HR 6 units IV now and
CBG was almost
TR: 6PM
HR 6 units SC now in attempting
the same so the
to lower down a CBG of 223
doctor ordered to
mg/dL
give HR 5 units
221 mg/dL
The result of the
SC now
DO: 11-11-13
DR: 11-11-13
CBG was elevated
TR: 12MN
attempting to lower down a CBG
so
of 221 mg/dL
ordered to give
230 mg/dL
The result of the
the
doctor
HR 3 units SC
now
DO: 11-11-13
DR: 11-11-13
CBG
TR: 6AM
elevated but the
of 230 mg/Dl
doctor
189 mg/dL
The result of the

was
did
still
not
order any insulin

or management to
decrease the CBG
107
level
of
189
mg/dL as of 6AM
results.
DO: 11-11-13
DR: 11-11-13
CBG
TR: 12PM
abnormally
290 mg/dL
The result of the

was
elevated
so
the
doctor ordered to
give HR 6 units
IV now and 6
units SC now
DO: 11-11-13
DR: 11-11-13
giving HR 6 units IV now and 6
CBG
TR: 6PM
units SC now in attempting to
elevated
lower down a CBG of 290 mg/dl
doctor ordered to
272 mg/dL
The result of the

was
so
still
the
give HR 6 units
IV now.
DO: 11-12-13
DR: 11-12-13
giving HR 6 units IV now in
CBG
TR: 12MN
normal
130 mg/dL
The result of the

was
in
level
108
of 272 mg/dl
which the doctor

did not order any
management.
DO: 11-12-13
DR: 11-12-13
CBG
TR: 6AM
decreased slightly
179 mg/dL
The result of the

was
but still elevated

yet the doctor did
not order insulin
for
increased
CBG, but the pt is

taking oral antihyperglycemia
(Linagliptin).
DO: 11-12-13
DR: 11-12-13
CBG was elevated
TR: 12NN
so
267 mg/dL
The result of the
the
doctor
ordered 6 units of
Mixtard as STAT
dose
109
DO: 11-12-13
DR: 11-12-13
giving
TR: 6PM
144 mg/dL
6 units of Mixtard as
The result of the

CBG
was
STAT dose in attempting to
decreased.
The
lower down a CBG of 267
doctor
has
mg/dL
ordered at 9AM
of 11/12/13 to give
Mixtard 24 units
SC (PM dose)
DO: 11-13-13
DR: 11-13-13
giving Mixtard 24 units SC (PM
CBG
was
TR: 12MN
dose) as ordered as of 9AM of
decreased.
The
11/12/13.
doctor
not
109 mg/dL
The result of the
did
order
further
management
lowering
for
down
CBG level.
DO: 11-13-13
DR: 11-13-13
CBG
was
TR: 6AM
increased.
The
doctor
has
125 mg/dL
The result of the
110
ordered at 9AM
of 11/12/13 to give
Mixtard 48 units
SC (AM dose)
BEFORE
Identify the patient by asking the patient to state his/her name. Also check the clients identification band. ( confirm patients
identity using two patient identifiers, based on the hospital protocol)
Explain the procedure to the patient or parents (if patient is a child) to gain cooperation
Choose the puncture site. For adults and children fingertips and earlobe can be use.
Wash hands and don clean gloves
If glucometer is used, load the strip into the device beforehand.
DURING
Swab alcohol pad to the chosen puncture site. Use sterile/clean gauze to dry it thoroughly. Piecing the skin with a wet skin
(alcohol) allows the chemical to pass through the outer layer of the skin thus, causing the procedure more painful and
uncomfortable
111
To collect a blood sample, position the lancet (pricking needle) at the side of the site. To minimize pain and patients anxiety
pierce the skin sharply and briefly. This technique also increases blood flow. For better results, some agencies are using a
lancing device (mechanical blood-letting device) wherein the lancets are simply loaded in the spring of the equipment. (Its
like using a spring-loaded pen, once you click the button the spring releases the lancet and immediately retracts it after piercing
the skin). However, be sure to load an unused lancet before using to prevent spread of blood-transmitted diseases.
Dont squeeze the puncture site to prevent diluting the sample with fluids from tissues.
Place gauze over the punctured area and briefly apply pressure until the bleeding stops.
AFTER
Apply an adhesive bandage once the bleeding on the puncture site has stopped.
Remove gloves and record the resulting glucose level from the digital display for glucometer or from the color of reagent strip
to the standardized chart
112
Diagnostic/
Date ordered
Laboratory
and date
Procedures
result(s) in
URINALYSIS
Date ordered:
11-07-2013
Results
Analysis and
Normal Value
interpretation
of results
Urinalysis is a test that evaluates

a
sample
of
your
urine.
Urinalysis is used to detect and
Volume
The
600 to 2500 mL
have
in 24 hours
Date results in:
assess a wide range of disorders,
11-07-2013
including urinary tract infection,
Color
Color
kidney disease and diabetes.
Light yellow
Pale yellow to
patient
components
that should not
Urinalysis involves examining
amber
the appearance, concentration
be present on
the
urine
(Albumin, Pus
cells,
and content of urine. Abnormal
Transparency
Transparency
Amorphous
urinalysis results may point to a
Slightly turbid
Clear to slightly
Urates,
disease or illness.
hazy
Specific gravity
Specific gravity
1.010
1.005 to 1.030
and
Bacteria).
with a normal
fluid intake
113
Reaction
Reaction
acidic
slightly acidic
Sugar
Sugar
Trace
negative
The patient has

traced
sugar
since
the
patient
is
diabetic.
Albumin
Albumin
Increased levels
Trace
Negative
of
protein
in
urine may be a
sign of kidney
disease.
Pus cells
Pus cells
Pus
3-5/HPF
negative
white
cells
cells
are
blood
that
114
signify infection
in
the
body,
especially if the
urine
also
contains
bacteria.
Presence of pus
cells
in
the
urine may also

be a sign of
infection
or
inflammation in
the kidneys and
bladder.
RBC
RBC
0-2/HPF
0-5/HPF
Epithelial Cells
Epithelial Cells
Rare
Few; hyaline
casts: 0-1/lpf
115
A. Urates
A. Urates
Few
negative
Amorphous
urates (Na, K,
Mg, or Ca salts)
tend to form in
acidic
urine
and may have a

yellow
or
yellow-brown
color.
Generally,
no
specific clinical
interpretation
can
be
based
made
on
finding
the
of
amorphous
crystals.
(Cornell
University).
116
Bacteria
Bacteria
The presence of
Few
Negative
bacteria
may
indicate
an
infection
or
contamination
of the sample.
BEFORE
Ensure that you have the correct equipment - urine dipsticks, disposable gloves and apron, sterile receiver and disposable
towel.
Obtain informed consent for procedure;
Provide any necessary patient education with regard to specimen collection;
Check manufacturers recommendations;
Check product expiry date;
Wash hands. Don gloves and apron;
117
DURING
Collect a midstream urine sample or catheter specimen from the patient using a sterile receiver and in accordance with
organizational policy
Remove reagent dipstick and immediately replace cap
Immerse the dipstick into urine, and then remove
Wait for appropriate length of time
Wipe the edge of the strip against the rim of the vessel in order to remove any excess urine. Dab the long edge and then the
back of the test strip on an absorbent surface such as a paper towel;
Hold dipstick at a slight angle. This prevents pad-to-pad contamination;
Read the reagent pads against the reference guide
AFTER
Dispose of urine and dipstick as with organizational policy;
Remove gloves and apron. Wash hands;
Document results
118
7. ANATOMY AND PHYSIOLOGY
RESPIRATORY SYSTEM
Respiration is necessary because all living cells of the body require oxygen and
produce carbon dioxide. The respiratory system assists in gas exchange and performs
other functions as well.
1. Gas Exchange. The respiratory system allows oxygen from the air to enter blood
and carbon dioxide to leave the blood and enter the air. The cardiovascular system
transport oxygen from the lungs to the cells of the body and carbon dioxide from
cells of the body to the lungs. Thus the respiratory and cardiovascular systems
work together to supply oxygen to all cells and remove carbon dioxide from the
cells and remove carbon dioxide. Without healthy respiratory and cardiovascular
systems, the capacity to carry out normal activity is reduced, and without
adequate respiratory and cardiovascular system function, life itself is impossible.
2. Regulation of blood pH. The respiratory system can alter blood pH by changing
blood carbon dioxide levels.
3. Voice production. Air movement past the vocal cords makes sound and speech
possible.
119
4. Olfaction. The sensation of smell occurs when airborne molecules are drawn into
the nasal cavity.
5. Innate immunity. The respiratory system provides protection against some
microorganisms by preventing their entry into the body and by removing them
from the respiratory surfaces.
Anatomy of the Respiratory System
The respiratory system consists of the external nose, the nasal cavity, the pharynx,
the larynx, the trachea, the bronchi, and the lungs. Although air frequently passes through
the oral cavity, it is considered to be part of the digestive system instead of the respiratory
system. The upper respiratory tract refers to the external nose, nasal cavity, pharynx, and
associated structures; and the lower respiratory tract includes larynx. Trachea, bronchi,
and lungs. These terms are not official anatomical terms, however, and there are several
alternative definitions.
Nose
The nose consists of the external nose and the nasal cavity. The external nose is
the visible structure that forms a prominent feature of the face. Most of the external nose
is composed of hyaline cartilage, although the bridge of the external nose consists of
bone. The bone and cartilage are covered by connective tissue and skin.
The nasal cavity extends from nares to the choane. The nares or nostrils are the
external openings of the nose and the choane are openings into the pharynx. The nasal
septum is a partition dividing the nasal cavity into the right and left parts. A deviated
nasal septum occurs when the septum bulges to one side or the other. The hard palate
forms the floor of the nasal cavity, separating the nasal cavity from the oral cavity. Air
can flow through the nasal cavity when the mouth is closed or when the oral cavity is full
of food.
120
Three prominent bony ridges called conchae are present on the lateral walls on
each of each side of the nasal cavity. The conchae increase the surface area of the nasal
cavity.
Paranasal sinuses are air- filled spaces within bone. The maxillary, frontal,
ethmoid, and sphenoidal sinuses are named after the bones in which they are located the
paranasal sinuses open into the nasal cavity and are lined with a mucous membrane. They
reduce weight of the skull, produce mucus, and influence the quality of the voice by
acting as resonating chambers.
The nasolacrimal ducts which carry tears from the eyes also open into the nasal
cavity. Sensory receptors for the sense of smell are found in the superior part of the nasal
cavity.
Air enters the nasal cavity through the nares. Just inside the nares the epithelial
lining is composed of stratified squamous containing coarse hairs. The hairs trap some of
the large particles of dust suspended in the air. The rest of the nasal cavity is lined with
pseudostratified columnar epithelial cells containing cilia and many mucus- producing
goblet cells also traps debris in the air. The cilia sweep the mucus posteriorly to the
pharynx, where it is swallowed. As air flows through the nasal cavities, it is humidified
by moisture from the mucous epithelium and is warmed by blood flowing through the
superficial capillary networks underlying the mucous epithelium.
Pharynx
The pharynx is the common passageway of both the respiratory and digestive
systems. It receives air from the nasal cavity and air, food, and water from the mouth.
Interferiorly, the pharynx leads to the rest of the respiratory system through the opening
into the larynx and to the digestive system through the esophagus. The pharynx can be
divided into three regions: the nasopharynx, the oropharynx, and the laryngopharynx.
121
The nasopharynx is the superior part of the pharynx. It is located posterior to the choanae
and superior to the soft palate, which is an incomplete muscle and connective tissue
partition separating the nasopharynx from the oropharynx. The uvula is the posterior
extension of the soft palate. The soft palate forms the floor of the nasopharynx. The
nasopharynx is lined with pseudostratified ciliated columnar epithelium that is continuous
with the nasal cavity. The auditory tubes extend from the middle ears and open into the
nasopharynx. The posterior part of the nasopharynx contains pharyngeal tonsil, which
aids in defending the body against infection. The soft palate elevated during swallowing;
this movement results in the closure of the nasopharynx, which prevents food from
passing from the oral cavity into the nasopharynx.
The oropharynx extends from the uvula to the epiglottis, and the oral cavity opens
into the oropharynx. Thus food, drink and air pass through the oropharynx. The
oropharynx is lined with stratified squamous epithelium, which protects against abrasion.
Two sets on tonsils, the palatine tonsil and the lingual tonsils, are located near the
opening between the mouth and the oropharynx. The palatine tonsils are located in the
lateral walls near the border of the oral cavity and the oropharynx. The lingual tonsil is
located o the surface of the posterior part of the tongue.
The laryngopharynx passes posterior to the larynx and extends from the tip of the
epiglottis to the esophagus. Food and drink pass through the laryngopharynx to the
esophagus. A small amount of air is usually swallowed with the food and drink
swallowing too much air can cause excess gas in the stomach and may result in belching.
The laryngopharynx is lined with squamous epithelium and ciliated columnar epithelium.
Larynx
The larynx is located in the anterior throat, and it is continuous superiorly with the
pharynx and inferiorly with the trachea. The larynx consists of an outer casting of nine
cartilages that are connected to one another by muscles and ligaments. Three of nine
cartilages are unpaired, and six of them form three pairs. The largest cartilage is the
unpaired thyroid cartilage, or Adams apple. The thyroid cartilage is attached superiorly
122
to the hyoid bone. The most inferior cartilage of the larynx is the unpaired cricoid
cartilage, which forms the base of the larynx on which the other cartilages rest. The
thyroid and cricoids cartilages maintain an open passageway for air movement.
The third unpaired cartilage is the epiglottis. It differs from the other cartilages in
that it consists of elastic cartilage rather than hyaline cartilage. Its inferior margin is
attached to the thyroid cartilage anteriorly, and the superior part of the epiglottis projects
as a free flap toward the tongue. The epiglottis helps prevent swallowed materials from
entering the larynx. As the larynx elevates during swallowing, the epiglottis tips
posteriorly to cover the opening of the larynx.
The six paired cartilages consist of three cartilages on either side of the posterior
part of the larynx. The top cartilage on each side is the cuneiform cartilage, the middle
cartilage is the corniculate cartilage, and the bottom cartilage is the arytenoids cartilage.
The arytenoids cartilages articulate with the cricoids cartilage inferiorly. The paired
cartilages form an attachment site for the vocal folds.
Two pairs of ligament extend from the posterior surface of the thyroid cartilage to
the paired cartilages. The superior pair forms the vestibular folds, or false vocal cords,
and the inferior pair composes the vocal cords or true vocal cords. The vestibular folds
comes together, they prevent air from leaving the lungs such as when a person holds his
breath. Along with the epiglottis, the vestibular folds also prevent food and liquids from
entering the larynx.
The vocal folds are the primary source of voice production. Air moving past the
vocal folds causes them to vibrate, producing sound. Muscles control the length and
tension of the vocal folds. The force of air moving past the vocal folds controls the
loudness, and the tension of the vocal folds controls the pitch of the voice. And
inflammation of the mucous epithelium of the vocal folds is called laryngitis. Swelling of
the vocal folds during laryngitis inhibits voice production.
123
Trachea
The trachea, or windpipe, is a membranous tube that consists of connective tissue
and smooth muscle, reinforced with 16- 20 C- shaped pieces of cartilage. The adult
trachea is about 1.4- 1.6 centimeter in diameter and about 10- 11 cm long. It begins
immediately inferior to the cricoid cartilage, which is the most inferior cartilage of the
larynx. The trachea projects through the mediastinum, and divides into the right and left
primary bronchi at the level of the fifth thoracic vertebra. The esophagus lies immediately
posterior to the trachea.
C- shaped cartilage form the anterior and lateral sides of the trachea. The
cartilages protect the trachea. The cartilages protect the trachea and maintain an open
passageway for air. The posterior walls of the trachea has no cartilage and consists of
ligamentous membrane and smooth muscle can alter diameter of the trachea.
The trachea is lined with pseudostratified columnar epithelium which contains
numerous cilia and goblet cells. The cilia propel mucus produced by the goblet cells, as
well as foreign particles embedded in the mucus, out of the trachea, through the larynx,
and into the pharynx, from which they are swallowed.
Constant irritation of the trachea by cigarette smoke can cause the tracheal
epithelium to change to stratified squamous epithelium. The stratified sqamous
epithelium has no cilia and therefore lacks the ability to clear the airway of mucus and
debris. The accumulations of mucus provide a place for microorganisms to grow,
resulting in respiratory infections. Constant irritation and inflammation of the respiratory
passages stimulate the cough reflex, resulting in smokers cough
Bronchi
The trachea divides into the left and right main bronchi, each of which connects to
a lung. The left main bronchus is more horizontal than the right main bronchus because it
is displaced by the heart. Foreign objects that enter the trachea usually lodge in the right
main bronchus, because it is more vertical than the left main bronchus and therefore more
in direct line with the trachea. The main bronchi extend from the trachea to the lungs.
124
Like the trachea, the main bronchi are lined with pseudostratified ciliated columnar
epithelium and supported by the C- shaped pieces of cartilage.
Lungs
The lungs are the principal organs of respiration. Each lung is cone-shaped, with
its base resting on the diaphragm and its apex extending superiorly to a point about 2.5
cm above the clavicle. The right lung has three lobes called the superior, middle, and
inferior lobes. The left lung has two lobes called the superior and inferior lobes. The
lobes of the lungs are separated by deep, prominent fissures on the surface of the lung.
Each lobe is divided into bronchopulmonary segments separated from one another by
connective tissue septa, but these separations are not visible as surface fissures.
Individual diseased bronchopulmonary segments can be surgically removed, leaving the
rest of the lung relatively intact, because major blood vessels and bronchi do not cross the
septa. There are 9 bronchopulmonary segments in the left lung and 10 in the right lung.
The main bronchi branch many times to form the tracheobronchial tree. Each
main bronchus divides into lobar bronchi as they enter their respective lungs. The lobar
(secondary) bronchi, two in the left lung and three in the right lung, conduct air to each
lobe. The lobar bronchi in turn give rise to segmental (tertiary) bronchi, which extend to
the bronchopulmonary segments of the lungs. The bronchi continue to branch many
times, finally giving rise to bronchioles. The bronchioles also subdivide numerous times
to give rise to terminal bronchioles, which then subdivide into respiratory bronchioles.
Each respiratory bronchiole subdivides to form alveolar ducts, which are like long,
branching hallways with many doorways. The doorways open into alveoli, which are
small air sacs. The alveoli become so numerous that the alveolar duct wall is little more
than a succession of alveoli. The alveolar ducts end as two or three alveolar sacs, which
are chambers connected to two or more alveoli. There are about 300 million alveoli in the
lungs.
As the air passageways of the lungs become smaller, the structure of their walls
changes. The amount of cartilage decreases and the amount of smooth muscles increases,
125
until at the terminal bronchioles, the walls have a prominent smooth muscle layer, but no
cartilage. Relaxation and contraction of the smooth muscle within the bronchi and
bronchioles can change the diameter of the air passageways. For example, during
exercise the diameter can increase, thus increasing the volume of air moved. During an
asthma attack, however, contraction of the smooth muscle in the terminal bronchioles can
result in greatly reduced air flow. In sever cases, air movement can be so restricted that
death results.
As the air passageways of the lungs become smaller, the lining of their walls also
changes. The trachea and bronchi have pseudostratified ciliated columnar epithelium, the
bronchioles have ciliated simple columnar epithelium, and the terminal bronchioles have
ciliated simple cuboidal epithelium. The ciliated epithelium of the air passageways
functions as a mucus-cilia escalator, which traps debris in the air and removes it from the
respiratory system.
As the air passageways beyond the terminal bronchioles become smaller, their
walls become thinner. The walls of the respiratory bronchioles are cuboidal epithelium
and those of the alveolar ducts and the alveoli are simple squamous epithelium. The
respiratory membrane of the lungs is where gas exchange between the air and blood takes
place. It is mainly formed by the walls of the alveoli and surrounding capillaries but
theres some contribution by the alveolar ducts and respiratory bronchioles. The
respiratory membrane is very thin to facilitate the diffusion of gases. It consists of:
1. A thin layer of fluid lining the alveolus
2. The alveolar epithelium composed of simple squamous epithelium
3. The basement membrane of the alveolar epithelium
4. A thin interstitial space
5. The basement membrane of the capillary endothelium
6. The capillary endothelium composed of simple squamous epithelium
The elastic fibers surrounding the alveoli allow them to expand during inspiration
and recoil during expiration. The lungs are very elastic, and when inflated, they are
126
capable of expelling air and returning to their original, uninflated state. Specialized
secretory cells within the walls of the alveoli secrete a chemical called surfactant that
reduces the tendency of alveoli to recoil.
Pleural Cavities
The lungs are contained within the thoracic cavity. In

addition, each lung is surrounded by a separate pleural
cavity. Each pleural cavity is lined with a serous membrane
called the pleura. The pleura consist of a parietal and
visceral part. The parietal pleura, which lines the walls of
the thorax, diaphragm, and mediastinum, is continuous with
visceral pleura, which covers the surface of the lung.
The pleural cavity, between the parietal and visceral

pleurae, is filled with a small volume of pleural fluid produced by the pleural membranes.
The pleural fluid performs two functions: (1) it acts as a lubricant, allowing the visceral
and parietal pleurae to slide past each other as the lungs and thorax change shape during
respiration, and (2) it helps hold the pleural membranes together. The pleural fluid acts
like a thin film of water between two sheets of glass (the visceral and parietal pleurae);
the glass sheets can slide over each other easily; but it is difficult to separate them.
Lymphatic Supply
The lungs have two lymphatic supplies. The superficial lymphatic vessels are
deep to the visceral pleura and function to drain lymph from the superficial lung tissue
and the visceral pleura. The deep lymphatic vessels follow the bronchi and associated
connective tissues. No lymphatic vessels are located in the walls of the alveoli. Both the
superficial and deep lymphatic vessels exit the lungs at the main bronchi.
127
Phagocytic cells within the lungs phagocytize carbon particles and other debris
from inspired air and move them to the lymphatic vessels. In older people, the surface of
the lungs can appear gray to black because of the accumulation of theses particles,
especially if the person smoked or lived most of his life in a city with air pollution.
Cancer cells from the lungs can also spread to other parts of the body through the
lymphatic vessels.
Ventilation and Lung Volumes
Ventilation, or breathing, is the

process of moving air into and out of the
lungs. There are two phases of ventilation: (1)
inspiration, or inhalation, is the movement
of air into the lungs; (2) expiration, or
exhalation, is the movement of air out of the
lungs. Changes in the thoracic volume, which
produce of changes in air pressure within the
lungs, are responsible for ventilation
Changing Thoracic Volume

Muscles associated with ribs are responsible
for ventilation. The muscles of inspiration include the
diaphragm and muscles that elevate the ribs and
sternum, such as the external intercostals. The
diaphragm is a large dome of skeletal muscle that
separates the thoracic cavity from the abdominal
cavity. The muscles of expiration, such as the internal intercostals, depress the ribs and
sternum.
At the end of a normal, quiet expiration, the respiratory muscles are relaxed.
During quiet inspiration, contraction of the diaphragm causes the top of the dome to
128
move inferiorly, which increases the volume of the thoracic cavity. The largest change in
thoracic volume results from movement of the diaphragm. Contraction of the external
intercostals also elevates the ribs and sternum, which increases thoracic volume by
increasing the diameter of the thoracic cage.
Expiration during quiet breathing occurs when the diaphragm and external
intercostals relax and elastic properties of the thorax and lungs cause a passive decrease
in thoracic volume.
There are several differences between normal, quiet breathing and labored
breathing. During labored breathing, all of the inspiratory muscles are active and they
contract more forcefully than during quiet breathing, causing a greater increase in
breathing, forceful contraction of the internal intercostals and the abdominal muscles
produces a more rapid and greater decrease in thoracic volume would be produced by the
passive recoil of the thorax and lungs.
Pressure Changes and Airflow

The flow of air into and out of the lungs is governed by two physical principles:
1. Changes in volume result in changes in pressure. As the volume of a container

increases, the pressure within the container decreases. As the volume of a
container decreases, the pressure within the container increases. The muscles of
respiration change thoracic volume and therefore pressure within the thoracic
cavity.
2. Air flows from areas of higher to lower pressure. If the pressure is higher at one
end of a tube than at the other, air or fluid flows from the area of higher pressure
toward the area of lower pressure. The greater the pressure difference, the greater
rate of airflow. Air flows through the respiratory passages because of pressure
differences between the outside of the body and the alveoli inside the body. These
pressure differences are produced by changes in thoracic volume.
129
The volume and pressure changes responsible for one cycle of inspiration and
expiration can be described as follows.
1. At the end of expiration, alveolar pressure, which is the air pressure within the
alveoli, is equal to atmospheric pressure, which is the air pressure outside the
body. There is no movement of air into or out of the lungs because alveolar
pressures are equal.
2. During inspiration, contraction of the muscles of inspiration Increases the volume
of the thoracic cavity. The increased thoracic volume causes the lungs to expand,
resulting in an increase in alveolar pressure becomes less than atmospheric
pressure, and air flows from outside the body through the respiratory passages to
the alveoli.
3. At the end of inspiration, the thorax and alveoli stop expanding. When the
alveolar pressure and atmospheric pressure become equal, airflow stops.
4. During expiration, the thoracic volume decreases, producing a decrease in
alveolar volume. Consequently, alveolar pressure increases above the air pressure
outside the body, and air flows from the alveoli through the respiratory passages
to the outside.
As expiration ends, the decrease in thoracic volume stops and the process repeats
beginning at step 1.
Lung Recoil
During quiet expiration, thoracic volume and lung decrease because of passive
recoil of the thoracic wall and lungs. The recoil of the thoracic wall results from the
elastic properties of the thoracic wall tissues. Lung Recoil is the tendency for an
expanded lung to decrease in size. It occurs for two reasons: (1) the elastic fibers in the
connective tissue of the lungs and (2) surface tension of the film of fluid that lines the
alveoli. Surface tension exists because the oppositely charged ends of water molecules
attract each other. As the water molecules pull together, they also pull on the alveolar
walls, causing the alveoli to recoil and become smaller. Two factors keep the lungs fro
collapsing: (1) surfactant, and (2) pressure in the pleural cavity.
130
ENDOCRINE SYSTEM
The
role
of
the endocrine
system is to maintain the body in balance

through
the
release
of hormones (chemical signals) directly

into the bloodstream. Hormones transfer
information and instructions from one set
of cells to another. Many different
hormones move through the bloodstream,
but each type of hormone is designed to
affect only certain cells.
A gland is a group of cells that produces and secretes chemicals. A gland selects
and removes materials from the blood, processes them, and secretes the finished chemical
product for use somewhere in the body. The endocrine gland cells release a hormone into
the blood stream for distribution throughout the entire body. These hormones act as
chemical messengers and can alter the activity of many organs at once.
The parts of the endocrine system are grouped together because they release
hormones into the blood without going through a duct (which is basically a tube) first.
This is different to an exocrine gland, which releases what it creates through a tube to
somewhere other than the blood.
Hormones can act on some specific cells because they themselves do not actually
cause an effect. It is only through binding with a receptor (part of the cell specifically
designed to recognize the hormone) like a key into a lock - that causes a chain reaction to
occur, changing the activity of the cells. If a cell does not have a receptor for a hormone
then there will be no effect. Also, there can be different receptors for the same hormone,
and so the same hormone can have different effects on different cells.
131
Pancreas: A fish-shaped spongy grayish-pink organ about 6 inches (15 cm) long that
stretches across the back of the abdomen, behind the stomach. The head of the pancreas
is on the right side of the abdomen and is connected to the duodenum (the first section of
the small intestine). The narrow end of the pancreas, called the tail, extends to the left
side of the body.
The pancreas makes pancreatic juices and hormones, including insulin. The
pancreatic juices are enzymes that help digest food in the small intestine. Insulin controls
the amount of sugar in the blood.
As pancreatic juices are made, they flow into the main pancreatic duct. This duct
joins the common bile duct, which connects the pancreas to the liver and the gallbladder.
The common bile duct, which carries bile (a fluid that helps digest fat,) connects to the
small intestine near the stomach.
The pancreas is thus a compound gland. It is "compound" in the sense that it is
composed of both exocrine and endocrine tissues. The exocrine function of the pancreas
involves the synthesis and secretion of pancreatic juices. The endocrine function resides
in the million or so cellular islands (the islets of Langerhans) embedded between the
exocrine units of the pancreas. Beta cells of the islands secrete insulin, which helps
control carbohydrate metabolism. Alpha cells of the islets secrete glucagon that counters
the action of insulin.
132
RENAL SYTEM
The Kidneys
The kidneys are two bean shaped organs of

the renal system located on the posterior wall of the
abdomen one on each side of the vertebral column
at the level of the twelfth rib. The left kidney is
slightly higher than the right. Why do you think that
the right kidney is lower than the left (Q1). Human
kidneys are richly supplied with blood vessels
which give them their reddish brown color.
The kidneys measure about 10cm in length and, 5cm in breadth and about 2.5 cm
in thickness.The kidneys are protected by three highly specialized layers of protective
tissues. The outer layer consists mainly of connective tissue which protects the kidneys
from trauma and infection. This layer is often called the renal fascia or fibrous
membrane. The technical name for this layer is the renal capsule.
The next layer (second layer from the exterior) is called the fascia and it makes a
fibrous capsule around the kidneys. This layer connects the kidneys to the abdominal
wall. The inner most layers is made up of adipose tissue and is essentially a layer of fatty
tissue which forms a protective cushions the kidney; and the renal capsule (fibrous sac)
surrounds the kidney and protects it from trauma and infection.
Blood Nerve and Supply
The kidneys receive their oxygenated blood supply from the renal arteries which
come off the abdominal portion of the aorta. Venous blood from the kidneys drains into
the renal veins to join the abdominal portion of the inferior vena cava.The hilum of the
kidneys is located toward the smaller curvature. The opening in the hilum allows for the
entry and exit of blood vessels and nerves. The funnel shaped extension of the kidneys is
133
called the renal pelvis and it connects the kidneys to the two ureters. This structure
facilitates the collection of the urine from the kidneys and drainage to the urinary
bladder.The functional parts of the kidneys are divided into two distinct regions. The
outer region is reddish brown in color and is called the renal cortex. This is where the
nephrons of the kidney are located. The inner layer of the kidney is more pinkish in color
and is called the renal medullat. The renal cortex houses the functional units of the
kidneys called nephrons. The inner area of the kidneys is supplied by a small blood vessel
network
called
the
vasa
recta.
The Nephron
The nephron is a functional part of the
kidneys. The Glomerulus is a collection of
capillaries which are surrounded by the
Bowmans capsule. The afferent arteriole enters
this capsule and the efferent arteriole leaves it.
In the glomerulus the blood pressue is high and
it pushes small structured molecules out (water,
salts, glucose and urea). However larger molecules (proteins and glycogen) stay within
the capillary network. The particles which are pushed out with water (filtrate) enter the
proximal convoluted tubule. This portion is convoluted and broad. The following portion
is straight and narrow; hence it is called the straight collecting tubule, also referred to as
the
Loop
of
Henle.
This
portion
is
located
in
the
Renal
medulla.
The collecting tubule upon re-entry into the renal cortex passes by the efferent
arteriole. The macula densa is the final part of the ascending collecting tubule very
closely. The filtrate is selectively reabsorbed in the distal broad convoluted and the
proximal narrow straight tubules. Water and salts are reabsorbed in the Loop of Henle.
Urine concentration occurs here.
134
Proximal tubule is broad and convoluted. It is located in the renal cortex. Distal
tubule is narrow and straight. It forms the Loop of Henle and is located in the renal
medulla. When the filtrate arrives in the distal tubule water is reabsorbed. However,
hydrogen ions, ammonia, histamines, and certain antibiotics are excreted into the distal
tubule. This process is selective and involves the expansion of energy i.e. ATP is used up.
It is called tubular excretion.
Functions of the Renal System
The renal system has many functions. The following are the best known. Each is
discussed under a separate subtitle because the functions are varied and complex:
Excretion of urea, a by product of protein metabolism
Regulations of the amount of water which stays in the body
Kidneys maintain the pH balance of the human body
Produce EPO hormone which has a role in the production of Red blood cells
Produce the enzyme rennin. This enzyme has a role in the maintenance of blood
pressure.
a. Urine production and b. water regulation: These are important functions of the
different parts of the nephrons. They filter blood of its small molecules and ions and
make urine. During this process it reclaims useful minerals and sugars. In one day (24hrs)
the kidneys reclaim 1,300 g of NaCl, 400 g of NaHCO3 and 180 g of glucose and 180
liters of water. These are the constituents which entered the tubules during the filtration
process.
b. Maintain pH value of human body: The human body is designed to function
optimally at a pH value of 7.35 to 7.45. Death will occur if pH drops below 6.8 or rises
above 7.8. It is for this reason that pH values are checked frequently during acute
illnesses. pH is maintained by buffers dissolved in the blood. However, the kidneys and
the lungs play a vital role in removing the H+ ion from the body. Metabolic Acidosis
occurs when the kidneys fail to remove the H+ ions. Respiratory acidosis occurs when
the
lungs
fail
to
remove
the
excess
of
CO2
from
circulation.
135
d. Hormone production: Kidneys produce two hormones known as erythropoietin

(EPO), and calcitriol. They also produce the enzyme known as rennin.
Erythropoietin (EPO): Is a hormone which is produced by the kidneys. It is
needed in the bone marrow for the formation of red blood cells. Chemically EPO is a
glycoprotein with a molecular weight of 34,000. A glycoprotein is a protein with an
attached sugar molecule.
Highly specialized cells of the kidney which are sensitive to low oxygen levels in
the blood produce EPO. The EPO subsequently stimulates the bone marrow to produce
RBCs to increase O2 carrying capacity. This also leads to greater production of hb. Hb is
the molecule which facilitates the transport of oxygen by the cardiovascular system.The
EPO gene is located on chromosome 7, band 7q21. Some EPO is also produced in
the liver. Normal levels of EPO are 0 to 19mU/ml (milliunits per milliliter). Elevated
levels of EPO indicate polycythemia. Lower levels are seen in chronic renal failure. EPO
is often prescribed to treat patients with Acute or Chronic Renal Failure.
Kidneys have a role in the manufacture of vitamin D (Calcitrol)

Calcitriol is 1,25[OH]2 = Vitamin D3, the active form of vitamin D.
Vitamin D3 (Cholecalciferol): Is synthesized in skin when it is exposed to sunlight.
Vitamin D2 (Ergocalciferol) is a synthetic vitamid D derivative
Both vitamin D2 and D3 are hydroxylated in the kidneys into Calcitriol.
Vitamin D regulates Calcium and Phosphorus levels in blood by promoting their
absorption from the food in the intestines and promoting re absorption of Calcium in the
kidneys.
e. Renin : Is an enzyme which is in the juxtaglomerular cells of the juxaglomerualr

apparatus of the renal system. This occurs when: a. the circulating blood volume is low or
136
b. or serum NaClconcentrarion is low. Overproduction causes hypertension and

underproduction causes hypotension.
Sympathetic stimulation of Beta 1 and Alpha 1 adrenergic receptors on the JGA cells also
bring about the production of renin. Normal concentration is 1.0 to 2.5 mg/ml.
137
CARDIOVASCULAR SYSTEM
The cardiovascular
system
consists
of
the
heart, blood vessels, and

the approximately 5 liters
of blood that the blood
vessels
transport.
Responsible
for
transporting
oxygen,
nutrients, hormones, and

cellular
waste
products
throughout the body, the

cardiovascular system is
powered by the bodys hardest-working organ the heart, which is only about the size
of a closed fist. Even at rest, the average heart easily pumps over 5 liters of blood
throughout the body every minute.
The Heart
The heart is a muscular pumping
organ located medial to the lungs along the
bodys midline in the thoracic region. The
bottom tip of the heart, known as its apex, is
turned to the left, so that about 2/3 of the heart is located on the bodys left side with the
other 1/3 on right. The top of the heart, known as the hearts base, connects to the great
blood vessels of the body: the aorta, vena cava, pulmonary trunk, and pulmonary veins.
138
Circulatory Loops
There are 2 primary circulatory loops in the human body: the pulmonary circulation
loopand the systemic circulation loop.
1.
Pulmonary circulation transports deoxygenated blood from the right side
of the heart to the lungs, where the blood picks up oxygen and returns to the left
side of the heart. The pumping chambers of the heart that support the pulmonary
circulation loop are the right atrium and right ventricle.
2.
Systemic circulation carries highly oxygenated blood from the left side of
the heart to all of the tissues of the body (with the exception of the heart and
lungs). Systemic circulation removes wastes from body tissues and returns
deoxygenated blood to the right side of the heart. The left atrium and left ventricle
of the heart are the pumping chambers for the systemic circulation loop.
Blood Vessels
Blood vessels are the bodys highways that allow blood to flow quickly and
efficiently from the heart to every region of the body and back again. The size of blood
vessels corresponds with the amount of blood that passes through the vessel. All blood
vessels contain a hollow area called the lumen through which blood is able to flow.
Around the lumen is the wall of the vessel, which may be thin in the case of capillaries or
very thick in the case of arteries.
All blood vessels are lined with a thin layer of simple squamous epithelium
known as the endothelium that keeps blood cells inside of the blood vessels and prevents
clots from forming. The endothelium lines the entire circulatory system, all the way to the
interior of the heart, where it is called the endocardium.
There are three major types of blood vessels: arteries, capillaries and veins. Blood
vessels are often named after either the region of the body through which they carry
blood or for nearby structures. For example, the brachiocephalic artery carries blood
139
into the brachial (arm) and cephalic (head) regions. One of its branches, the subclavian
artery, runs under the clavicle; hence the name subclavian. The subclavian artery runs
into the axillary region where it becomes known as the axillary artery.
1.
Arteries and Arterioles: Arteries are blood vessels that carry blood away
from the heart. Blood carried by arteries is usually highly oxygenated, having just
left the lungs on its way to the bodys tissues. The pulmonary trunk and arteries of
the pulmonary circulation loop provide an exception to this rule these arteries
carry deoxygenated blood from the heart to the lungs to be oxygenated.
Arteries face high levels of blood pressure as they carry blood being
pushed from the heart under great force. To withstand this pressure, the walls of
the arteries are thicker, more elastic, and more muscular than those of other
vessels. The largest arteries of the body contain a high percentage of elastic
tissue that allows them to stretch and accommodate the pressure of the heart.
Smaller arteries are more muscular in the structure of their walls. The
smooth muscles of the arterial walls of these smaller arteries contract or expand
to regulate the flow of blood through their lumen. In this way, the body controls
how much blood flows to different parts of the body under varying
circumstances. The regulation of blood flow also affects blood pressure, as
smaller arteries give blood less area to flow through and therefore increases the
pressure of the blood on arterial walls.
Arterioles are narrower arteries that branch off from the ends of arteries
and carry blood to capillaries. They face much lower blood pressures than
arteries due to their greater number, decreased blood volume, and distance from
the direct pressure of the heart. Thus arteriole walls are much thinner than those
of arteries. Arterioles, like arteries, are able to use smooth muscle to control their
aperture and regulate blood flow and blood pressure.
140
2.
Capillaries: Capillaries are the smallest and thinnest of the blood vessels
in the body and also the most common. They can be found running throughout
almost every tissue of the body and border the edges of the bodys avascular
tissues. Capillaries connect to arterioles on one end and venules on the other.
Capillaries carry blood very close to the cells of the tissues of the body in
order to exchange gases, nutrients, and waste products. The walls of capillaries
consist of only a thin layer of endothelium so that there is the minimum amount
of structure possible between the blood and the tissues. The endothelium acts as
a filter to keep blood cells inside of the vessels while allowing liquids, dissolved
gases, and other chemicals to diffuse along their concentration gradients into or
out of tissues.
Precapillary sphincters are bands of smooth muscle found at the arteriole
ends of capillaries. These sphincters regulate blood flow into the capillaries.
Since there is a limited supply of blood, and not all tissues have the same energy
and oxygen requirements, the precapillary sphincters reduce blood flow to
inactive tissues and allow free flow into active tissues.
3.
Veins and Venules: Veins are the large return vessels of the body and act
as the blood return counterparts of arteries. Because the arteries, arterioles, and
capillaries absorb most of the force of the hearts contractions, veins and venules
are subjected to very low blood pressures. This lack of pressure allows the walls
of veins to be much thinner, less elastic, and less muscular than the walls of
arteries.
Veins rely on gravity, inertia, and the force of skeletal muscle contractions
to help push blood back to the heart. To facilitate the movement of blood, some
veins contain many one-way valves that prevent blood from flowing away from
the heart. As skeletal muscles in the body contract, they squeeze nearby veins
and push blood through valves closer to the heart.
141
When the muscle relaxes, the valve traps the blood until another
contraction pushes the blood closer to the heart. Venules are similar to arterioles
as they are small vessels that connect capillaries, but unlike arterioles, venules
connect to veins instead of arteries. Venules pick up blood from many capillaries
and deposit it into larger veins for transport back to the heart.
Coronary Circulation
The heart has its own set of blood vessels that provide the myocardium with the
oxygen and nutrients necessary to pump blood throughout the body. The left and right
coronary arteries branch off from the aorta and provide blood to the left and right sides of
the heart. The coronary sinus is a vein on the posterior side of the heart that returns
deoxygenated blood from the myocardium to the vena cava
Hepatic Portal Circulation

The veins of the stomach and intestines perform a unique function: instead of
carrying blood directly back to the heart, they carry blood to the liver through
the hepatic portal vein. Blood leaving the digestive organs is rich in nutrients and other
chemicals absorbed from food. The liver removes toxins, stores sugars, and processes the
products of digestion before they reach the other body tissues. Blood from the liver then
returns to the heart through the inferior vena cava.
Blood
The average human body contains about 4 to 5 liters of blood. As a liquid
connective tissue, it transports many substances through the body and helps to maintain
homeostasis of nutrients, wastes, and gases. Blood is made up of red blood cells, white
blood cells, platelets, and liquid plasma.
Red Blood Cells: Red blood cells, also known as erythrocytes, are by far
the most common type of blood cell and make up about 45% of blood volume.
Erythrocytes are produced inside of red bone marrow from stem cells at the
astonishing rate of about 2 million cells every second. The shape of erythrocytes
142
is biconcavedisks with a concave curve on both sides of the disk so that the
center of an erythrocyte is its thinnest part. The unique shape of erythrocytes
gives these cells a high surface area to volume ratio and allows them to fold to fit
into thin capillaries. Immature erythrocytes have a nucleus that is ejected from the
cell when it reaches maturity to provide it with its unique shape and flexibility.
The lack of a nucleus means that red blood cells contain no DNA and are not able
to repair themselves once damaged.
Erythrocytes transport oxygen in the blood through the red pigment
hemoglobin. Hemoglobin contains iron and proteins joined to greatly increase the
oxygen carrying capacity of erythrocytes. The high surface area to volume ratio of
erythrocytes allows oxygen to be easily transferred into the cell in the lungs and
out of the cell in the capillaries of the systemic tissues.
White Blood Cells: White blood cells, also known as leukocytes, make up
a very small percentage of the total number of cells in the bloodstream, but have
important functions in the bodys immune system. There are two major classes of
white
blood
cells:
granular
leukocytes
and
agranular
leukocytes.
1.Granular Leukocytes: The three types of granular leukocytes are

neutrophils, eosinophils, and basophils. Each type of granular leukocyte is
classified by the presence of chemical-filled vesicles in their cytoplasm that
give them their function. Neutrophils contain digestive enzymes that
neutralize bacteria that invade the body. Eosinophils contain digestive
enzymes specialized for digesting viruses that have been bound to by
antibodies in the blood. Basophils release histamine to intensify allergic
reactions and help protect the body from parasites.
2.Agranular Leukocytes: The two major classes of agranular leukocytes are
lymphocytes and monocytes. Lymphocytes include T cells and natural killer
cells that fight off viral infections and B cells that produce antibodies against
infections by pathogens. Monocytes develop into cells called macrophages
143
that engulf and ingest pathogens and the dead cells from wounds or
infections.
Platelets : Also known as thrombocytes, platelets are small cell fragments
responsible for the clotting of blood and the formation of scabs. Platelets form in
the red bone marrow from large megakaryocyte cells that periodically rupture and
release thousands of pieces of membrane that become the platelets. Platelets do
not contain a nucleus and only survive in the body for up to a week before
macrophages capture and digest them.
Plasma: Plasma is the non-cellular or liquid portion of the blood that
makes up about 55% of the bloods volume. Plasma is a mixture of water,
proteins, and dissolved substances. Around 90% of plasma is made of water,
although the exact percentage varies depending upon the hydration levels of the
individual. Theproteins within plasma include antibodies and albumins.
Antibodies are part of the immune system and bind to antigens on the surface of
pathogens that infect the body. Albumins help maintain the bodys osmotic
balance by providing an isotonic solution for the cells of the body. Many different
substances can be found dissolved in the plasma, including glucose, oxygen,
carbon dioxide, electrolytes, nutrients, and cellular waste products. The plasma
functions as a transportation medium for these substances as they move
throughout the body.
Cardiovascular System Physiology

Functions of the Cardiovascular System
The cardiovascular system has three
major functions: transportation of materials,
protection from pathogens, and regulation of
the bodys homeostasis.
144
Transportation: The cardiovascular system transports blood to almost all

of the bodys tissues. The blood delivers essential nutrients and oxygen and
removes wastes and carbon dioxide to be processed or removed from the body.
Hormones are transported throughout the body via the bloods liquid plasma.
Protection: The cardiovascular system protects the body through its white
blood cells. White blood cells clean up cellular debris and fight pathogens that
have entered the body. Platelets and red blood cells form scabs to seal wounds
and prevent pathogens from entering the body and liquids from leaking out.
Blood also carries antibodies that provide specific immunity to pathogens that
the body has previously been exposed to or has been vaccinated against.
Regulation: The cardiovascular system is instrumental in the bodys
ability to maintain homeostatic control of several internal conditions. Blood
vessels help maintain a stable body temperature by controlling the blood flow to
the surface of the skin. Blood vessels near the skins surface open during times
of overheating to allow hot blood to dump its heat into the bodys surroundings.
In the case of hypothermia, these blood vessels constrict to keep blood flowing
only to vital organs in the bodys core. Blood also helps balance the bodys pH
due to the presence of bicarbonate ions, which act as a buffer solution. Finally,
the albumins in blood plasma help to balance the osmotic concentration of the
bodys cells by maintaining an isotonic environment.
The Circulatory Pump
The heart is a four-chambered double pump, where each side (left and right)
operates as a separate pump. The left and right sides of the heart are separated by a
muscular wall of tissue known as the septum of the heart. The right side of the heart
receives deoxygenated blood from the systemic veins and pumps it to the lungs for
oxygenation. The left side of the heart receives oxygenated blood from the lungs and
pumps it through the systemic arteries to the tissues of the body. Each heartbeat results in
the simultaneous pumping of both sides of the heart, making the heart a very efficient
pump.
145
Regulation of Blood Pressure

Several functions of the cardiovascular system can control blood pressure. Certain
hormones along with autonomic nerve signals from the brain affect the rate and strength
of heart contractions. Greater contractile force and heart rate lead to an increase in blood
pressure. Blood vessels can also affect blood pressure. Vasoconstriction decreases the
diameter of an artery by contracting the smooth muscle in the arterial wall. The
sympathetic (fight or flight) division of the autonomic nervous system causes
vasoconstriction, which leads to increases in blood pressure and decreases in blood flow
in the constricted region. Vasodilation is the expansion of an artery as the smooth muscle
in the arterial wall relaxes after the fight-or-flight response wears off or under the effect
of certain hormones or chemicals in the blood. The volume of blood in the body also
affects blood pressure. A higher volume of blood in the body raises blood pressure by
increasing the amount of blood pumped by each heartbeat. Thicker, more viscous blood
from clotting disorders can also raise blood pressure.
Hemostasis
Hemostasis, or the clotting of blood and formation of scabs, is managed by the
platelets of the blood. Platelets normally remain inactive in the blood until they reach
damaged tissue or leak out of the blood vessels through a wound. Once active, platelets
change into a spiny ball shape and become very sticky in order to latch on to damaged
tissues. Platelets next release chemical clotting factors and begin to produce the protein
fibrin to act as structure for the blood clot. Platelets also begin sticking together to form a
platelet plug. The platelet plug will serve as a temporary seal to keep blood in the vessel
and foreign material out of the vessel until the cells of the blood vessel can repair the
damage to the vessel wall.
146
B. PATHOPHYSIOLOGY
a. Schematic Diagram (Book-Centered)
DM Type II
Modifiable Factors:
- Obesity
- Sedentary Lifestyle
Non-modifiable Factors
- Genetics
- Age
- Ethnicity
Defective Insulin Receptors
Hyperglycemia
Hypersecretion of Insulin
Toxic to Pancreatic Beta Cells
Hyperinsulinemia
Destruction of Pancreatic Beta Cells
Production of Glucagon
Decreased Secretion of Insulin
Hyperglycemia
HHNK
Gluconeogenisis from Fats and Proteins
Chronic Hyperglycemia
Wasting of Lean Body Mass
Polyuria
DKA
Acetone
Breath
Weight Loss
Increased Osmolality Due to Hyperglycemia
Polydipsia
Increased Ketones
Fatigue
Non-Enzymatic Glycosylation
Cellular Starvation
Polyphagia
Advanced Glycation End-Products
147
Weight loss
Dehydration
Immunosupression
Hypovolemia
Infection
Persistent Candidiasis
Infection
Recurrent Skin
Infection
Other Risk Factors:
- Poverty
Malignant Otitis
- Malnutrition
Externa
- Contact with Infected Person
- Alcohol Abuse
- Immunosuppression
Necrotizing Fasciitis
-Smoking
-Exposure to Chemicals (Pesticides)
-Employment
Genital Pruritus
Diabetic Neuropathies
Autonomic
Neuropathy
Macrovascular Problems
Sensory
Neuropathy
Stroke (Ischemic)
Peripheral Vascular
GI Disturbances
Paresthesia
Bladder Dysfunction
Cardiovascular Dse
Loss of Protective
Sensation
Microvascular Problems
Retinopathy
Nephropathy
Tachycardia
Diabetic Foot Ulceration
Postural HTN
Disregulated Detection
of Serum Osmolality
by Atrium and Kidney
Increased Pressure in Arteries

Sexual Dysfunction
Stimulation of RAAS
Hypertrophy and Hyperplasia
of Smooth Muscle Cells
Aldosterone Secretion
Tuberculosis
Fibromuscular Thickening and

Endothilial Damage
Fluid Retention
Entrance of Myobacterium Tuberculosis

Lipid Deposition in Lesions
Migration to Alveoli
Atherosclerosis
Elevation in
Blood Pressure
Low Grade Fever

Pneumonitis
Night Sweats
Inflammation Process
Increased Peripheral Resistance
Malaise
J
148
I
Activation of Macrophages and Neutrophils
Formation of Tubercles
Chronic
Tubercle
Formation
Hemoptysis
Loss of Appetite
Collapse of Small Airway

on Expiration
Caseation Necrosis
Weight Loss
Hyperglycemia
Anorexia
Increased Glomerular
Flow Rate
Chronic Bronchitis
Scar Tissue Formation
Bronchiectasis
Other Risk Factors:

-Exposure to Rotten Fruits
Hyperfiltration
Calcification of Tubercles
Predisposed to Fungal Invasion
Glomerular Damage
Release of Myobacterium Tuberculosis

Fungus Ball Formation
Glumerularnecrosis
Reactivation of Microorganism
Thickening and Harderning
of Blood Vessels
Serum Creatinine
Decreased Blood Flow
Microalbuminuria
Renal Damage
Fluid Shifting
Renin-Angiotensin
Imbalance
Puffy Face
Serum BUN
Untreated or Prolonged
Increased Scarring of
Kidney Tissues
Bleeding
Hematuria
Dec. Hemoglobin
Decreased Filtering Surface
Edema
Fatigue
Renal Failure
149
b.1. Definition of the Disease
Tuberculosis (TB) is an infection caused by a rod-shaped, non-spore-forming,

aerobic bacterium Myobacterium tuberculosis. This bacilli has a unique cell wall
structure that is crucial for its survival, its wall contains a considerable amount of fatty
acids that is capable of producing an extraordinary barrier that is able to resist antibiotics
and host defense mechanisms and is also responsible for its virulence growth rate
(Knechel, 2009). This organism has also been labeled as an opportunistic infection
because it is likely to develop in someone with a weakened immune system (Madara &
Denino, 2008). The disease process starts once the bacilli is inhaled into the lungs and
migrating to the alveoli causing inflammation. Pulmonary macrophages and white cell
migrate to the infected area, surrounding and isolating the bacilli and producing a lesion
called a tubercle. A scar tissue then grows around the tubercle to prevent further
multiplication. The bacilli within the tubercle become inactive that forms into a
cheeselike substance called caseation necrosis. These isolated bacilli remain dormant for
life but if a clients immune system becomes impaired due to other underlying diseases,
live bacilli will escape into the bronchial tree thus starting another cycle that if left
untreated may ultimately lead to respiratory damage that is beyond repair.
As TB progresses, different stages are realized, these stages are: latency, primary
disease, primary progressive disease and extrapulmonary disease. As explained by
Knechel (2009), in latent TB signs and symptoms of the disease are not apparent hence
the client do not feel sick and at this stage is not yet infectious. Primary pulmonary
tuberculosis is often asymptomatic but diagnostic tests will result positive as the only
evidence of being infected by the bacilli but it has been reported as well that there is a
possibility of pleural effusion because the bacilli is able to infiltrate the pleural space
from adjacent area, though these effusions may remain small and able to resolve
themselves some may become large enough to produce symptoms such as fever, pleuritic
chest pain, and dyspnea. Primary progressive TB have early signs and symptoms that are
often nonspecific which includes manifestations such as progressive fatigue, malaise,
weight loss, and low grade fever accompanied by chills and night sweats. This phase can
150
also present wasting due to lack of appetite and altered metabolism associated with the
inflammatory and immune response, also, productive cough may be present that would
have purulent sputum, hemoptysis can be due to destruction of a patent vessel located in
the wall of the cavity, rupture of a dilated vessel in a cavity, or the formation of an
aspergilloma in an old cavity.
In response of the body to these alterations in the body, hematologic studies may
reveal anemia which causes fatigue and weakness, leukocytosis will also present as
response to the infection. Extrapulmonary TB is a complication of TB wherein if TB is
not immediately prevented has the capability to infiltrate to other systems of the body one
of which is the central nervous system that can result in meningitis as the fatal case and
miliary TB where the bacilli will spread throughout the body via the bloodstream that
will lead to multiorgan involvement. If this disease is not properly managed or an
individual would have another episode of having a weak immune system, recurrence may
take place.
b.2. Predisposing/Precipitating Factors (Book-Centered)

Non-Modifiable Factors:
1. Age: As people age, their immune system weakens, specifically those in the age
group of age 65 and above. Myobacterium tuberculosis being an infectious
microorganism, it can easily invade a weaken immunity and able to reproduce
with ease.
Modifiable Factors:
1. Exposure to Chemicals: It has been studied by Dr. Repetto & Baliga (2009) that
exposure to pesticides has its own implications, one of which is it suppression of
the immune system thus leaving an individual to contract infectious diseases.
Pesticides have been found to reduce the numbers of white blood cells and
disease-fighting lymphocytes and impair their ability to respond to and kill
bacteria and viruses.
151
2. Diabetes: According to WHO (2011), through the years of being a diabetic, it is

inevitable that a client may develop a weakened immune system and a chance of
2-3 times higher risk of acquiring TB compared to individuals who do not have
DM and it was collated that 10% of TB cases globally are linked to DM. It was
also reported by the International Union Against Tuberculosis and Lung Disease
(IUATLD, 2012) that with people who have DM that coexist with TB have a 4
time higher rate of death during treatment and higher risk of TB relapse after
treatment, also that TB is associated with worsening glycemic control with people
who have DM. Copstead & Bansik (2010) also reported that Tuberculosis
infection and reactivation can be a particular problem in diabetic residents.
3. Alcohol Abuse: The Mayo Clinic (2013) as well as Madara & Denino (2008)
concluded that with alcohol abuse, the immune defense is altered and exposing an
individual to be easily contracted by microorganisms and Myobacterium
tuberculosis being labeled as an opportunistic infection.
4.
Smoking: Schneider & Novotny (2008) and the Public Health Agency of Canada
(2010) that smoking damages the lungs and interacts at an immunologic and
cellular level to reduce treatment efficacy. Smoking suppresses the innate and
adaptive immune response with decreased levels of pro-inflammatory cytokines
and circulating immunoglobulins, and reduces activity of alveolar macrophages,
dendritic cells and natural killer cells thus predisposing an individual to acquire
TB.
5. Contact with an Infected Person: Tuberculosis is a disease caused by bacteria

that are spread through the air from person to person. Myobacterium tuberculosis
bacilli in particular are put into the air when a person with TB disease of the lungs
or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these
bacteria and become infected (CDC, 2013).
152
6. Immunosuppression: Since the bacteria that cause TB, immunosuppressed

individuals are more prone to contract this disease especially when they are
exposed to infected patients. In particular these immunosuppressed clients may
have HIV, under chemotherapy and those who are taking steroids (The Mayo
Clinic, 2012).
7. Malnutrition and Diet: In order to have an effective immune system, proper

nutrition is necessitated. For the body to properly maintain its defense
mechanisms, energy is needed and only through proper nutrition that this needed
energy can be acquired (NHS, 2012).
8. Employment: Another factor that needs to be considered is the surrounding

environment. Some individuals may have to work in settings that may not be
conducive to their health that leaves them prone to acquire infectious diseases
without their knowledge (CDC, 2013).
9. Poverty: This factor may be attributed to the inability of an individual to avail

needed nutrition that is needed to maintain suitable immunity. Also, their inability
to avail necessary healthcare needs may not be met thus aggravates the low
immunity that may have already developed (WHO, 2011).
10. Mode of Transmission: Mycobacterium tuberculosis is spread by small airborne
droplets, called droplet nuclei, generated by the coughing, sneezing, talking, or

singing of a person with pulmonary or laryngeal tuberculosis. These minuscule
droplets can remain airborne for minutes to hours after expectoration. Meaning
that if an infected person is living within a household that has small living space,
those who are living with him may easily acquire this bacterium.
153
a. Schematic Diagram (Patient-Centered)

DM Type II
Non-Modifiable Factors:
- Genetics
- Age (58 y/o)
- Ethnicity (Asian)
Defective Insulin Receptors
Hyperglycemia
Over Stimulation of Pancreatic Beta Cells (Causes Toxicity)
Destruction of Pancreatic Beta Cells
Decreased Secretion of Insulin
Hyperglycemia
Chronic Hyperglycemia
Non-Enzymatic Glycation
Advance Glycation End-Products
Immunosuppression
Macrovascular Problems
Microvascular Problems
Infection
Cardiovascular Disease
Diabetic Nephropathy
Tuberculosis
Hyperglycemia
154
Other Risk Factors:

Entrance of Myobacterium Tuberculosis
- Smoking (76 pack years)
- Exposure to Chemicals
(Pesticides)
Migration to Alveoli
- Employment (Tricycle Driver)
Increased Pressure in the Arteries
Hypertrophy and Hyperplasia

of Smooth Muscle Cells
Pneumonitis
Chronic Tubercle
Formation
Disregulated
Increased Glomerular
Detection of Serum
Flow Rate
Osmolality by Atrium
and Kidney
Hyperfiltration
Stimulation of RAAS
Fibromuscular Thickening and

Endothilial Damage
Inflammation Process
Glomerular Damage
Aldosterone Secretion
Glomerularnecrosis
Lipid Deposition in Lesions

Further Damage to
Lung Parenchyma
Activation of Macrophages
and Neutrophils
Fluid Retention
Thickening and Hardening
of Blood Vessels
Atherosclerosis
Formation of Tubercles
Increased Peripheral Resistance
Collapse of Small
Airway on Expiration
Chronic Bronchitis
Hemoptysis
(07/2013 and 09/2013)
Bronchiectasis
Elevation in BP
(160/100 mmHg
11/06/13)
Decreased Blood Flow
Caseation Necrosis
Scar Tissue Formation
Creatinine
(3.29-11/06/13
3.61-11/07/13)
Calcification of Tubercles
Serum BUN
(46.27-11/07/13)
Renal Damage
Microalbunemia
Fluid Shifting
Edema
(11/06/13)
Predisposed to Fungal Invasion
Release of Myobacterium
Tuberculosis
Fungus Ball Formation

(11/05/13-Lobectomy)
Reactivation of Microorganism
Other Risk Factors: Rotten Fruits (Mangoes)
155
b.2. Predisposing/Precipitating Factors (Patient-Centered)

Modifiable Factors:
1. Exposure to Chemicals: The client that was chosen for the study has a history of
working as a farmer for 32 years. In those years, it has been noted that the client
was not utilizing any kind of protection such as facial masks from pesticides that
was being used in farming. With this occurring for a long period, the clients
immune system has been compromised leaving him exposed to any invading
pathogens. As studied by Dr. Repetto & Baliga (2009), this is implicated to
reduce the function of the immune system.
2. Diabetes Mellitus: The client under study has a history of being diabetic, with
diabetes, immunity as well is weakened and with a high glucose content that the
blood has, it is a perfect thriving environment for pathogens thus leaving Mr.
Baga prone to acquire infectious diseases.
3. Smoking: Given that Mr. Baga was a 76 pack year smoker, with the
accumulation of nicotine in his system, significant changes have occurred in the
physiology and immunity of his pulmonary system.
4. Employment: It was also shared by Mr. Baga that he is also a tricycle driver
when farming season is over. Given the other risk factor that Mr. Baga has, to
come across someone who is infected with TB is possible that may lead Mr. Baga
to acquire this bacteria as well.
b.3. Signs and Symptoms (Book-Centered)

1. A bad cough that lasts for 3 weeks or longer: Due to the invading bacteria in
the lungs, a compensatory mechanism that is coughing is activated but with the
persistent activity of the bacteria, this coughing reflex lasts longer than the usual
course of coughing.
156
2. Hemoptysis: As explained by Knechel (2009), hemoptysis or coughing of blood

may be caused by destruction of a patent vessel located in the wall of the cavity,
rupture of a dilated vessel in a cavity, or the formation of an aspergilloma in an
old cavity. In response of the body to these alterations in the body, hematologic
studies may reveal anemia which causes fatigue and weakness, leukocytosis will
also present as response to the infection.
3. Chest pain, dyspnea or othopnea: With damage being made by the bacteria
responsible, pain is felt through these destructions may also be attributed to the
increased in interstitial volume that leads to a decrease in lung diffusion capacity.
4. Loss of appetite: This symptom has been attributed to nausea that may cause an
individual to loss of appetite.
5.
Low grade fever, chills and night sweats: These are being experienced due to
the invading bacteria in the body as part of the inflammation process.
6. Wasting: Is classical symptom that is due to lack of appetite and the altered
metabolism associated to the inflammatory and immune responses.
7. Fatigue: This symptom is due to loss of body fat and lean tissue associated to
wasting that decreases muscle mass as well.
b.3. Signs and Symptoms (Client-Centered)

a. Hemoptysis: This symptom was experienced by this particular client while
farming on 2008 and recurred on July of 2013 as well as September of 2013.
b. Fatigue: This instance occurred simultaneously when the episode of hemoptysis
happened on 2008 even of the recurrence dates of July and September 2013.
157
LIST OF PROBLEMS
Pre-operative
PROBLEM #1:
INEFFECTIVE AIRWAY CLEARANCE r/t RETAINED SECRETIONS
PROBLEM #2:
DECREASED CARDIAC OUTPUT RELATED TO ALTERED STROKE VOLUME
PROBLEM #3:
CONSTIPATION r/t DECREASE PHYSYCAL ACTIVITY
Operative
PROBLEM #1:
PROBLEM #2:
RISK FOR INFECTION r/t INADEQUATE PRIMARY DEFENSE AEB

SURGICAL INCISION
RISK FOR IMPAIRED GAS EXCHANGE R/T ALVEOLAR-CAPILLARY
CHANGES
PROBLEM #2:
Post-operative
PROBLEM #1
ACUTE PAIN r/t SURGICAL INCISION
PROBLEM #2:
HYPERTHERRMIA
PROBLEM #3:
PROBLEM #4:
INEFFECTIVE BREATHING PATTERN r/t POOR LUNG COMPLIANCE AEB

CTT INSERTION
PROBLEM #5:
PROBLEM #6:
INEFFECTIVE TISSUE PERFUSION R/T HYPERTENSION SECONDARY TO

DIABETES
FLUID AND ELECTROLYTR IMBALANCE R/T FLUID RETENSION AEB
PITTING EDEMA AND OLIGURIA
FLUID VOLUME EXCESS R/T INABILITY TO MAINTAIN FLUID BALANCE
AEB DECREASED OUTPUT SECONDARY TO DIABETIC NEPHROPATHY
IMPAIRED URINARY ELIMINATION R/T FLUID RETENTION SECONDARY
TO DIABETIC NEPHROPATHY
PROBLEM #7:
PROBLEM #8:
PROBLEM #9:
PROBLEM #10:
IMPAIRED SKIN INTEGRITY r/t SURGICAL INCISION
PROBLEM #11:
RISK FOR INFECTION r/t INADEQUATE PRIMARY DEFENSE AEB

SURGICAL INCISION
PROBLEM #12:
PROBLEM #13:
IMPAIRED PHYSICAL MOBILITY r/t WEAKNESS
PROBLEM #14:
RISK FOR IMPAIRED GAS EXCHANGE R/T ALVEOLAR-CAPILLARY

CHANGES
ACTIVITY INTOLERANCE R/T POSTOPERATIVE THORACOTOMY,
LOBECTOMY AND PRESENCE OF CTT
PROBLEM #15:
PROBLEM #16:
FATIGUE r/t ALTERED OXYGEN SUPPLY AND DEMAND
158
B. PLANNING (NURSING CARE PLAN)

ACUTE PAIN r/t SURGICAL INCISION
ASSESSMENT
NURSING
SCIENTIFIC
DIAGNOSI EXPLANATIO
S
N
S: Masakit ya ing Acute Pain Pain
is
an
tahi ku (my suture is related
to uncomfortable
painful) as verbalized surgical
feeling that tells
by the client
incision
an individual that
AEB CTT something
is
O:
The
client insertion
wrong with the
manifested
the
individual body.
following:
Pain
is
the
bodys way of
Complains of
sending warning
pain on CTT
to the brain. The
site
upon
spinal cord and
moving
and
the
nerves
coughing
provide
the
pathways
for
P: pain upon
messages
to
movement; Q:
travel
to
and
quality
is
from the brain
stabbing; R:
and other parts of
localized
on
the body. There
surgical site;
are thousands of
S:
7/10
receptor cells in
severity;
T:
and beneath the
pain
occurs
skin that senses
upon
heat,
cold,
movement and
pressure,
touch
relieved at rest
OBJECTIVE
S
NURSING
RATIONALE
INTERVENTION
S
1.Assess
clients 1.To
obtain
Short term:
After 4 hours general condition
baseline data
of
nursing
interventions, 2.Assess
for 2.To determine
the client will referred pain
characteristics,
demonstrate
location
and
use
of
severity of pain
relaxation
skills
& 3.Observe
non- 3.To observe
diversional
verbal cues and verbal reports
activities
as other objectives
that may or
indicated
to
may not be
minimize
if
congruent that
not
relieve
indicates needs
pain.
for
further
evaluation
Long term:
After 3 days of 4.Perform
pain 4.To identify
nursing
assessment
each the factors that
interventions, time pain occurs, may contribute
the client will not and investigate to pain
demonstrate
changes
from
behaviors to previous reports
relieve
pain
and pain scale 5.Note when pain 5.To provide
will decrease occurs
non-
EVALUATIO
N
Short term:
The client shall
have
demonstrated
use
of
relaxation skills
& diversional
activities
as
indicated.
Long term:
The client shall
have
demonstrated
behaviors
to
relieve pain and
pain scale will
decrease
to
below 3.
159
with
deep
regular rhythm
of
breathing
with use of
accessory
muscles
(+) grimace
VS are as follows:
BP: 140/70mmHg
T:36
RR:18cpm
PR:64bpm
The
client
may
manifest
the
following:
Guarding
behavior
Sleep
disturbance
Demonstrate
protective
gestures
and pain. Upon to below 3.

the insertion of
the
CTT,
affectation
to
these
pain
receptors cannot
be avoided thus
causing
discomfort and
pain to the client.
pharmacologic
al
pain
management
6.Encourage
6. To rule out
diversional
worsening of
activities such as underlying
watching TV o conditions/
socialization
development of
complications
7.Provide comfort
measures such as
repositioning, touch
or providing quiet
environment
8.Encourage
adequate
periods
7.Timely
intervention is
more likely to
be successful in
alleviating pain
8.To
prevent
rest fatigue
9.Discuss
with 9.To provide
SOs ways in which support to the
they can assist client
clients and reduce
precipitating factor
that may cause or
increase pain.
Facial mask
160
10.Provide
for
individualized
physical therapy/
exercise program
that
can
be
continued by the
client
11.Administer
analgesics,
ordered
10.To enhance
self-concept
and sense of
independence
and to promote
active and not
passive role
11.To maintain
as acceptable
level of pain
161
HYPERTHERMIA
ASSESSMENT
NURSING
DIAGNOSIS
S: Client may verbalize Hyperthermia

headache
O: Client manifested
an increase in body
temperature, flushed
skin and warm to touch
Client
may
also
manifest:
Tachypnea
Tachycardia
Confusion
Convulsion
SCIENTIFIC
EXPLANATION
OBJECTIVES
NURSING
INTERVENTIONS
RATIONALE
Hyperthermia is an
elevation of body
temperature above
normal
range.
There have been
occurrences that lab
results have shown
that this particular
client
had
an
elevation of white
blood cells would
also mean there are
pathogens trying to
invade his body and
with the presence of
stress due to the
operation that has
just
been
undergone, there is
a
compromised
immune system an
opportunity
for
these microbes that
triggers
the
inflammation
response, one of
Short Term:
After 1-2 hours
of
nursing
interventions, the
client will be
able
to
participate
in
techniques
on
lowering body
temperature such
as TSB
1. Monitor
temperature
1. Toe evaluate Short Term:

degree
of The client shall
hyperthermia
have been able to
participate
in
2. To assist techniques
on
with measures lowering
body
to reduce body temperature such
temperature
as TSB
body
2. Promote surface
cooling by cool,
tepid sponge bath
3.
Administer
replacement fluids
and electrolytes
Long Term:
After 2-3 days of
nursing
interventions, the 4. Maintain bed rest
client will be
able to maintain
core temperature
within
normal
range
5. Provide highcaloric diet
EVALUATION
3. To support
circulating
volume
and
tissue
perfusion
Long Term:
The client shall
have been able to
maintain
core
temperature
within
normal
4. To reduce range
metabolic
demands and
oxygen
consumption
5. To meet
increased
metabolic
demands
162
which is an increase
in temperature to
keep
these
pathogen at bay.
6.
Emphasize
importance
of
adequate fluid intake
6. To prevent
dehydration
7.
Administer
antipyretics
as
indicated
7. To assist
with measures
to reduce body
temperature
163

ASSESSMENT
NURSING
SCIENTIFIC
OBJECTIVE
NURSING
DIAGNOSI EXPLANATIO
S
INTERVENTION
S
N
S
S:
Ineffective
Normally lungs Short term:
1.Monitor
airway
are free from After 4 hours respiration
and
O: The client manifest clearance r/t secretions. Due of
nursing breath
sounds,
the following:
retained
to infected lungs interventions,
noting rate and
secretions
a substance and the client will sounds
Restlessness
discharged
are expectorate/
formed
by
a
cell
clear
2.Evaluate clients
DOB
after
and tissues in the secretions
cough/gag
reflex
talking
lungs
which readily.
and
swallowing
indeed blocks the
ability
presence
of
passage
way
of
Long
term:
crackles
on
oxygen,
since After 3 days of
both
lung
oxygen
cannot
nursing
3.Encourage deep
fields
upon
truly pass and interventions,
breathing
and
auscultation
enter to it, this the client will coughing exercises
result for the maintain
with regular
clients
to airway
4.Position
head
depth and
experience
patency.
appropriate
for
age
rhythm of
difficulty
of
and condition
breathing
breathing and for
him to have
amount
of
ineffective
CTT
airway clearance
for the reason of
The
client
may
the
present
5.Encourage
manifest
the
secretions.
adequate
fluid
following:
intake with strict
RATIONAL
E
EVALUATIO
N
1.Inidicative
of respiratory
distress and/or
accumulation
of secretions
Short term:
The client shall
have
expectorated/
cleared
secretions
readily.
2.To
determine
ability
to Long term:
protect own The client shall
airway
have
maintained
3.To
airway patency.
maximize
effort
4.To open or
maintain open
airway in atrest
or
compromised
individual
5.Hydration
can
help
liquefy
164
Dyspnea
aspiration
precaution
Difficulty
vocalizing
viscous
secretions and
improve
secretion
clearance
Orthopnea
Changes
in
respiratory
rate/rhythm
6.Encourage
and 6.To prevent/
provide
reduce fatigue
opportunities
for
rest; limit activities
to
level
of
respiratory
tolerance
7.Observe for signs 7.To identify

and symptoms of infectious
infection
process and
promote
timely
interventions
8.Suction
naso/tracheal/oral
as necessary
8.To
clear
airway when
excessive or
viscous
secretions are
blocking
airway
or
client
is
unable
to
165
swallow
or
cough
effectively
9.Administer
analgesic,
ordered
9.To improve
as cough when
pain
is
inhibiting
effort.
10.Assist with use

of
respiratory
devices
and
treatments
10.Various
therapies/
modalities
may
be
required
to
acquire and
maintain
adequate
airways,
improve
respiratory
function
166
INEFFECTIVE BREATHING PATTERN r/t POOR LUNG COMPLIANCE AEB CTT INSERTION
ASSESSMENT
NURSING
SCIENTIFIC
OBJECTIVES
NURSING
RATIONALE
DIAGNOSIS EXPLANATION
INTERVENTIONS
S:
Ineffective
Breathing pattern Short term:
1.Auscultate chest
1.To
evaluate
breathing
refers to the rate, After 4 hours
presence/character
O: The client
pattern
r/t volume, rhythm of
nursing
of breath sounds
manifested the
poor
lung and relative ease interventions,
and secretions
following:
compliance
or
effort
of the client will
secondary to respiration.
take part in 2.Encourage
2.To assist client
Use of
bronchiectasis
Ineffective
efforts
to
wean
slower/deeper
in taking control
accessory
after
breathing pattern within
respirations, use of of the situation
muscles to
lobectomy
refers
to
the
individual
pursed lip technique
breathe
inspiration
and capacity.
expiration
that
3.Note muscles for 3.To identify that
Complains of
does not provide Long term:
breathing
may signify an
DOB after
adequate
After
3
days
of
increase in work
activity or
ventilation. As the nursing
of breathing
talking
client
have interventions,
suffered
from the client will 4.Maintain
calm 4.To limit level of
Complained
having
establish
a
attitude
while
anxiety
pain upon
tuberculosis
an
normal,
dealing
with
client
breathing or
episode
of effective
coughing
bronchiectasis
respiratory
5.Stress importance 5.To
maximize
have
happend, pattern
AEB of good posture and respiratory effort
with regular
there
is
an
absence
of effective use of
depth and
impairment in the cyanosis and accessory muscles
rhythm of
air passage with other signs and
breathing
the addition of a symptoms of 6.Encourage
6.To limit fatigue
lobectomy
hypoxia.
adequate
rest
VS are as follows:
procedure,
the
periods
between
EVALUATION
Short term:
The client shall
have taken part
in efforts to
wean
within
individual
capacity.
Long term:
The client shall
have established
a
normal,
effective
respiratory
pattern
AEB
absence
of
cyanosis
and
other signs and
symptoms
of
hypoxia.
167
BP: 140/80mmHg
T:36
RR:23cpm
PR:64bpm
The client may
manifest the following:
Alterations in
deep depth of
breathing
Decreased
inspiratory or
expiratory
pressure
Nasal flaring
With abnormal
ABG
lung capacity is
further
diminished thus
decreasing lung
compliance even
more.
activities
7.To
promote
7.Elevate head of physiological and
bed and/or have psychological
client sit up in chair, ease of maximal
as appropriate
inspiration
8.Administer
O2
regulated at 2Lpm
via nasal cannula as
ordered
8.To manage of
underlying
pulmonary
condition
and
respiratory
distress
9.Advise client to 9.This may cause

avoid overeating/gas abdominal
forming foods, as distention
ordered
10.To determine
10.Advise regular effectiveness of
medical evaluation current
with primary care therapeutic
provider
regimen and to
promote general
well-being
11.Administer
analgesics,
11.to
promote
antibiotic,
deeper respiration
bronchodilators and and
use
of
nebulization
as pharmacological
ordered
drugs
168

ASSESSMENT NURSING
SCIENTIFIC
OBJECTIVES
NURSING
INTERVENTIONS
S:
Decreased
Decreased cardiac Short
Term 1. evaluate client
cardiac
output
results Goal:
reports and evidence
O: The client output related from
the
of extreme fatigue,
manifested the to
altered inadequate blood Within 8 hours intolerance
for
following:
stroke
pumped to meet of nursing care, activity,
and
volume
metabolic
client will be progressive
-altered
heart
demands of the able
to shortness of breath
rate and rhythm
body. Onset of participate in
-restlessness
diabetic
activities that 2. determine vital
-decreased
hyperglycemia
reduce
the signs/hemodynamic
peripheral
causes
a workload of the parameter
and
pulses
significant
and heart such as response to activities
-unstable VS:
progressive
therapeutic
or procedures and
>T: 36.2 C
decrease
in medication
time required to
>P: 66bpm
cardiac
output regimen, and return to baseline
>R: 24cpm
because of the balanced
>BP:
140/70
viscosity of the activity/rest
3. keep client on bed
mmHg
blood
that plan.
or chair in rest
circulates
position of comfort
sluggishly that in Long
Term
turn equates to a Goal:
systemic vascular Within
3-5
resistance.
days of nursing 4. decrease stimuli,
care, client will provide
quiet
be able to environment
demonstrate
activities that 5. instruct client to
will lessen the avoid
or
limit
RATIONALE
EVALUATION
1. to assess for Short

Term
signs of poor Goal:
ventricular
The client shall
function
have
participated in
activities
that
reduce
the
workload of the
2.
provide heart such as
baseline
for therapeutic
comparison
to medication
follow trends and regimen, weight
evaluate response reduction, and
to interventions
balanced
activity/rest
plan.
3. to decrease
oxygen
consumption and
risk
or Long
Term
decompression
Goal:
The client shall
4. to promote have
adequate rest
demonstrated
decreased
restlessness
5. for this can
cause change in
169
workload of the activities that may cardiac pressures

heart
stimulate Valsalva and impede blood
response
flow
6.
encourage 6. to promote
relaxation
comfort or rest
techniques
7.
administer 7. to increase
oxygen via nasal oxygen available
cannula as indicated for
cardiac
function
tissue
perfusion
8.
administer 8. to promote
analgesics
as comfort and rest
appropriate
170
INEFFECTIVE TISSUE PERFUSION R/T HYPERTENSION SECONDARY TO DIABETES

NURSING
SCIENTIFIC
NURSING
ASSESSMENT
OBJECTIVES
INTERVENTIONS
Ineffective
As
part
of
a
1. Assess clients
Short
Term:
S:
peripheral
physiologic
After 24 of
condition
tissue
response
of
the
NI,
the
client
O:
The
client
perfusion
body
to will
have
manifested
related
to
hyperglycemia,
in
tolerable
2. Monitor
and
Altered blood
hypertension order to move perfusion AEB
record VS
pressure
viscous
blood vital
signs
Low
throughout
the within normal
hemoglobin and
body, it has to range.
hematocrit
compensate
by
3. Provide
foam
count
increasing
the
padding,
workload of the
bed/foot cradle.
heart. Also, due to Long Term:
Client may manifests:
an episode of a After 3 days of 4. Elevate head of
Skin
massive
NI, the client
bed
temperature
hemoptysis,
blood
will
changes
volume
has demonstrate
Skin
decreased
thus
behaviors that 5. Encourage early
discolorations
diminishing
RBC
will improve
ambulation,
Edema
count.
RBC lifestyle
to
when possible.
Delayed healing
contains
the prevent further
Weak/absent
hemoglobin,
complications
6. assess motor and
pulses
which is known to
sensory function
Bruit
be the oxygen
Diminished
carrying capacity
arterial
of the blood if
pulsations
there would be
Altered
decreased RBC in
EXPECTED
OUTCOMES
1. To assess Short Term:
causative
The
client
factors
shall
have
improved
2. To
perfusion aeb
establish
vital
signs
baseline
within normal
data
range.
RATIONALE
3. To protect
the
extremities
.
4.To increase
gravitational
blood flow.
5.Enhances
venous return
Long Term:
The
client
shall
have
demonstrated
behaviors that
will improve
lifestyle
to
prevent
further
complications
6. Problems
with
ambulation or
loss
of
sensation,
numbness or
tingling are
171
sensations
the blood it will

lead to decreased
perfusion because
of the decreased
hemoglobin.
changes that
may indicate
neurovascular
dysfunction
or
limb
ischemia
7. Assist or instruct
client to change
positions in timed
intervals rather than
using
sense
presence of pain as
signal to change
position
7. To promote
circulation and
limit
complications
associated
with
poor
perfusion and
tissue injury
8.
Provide
education
about
relationship
between smoking
and
peripheral
vascular circulation
8.
Smoking
contributes to
development
and
progression of
peripheral
vascular
disease
9.
Administer
fluids, electrolytes,
nutrients
and
oxygen as indicated
9. to promote
optimal blood
flow,
organ
perfusion and
function
172
FLUID AND ELECTROLYTR IMBALANCE R/T FLUID RETENSION AEB PITTING EDEMA AND OLIGURIA
ASSESSMENT
NURSING
SCIENTIFIC
OBJECTIVES
NURSING
RATIONALE EVALUATION
INTERVENTIONS
Fluid
and Body fluid is Short term:
1. Assess general to determine
S:
Short Term
electrolyte
composed
After 8 hrs of
condition
individual
The client shall
imbalance
primarily of water nursing
needs
have prevented/
O: The client
related
to and electrolytes. interventions,
minimized
manifested:
fluid
The
body
is the client will
2. Monitor intake to assess
complication.
retention
equipped
with prevent/
and output
clients ability
Pitting edema
AEB pitting homeostatic
minimize
every shift
to excrete
on upper
edema
and
mechanisms
to
complication.
fluids from the
extremities
oliguria
keep
the
body
Long term:
Oliguria
composition
and
The client shall
Long
term:
Fever (temp of
volume of body After 5 days of 3. Assess
to determine
have restored
38.0)
fluids
within nursing
cardiovascular
degree of
homeostasis
narrow
limits. interventions,
and respiratory imbalance and AEB absence of
Organs involved the client will
status
the affected
edema and
in this mechanism restore
systems
intake should
The client may
include
the
homeostasis
equal to fluid
manifest:
kidneys,
lungs, AEB absence 4. Review
to monitor
output
Generalized
heart,
blood
of
edema
and
laboratory
tests
imbalances
weakness
vessels, adrenal intake should
and results
Nausea and
glands,
equal to fluid
vomiting
parathyroid
output
5. Weight client
to assess
Changes in the
glands,
and
on a daily basis effectiveness
level of
pituitary
gland.
with the same
of
consciousness
Due to decreased
time
management
Muscle
urine
output,
rendered
twitching and
client will retain
tremors
more sodium in
6. Note location
to assess fluid
the body thus
and extent of
retention and
173
decreasing
potassium.
edema
progress of
condition
7. Assess level of
consciousness
and mental
status
to assess
degree of
imbalances
and effect to
mental status
8. Position client
appropriately
to promote
comfort and
prevent skin
ulcers
9. Schedule rest
periods
to minimize
energy
requirement
10. Provide health

teaching on
how to
conserve
energy
to minimize o2
demand
11. Administer
prescribed
medications
such as diuretic
to aid in fluid
excretion
174
FLUID VOLUME EXCESS R/T INABILITY TO MAINTAIN FLUID BALANCE AEB DECREASED OUTPUT
SECONDARY TO DIABETIC NEPHROPATHY
ASSESSMENT
NURSING
SCIENTIFIC
OBJECTIVES
NURSING
RATIONALE
INTERVENTIONS
S:
Fluid volume Fluid
volume Short term:
1.Auscultate breath 1.For presence
excess r/t
excess
is
a After 4 hours sounds
of
crackles,
O: The client
inability to
circumstance
of
nursing
congestion
manifested the
maintain
where
an interventions,
following:
fluid balance individual
the client will 2.Measure
2.For changes
AEB
experiencing or at demonstrate
abdominal girth
that
may
Edema
decreased
risk of excess behaviors
to
indicate
output and
intracellular
or monitor fluid
increasing fluid
Intake exceeds
edema
interstitial
fluid.
status
and
retention/edema
output
With DM as one reduce
of the disease recurrence of 3.Evaluate
3.For
Presence of
being managed, fluid excess
mentation
confusion,
crackles on both
this
disease
has
personality
lung fields upon
reached to effect Long term:
changes
auscultation
the kidneys a After 3 days of
complication
nursing
4.Assess
4.To evaluate
Decrease I & O
called
diabetic
interventions,
neuromuscular
for presence of
or imbalance
nephropathy
the client will reflexes
electrolyte
where in there has stabilize fluid
imbalances
been
damage
volume
as
such
as
The client may manifest
done
to
the evidenced by
hypernatremia
the following:
kidneys
and
is
balanced
I&O
Weight gain
now able to pass and absence of 5.Observe skin and 5.For presence
over short period
albumin through signs
of mucous membrane
of
decubitus
of time
the urine where ingestions
and ulceration
albumin
is
needed
Hypertension
to preserve the
6.Stress need for 6.To
prevent
EVALUATION
Short term:
The client shall
have
demonstrated
behaviors
to
monitor
fluid
status
and
reduce
recurrence
of
fluid excess
Long term:
The client shall
have stabilized
fluid volume as
evidenced
by
balanced I&O
and absence of
signs
of
ingestions
175
Specific gravity
changes
oncotic pressure
so not to let water
escape into the
interstitial space
of the cells.
mobility
frequent
changes
and/or stasis
and
position reduce risk of
tissue injury
7.Place in semi- 7.To facilitate

fowlers position, as movement of
appropriate
diaphragm,
thus improving
respiratory
effort
8.Record intake and 8.Accuarte
I
output
and
O
is
necessary for
determining
renal function
and
fluid
replacement
needs
and
reducing risk of
fluid overload
9.Restrict
sodium 9.Fluid
and fluid intake, as management is
indicated
usually
calculated
to
prevent further
fluid retention
10.Set
an 10.To
appropriate rate of peaks
prevent
and
176
fluid
intake
or valleys in fluid
infusion throughout level and thirst
24-hour period
11.Administer
diuretics, as ordered
11.To excrete
excess fluid
177
IMPAIRED URINARY ELIMINATION R/T FLUID RETENTION SECONDARY TO DIABETIC NEPHROPATHY

ASSESSMENT
NURSING
DIAGNOSI
S
Impaired
S:
urinary
O: The client manifests elimination
r/t
fluid
the following:
retention
Weakness
secondary to
Activity
diabetic
intolerance
nephropathy
Dysuria
Oliguria
Edema
The
client
may
manifest the following:
Incontinence
Retention
SCIENTIFIC
EXPLANATIO
N
With
damage
made
to
the
kidneys due to
diabetic
nephropathy and
a decreased blood
flow
due
to
hypertension
there
is
an
impairment in the
glomerular
filtration
that
diminishes
the
ability of the
kidney to excrete
urine effectively.
PLANNING NURSING
INTERVENTION
S
Short term: 1.Determine clients
After 8 hours usual daily fluid
of
nursing intake
interventions
, the client
will
2.Ascertain clients
demonstrate previous pattern of
behaviors
elimination
and
techniques to
prevent
3.Demonstrate
urinary
proper positioning
infection
of catheter drainage
tubing and bag
Long term:
After 3 days 4. Check frequently
of
nursing for
bladder
interventions distention
and
, the client observe for flow
will achieve
normal
5. Help client keep a
elimination
voiding diary for 3
pattern
or days to record fluid
participate in intake,
voiding
measures to times, precise urine
correct
or output and dietary
RATIONAL
E
EVALUATIO
N
1.To
help
determine
level
of
hydration
Short term:
The client shall
have
demonstrated
behaviors and
techniques
to
prevent urinary
infection
2.For
comparison
with current
situation
3.To facilitate
drainage and
prevent reflux
Long term:
4. to reduce The client shall
risk
of have achieved
infection
normal
elimination
pattern
or
5.
Helps participate
in
determine
measures
to
baseline
correct
or
symptoms,
compensate for
severity
of defects
frequency or
178
compensate
for defects
intake
urgency, and
whether diet is
a factor
6. Discuss possible
dietary restrictions
such as coffee and
carbonated drinks
6. To assist in
treating
or
preventing
urinary
alteration
7. Implement and
monitor
interventions
for
specific elimination
problem
and
evaluate
clients
response
7. To monitor
and
modify
treatment
if
needed
8. Maintain acidic
environment of the
bladder by use of
agents
such
as
vitamin C
8.
To
discourage
bacterial
growth
179
IMPAIRED SKIN INTEGRITY r/t SURGICAL INCISION

ASSESSMENT
NURSING SCIENTIFIC
OBJECTIVES
S:
Impaired skin Skin
is
the Short term:
integrity r/t
primary defense After 4 hours
O:
The
client surgical
of the body; it of
nursing
manifested
the incision
protects the
interventions,
following:
secondary to body
against the client will
infections
and participate in
Complains
of presence of
diseases brought
prevention
pain on the CTT CTT
about
by
the
measures and
site
invasion
of treatment
microbes
in
the
program such
With dry and
body. Hence, the as keeping the
intact dressing
client
has affected
part
on the CTT site
undergone
a clean and dry
surgical
procedure,
the Long term:
The client may manifest
intactness
of
the After 2 days of
the following:
skin has been nursing
Inflammation of
compromised that interventions,
the CTT site
may be a portal of the client will
entry
by demonstrate
microbes.
proper
techniques to
keep
the
affected area
clear of signs
of infection
NURSING
INTERVENTIONS
1. Keep the area
clean
and
dry,
carefully
dress
wounds,
support
incision,
prevent
infection
and
stimulate circulation
to surrounding areas
2.Use
appropriate
barrier dressings or
wound coverings
3.Apply appropriate
dressing
4. Reposition the
client on regular
schedule, involving
client in reasons for
and decisions about
times and positions
RATIONALE EVALUATION
1 .To assist
bodys natural
process
of
repair
Short term:
The client shall
have
participated in
prevention
measures
and
treatment
program such as
keeping
the
2. To protect affected
area
the
wound clean and dry
and/or
surrounding
tissues
Long term:
3. For wound The client shall
healing and to have
best
meet demonstrated
needs of client proper
and caregiver techniques
to
or care setting keep
the
affected
area
4. To enhance clear of signs of
understanding infection
and
cooperation
180
5.
Promotes
5. Encourage early circulation and
ambulation
or reduce
risks
mobilization
associated
with
immobility
6. To provide
a
positive
6. Provide optimum nitrogen
nutrition, including balance to aid
vitamins, as ordered in skin and
tissue healing
and
to
maintain
general good
health
7.
Inspect
surrounding skin for
erythema, induration
or maceration
7. To asses
progress
of
healing or any
signs
of
infection
8.
Review
medication
and 8. To promote
therapy regimen
timely healing
and
prevent
infection
181
RISK FOR INFECTION r/t INADEQUATE PRIMARY DEFENSE AEB SURGICAL INCISION
NURSING
SCIENTIFIC
OBJECTIVES
NURSING
RATIONALE
ASSESSMENT
INTERVENTIONS
S:
Risk for
Since DM is Short term:
1.Note risk factors 1.To help the
infection r/t
being faced by the After 4 hours for occurrences of client identify
O:
The
client impaired
client as one of of
nursing infection
in
the the present risk
manifested
the immunity
the
major interventions,
incision
factors
that
following:
secondary to diseases, there is the client will
may add up to
impairment in the identify
the infection
Presence
of DM
mobilization of interventions to
surgical
WBC into the site prevent
or 2.Observe
for 2.To evaluate
incision on the
of infection due to reduce risk of localized sign of if the character,
CTT site at
the
viscous infection
infection at insertion presence and
left anterior
consistency of the
sites of surgical condition
of
posterior area
blood.
Also, Long term:
incision
the presence of
hyperglycemia is After 3 days of
infection
The
client
may
a
conducive nursing
manifest
the
environment for interventions,
3.Stress proper hand 3.A first line
following:
pathogens
to
the
client
will
hygiene
by
all defense against
Decreased
flourish and with be free from caregivers between health
care
tissue
the presence of an any signs and therapies and clients associated
perfusion
incision site, there symptoms of
infections
is a portal of entry infection
Decreased
for microbes thus
4.Maintain adequate 4.To
avoid
wound
predisposing the
hydration
bladder
healing time
client to acquire
distention and
infection
urinary stasis
Nutritional
imbalances
5.Provide
regular 5.To
reduce
urinary catheter and risk
of
genital care
ascending
EVALUATION
Short term:
The client shall
have identified
interventions to
prevent
or
reduce risk of
infection
Long term:
The client shall
have been free
from any signs
and symptoms
of infection
182
urinary
tract
infection
6.Make
health
teachings especially
in identification of
environmental risk
factors that could add
up on infection
6.To help the

client
modify/change/
avoid some of
the
environmental
factors present
which
could
reduce
the
incidence
of
infection
7.Recommend
7.To prevent
routine body shower bacterial
or scrubs, as ordered colonization
8.Administer/monitor 8.To determine
medication regimen
effectiveness
of therapy or
presence
of
side effects
183

ASSESSMENT
NURSING
SCIENTIFIC
OBJECTIVES
S>
O:The
client
manifested:
Weakness
Immobility
Fatigue
Acute pain
The client may
manifest:
Abdominal
pain
Change in
bowel patterns
Decreased
frequency and
stool volume
Straining and
possibly pain
during
defecation
Iinability to
increase intraabdominal
pressure
Constipation
r/t decrease
physical
activity
Constipation is the
decrease in normal
frequency
of
defecation.
It
occurs when the
movement of feces
through the large
intestine is slow,
thus allowing time
for additional reabsorption of fluid
from the large
intestine
accompanied by
difficult
or
incomplete
passage of stool
and/or passage of
excessively hard
and dry stool. Due
to
decrease
physical activity
the movement of
feces through the
large intestine is
Short
Term:
After 4-6 hours
of
nursing
interventions,
the client will
verbalize
understanding
of etiology and
appropriate
interventions or
solutions
for
individual
situation
in
order to initiate
proper
bowel
movement.
INTERVENTIONS RATIONALE
EXPECTED
OUTCOMES
Short Term:
1. Assess clients 1. To determine
condition
what
intervention will
be perform
2. Instruct client to
increase fluid intake 2. To facilitate
as indicated
absorption
of
sufficient
amount of fluid
in the intestines
3. Instruct client to
eat foods rich in 3. To facilitate
fiber such as bread, expulsion of soft
whole grains. Fruits consistency of
and vegetables
stools.
Fiber
absorbs
water
which
add
softness to stools
4.
Encourage
ambulation within 4. To facilitate
individuals ability
feces expulsion
Long Term:
After 1-2 days
of
nursing
interventions,
the client will
establish normal
pattern of bowel
elimination
5. Provide privacy
and
routinely 5. So client can
The client shall

have
verbalized
understanding
of
verbalize
understanding
of
etiology
and
appropriate
interventions
or
solutions
for
individual situation.
Long Term:
The client shall
have
established
normal
bowel
functioning
184
low, thus, the may

client
manifest
difficulty
or
decrease
frequency
in
defecation.
scheduled time for respond to the

defacation
urge to defacate
6. Identify specific
actions to be taken if 6. To promote
problem recurs
timely
intervention,
enhancing
clients
independence
7.
Administer 7. To facilitate
medication
as expulsion of soft
ordered
stools
185
IMPAIRED PHYSICAL MOBILITY r/t WEAKNESS

ASSESSMENT
NURSING
DIAGNOSIS
S:
Impaired
physical
mobility
related
weakness
O: The client
manifested:
Slowed
movement
Limited range
of motion
Needs
assistance when
moving
Body weakness
DOB after
activity
Client may manifest:
Difficulty in
turning
Difficulty
initiating
movement
Postural
instability
during
SCIENTIFIC
EXPLANATION
Bronchiectasis, as
defined
is
the
permanent dilation
to of bronchial tree
caused
by
destruction of the
muscle and elastic
tissues, will result
to
airway
obstruction
and
impaired clearance
of secretions. This
will also entail
impairment in the
clients
normal
respiratory patterns
and effort that is
needed to supply
the body with the
necessary oxygen
concentration,
When the clients
mechanism
to
compensate
for
changing oxygen
OBJECTIVES
NURSING
INTERVENTIONS
RATIONALE
EVALUATION
SHORT
TERM:
1. Assist the client in

positioning self
1. To prevent
the formation
of
pressure
sores or bed
sores
SHORT TERM:
After 3 hours of
nursing
Interventions the
client
will
demonstrate
a
change
in
behavior in the
health teachings
provided.
2. Instruct the client

to use side rails, over
head trapeze, roller
pads in moving
LONG TERM:
3.
Schedule
activities
with
adequate rest periods
during the day
After 8 hours of
nursing
Interventions the
client
will
manifest
an
improvement on
physical
mobility.
4.
Encourage
participation in self
care
occupational
diversional
or
recreational
activities
The client shall

demonstrated
a
change
in
behavior in the
2. For position health teachings
changes
and provided.
transfers
3.
Limits
fatigue,
conserves
energy and can LONG TERM:
enhance coping
ability
The client shall
have manifested
4.
Promotes an improvement
well being and on
physical
maximizes
mobility.
energy
production
186
performance of
ADLs
Bed sores
demands
is
impaired, the body
will not be supplied
with
sufficient
oxygen to support
normal functioning.
When
left
unmanaged,
the
client will not be
able to resume his
daily activities due
to weakness and
easy
fatigability
caused by oxygen
supply and demand
mismatch.
Furthermore,
clients condition
required insertion
of CTT which will
further
impede
clients ability to
move
due
to
equipment
placement.
5.
Instruct
and
demonstrate the use
of
adjunctive
devices such as
walkers, canes
5.
Promotes
independence
and enhances
safety
6. Instruct the client

to provide regular
skin care to include
pressure
area
management
6. To maintain
the
optimal
skin integrity
and to prevent
the formation
of
pressure
sores
7. Support affected
body parts or joints
using pillows, rolls,
foot supports
7. To maintain
position
of
function
and
reduce risk of
pressure ulcers
8.
Administer
medications prior to
activities as needed
for pain
8. To permit
maximal effort
and
involvement in
activities
187
RISK FOR IMPAIRED GAS EXCHANGE R/T ALVEOLAR-CAPILLARY CHANGES

ASSESSMENT
S: The client may

verbalize dyspnea and
headache
upon
awakening
NURSING
DIAGNOSIS
Risk
impaired
exchange
related
alveolarO: The client may capillary
manifest:
changes
Restlessness
Abnormal
breathing
The client may also
manifest:
Confusion
Irritability
Cyanosis
Diaphoresis
Tachycardia
SCIENTIFIC
EXPLANATION
for An impairment in
gas gas
exchange
means that there is
to an excess or deficit
in oxygenation and
carbon
dioxide
elimination at the
alveolar-capillary
membrane. As a
result
of
the
procedure that has
undergone, which
was
lobectomy,
there
is
an
alteration in the
respiratory function
of the client
OBJECTIVES
NURSING
INTERVENTIONS
RATIONALE
Short Term:
After 1-2 hours
of
nursing
interventions, the
client will be
able
to
participate in the
treatment
regimen such as
breathing
exercises
with
the
use
of
spirometer
within level of
ability
1. Note respiratory
rate, depth, use of
accessory muscles
and areas of pallor
1. To assess Short Term:

level
of The client shall
compromise
have been able to
participate in the
treatment regimen
2. To evaluate such as breathing
respiratory
exercises with the
status
use of spirometer
within level of
ability
Long Term:
After 2-3 days of
nursing
interventions, the
client will be
able
to
demonstrate
improved
ventilation and
adequate
2. Auscultate breath
sounds, note areas of
decrease
breath
sounds as well as
fremitus
3. Elevate head of
bed and position
client appropriately
3. To maintain
airway patency
4.
Encourage
frequent changes in
position and deep
breathing
and
coughing exercises,
use
incentive
spirometry
4. To promote
optimal chest
expansion and
drainage
of
secretions
5.
Provide
supplemental
oxygen at lowest
EVALUATION
Long Term:
The client shall
have been able to
demonstrate
improved
ventilation
and
adequate
5. To improve oxygenation
of
existing
tissues by ABGs
deficiencies
within
clients
188
oxygenation of
tissues
by
ABGs
within
clients normal
limits
and
absence
of
symptoms
of
respiratory
distress
concentration
indicated
as
6.
Encourage
adequate rest and
limit activities to
within
client
tolerance
7.
environment
allergen
pollutant free
Keep
and
normal limits and

absence
of
symptoms
of
6. Helps limit respiratory
oxygen needs distress
and
consumption
7. To reduce
irritant effect
of dust and
chemicals on
airways
8.
Discuss
implication
of
smoking related to
the illness condition
8. To promote
wellness
9.
Administer
medications
as
indicated such as
analgesics
that
restricts
optimal
respiratio
9. To help
improve client
respiratory
efforts
189
ACTIVITY INTOLERANCE R/T POSTOPERATIVE THORACOTOMY, LOBECTOMY AND PRESENCE OF CTT

ASSESSMENT
NURSING
DIAGNOSIS
S: Client may verbalize Activity

reports of fatigue
intolerance r/t
postoperative
O: Client may manifest thoracotomy,
abnormal heart rate lobectomy and
and blood pressure presence of ctt
response to activity
Client
may
also
manifest:
Pressure ulcers
Weakness
Pallor
Cyanosis
Constipation
SCIENTIFIC
EXPLANATION
OBJECTIVES
NURSING
INTERVENTIONS
RATIONALE
Activity intolerance
is an insufficient
physiological
or
psychological
energy to endure or
complete required
or desired daily
activities.
Given
that client have
undergone
lobectomy, there is
a decrease in the
lung capacity that
decreases oxygen
availability to the
cells. Also, with the
incision site giving
discomfort,
the
client would rather
stay in one position
of comfort that
moving around and
feeling the pain of
the affected area.
Prolonged bed rest
as well can promote
Short Term:
After 1-2 hours
of
nursing
interventions, the
client will be
able
to
use
identified
techniques
to
enhance activity
intolerance such
as
gradual
increase
in
activity within
the clients limits
1. Evaluate clients
actual and perceived
limitations,
and
severity of deficit in
light of usual status
1.
Provides
comparative
baseline
and
information
about needed
education
or
interventions
regarding
quality of life
Long Term:
After 2-3 days of
nursing
interventions, the
patient will be
able to report
measurable
increase
in
activity tolerance
2. Note clients
reports of pain,
fatigue,
weakness
difficulty
accomplishing task
3. Ascertain ability
to stand and move
about, and degree of
assistance necessary
or use of equipment
4. Adjust activities,
EVALUATION
Short Term:
The patient shall
have been able to
use
identified
techniques
to
enhance activity
intolerance such
as
gradual
increase
in
activity within the
2. Symptoms clients limits
may be result
or contribute to
intolerance of
activity
Long Term:
3.
To The patient shall
determine
have been able to
current status report measurable
and
needs increase
in
associated with activity tolerance
participation in
needed/ desired
activities
4. To prevent
190
activity intolerance
and this may be due
to the existence of
pain.
reduce intensity or
discontinue activities
that cause undesired
physiological
changes
overexertion
5.
Increase
exercise/activity
gradually
6. Plan care to
carefully
balance
rest periods with
activities
5. To conserve
energy
7. Promote comfort
measures
and
provide relief of pain
7. to enhance
ability
to
participate in
activities
8.
Provide
and
monitor response to
supplemental
oxygen, medication
and
changes
in
treatment regimen
8. To assist
client to deal
with
contributing
factors
and
manage
activities
within
individual
limits
6. To reduce
fatigue
191
FATIGUE r/t ALTERED OXYGEN SUPPLY AND DEMAND

ASSESSMENT
S: Mapapagal ku
patse magsalitaku (
I get easily tired even
when talking) as
verbalized by the
client
O:
The
client
manifested
the
following:
needs
assistance
with changing
position and
activity with
good muscle
strength
Lethargy
With
good
capillary refill
less than 2
seconds
with regular
NURSING
DIAGNOSIS
Fatigue related
to altered
oxygen supply
and demand
SCIENTIFIC
EXPLANATION
Fatigue
is
an
overwhelming,
sustained sense of
exhaustion
and
decreased capacity
for physical and
mental work at
usual level. This
problem
has
materialized due to
the impairment in
the respiratory tract
that deceases the
ability of the body
to acquire enough
oxygen needed for
metabolism so as to
be able to perform
activities desired.
OBJECTIVES
NURSING
RATIONALE
INTERVENTIONS
1.Assess vital signs
1.To evaluate fluid
Short term:
After 4 hours of
status
and
nursing
cardiopulmonary
interventions, the
response to activity
client
will
identify basis of 2.Determine
2.Fatigue can be a
fatigue and will presence/degree of consequence
of,
demonstrate
sleep disturbances
and/or exacerbated
way/interventions
by, sleep deprivation
to prevent it
3.Assess the clients 3.Fatigue can limit
ability to perform the persons ability
Long term:
After 3 days of activities of daily to participate in selfnursing
living
care and perform his
interventions, the
role responsibilities
client
will
perform activities 4.Assist the client to 4.A
plan
that
of daily living develop a schedule balances periods of
and participate in for daily activity and activity with periods
desired activities rest
of rest can help the
at level of ability
client
complete
desired
activities
without adding to
levels of fatigue
5.Obtain
SOs 5.To
assist
EVALUATION
Short term:
The client shall
have identified
basis of fatigue
and demonstrated
way/interventions
to prevent it
Long term:
The client shall
have performed
activities of daily
living and
participated in
desired activities
at level of ability
in
192
depth and
rhythm of
breathing
with use of
accessory
muscle
The
client
may
manifest
the
following:
Disinterest in
surroundings
description
fatigue
of evaluating impact on
clients life
6.Note daily energy 6.To

help
patterns
determining
pattern/timing
activity
7.Esatablish realistic
activity goals with
client and encourage
forward movement
in
of
7.To
enhance
commitment
to
promoting optimal
outcomes
8. Plan interventions 8.To

maximize
to allow individually participation
adequate rest periods
9.Instruct client in 9.To indicate the
ways to monitor need to alter activity
responses to activity level
and
significant
signs/symptoms
10.Assist client to 10.To promote sense
identify appropriate of
control
and
coping behaviors
improves
selfesteem
11.Encourage
to 11.to
nutritionally dense, energy
easy to prepare and
promote
193
consume foods and

avoidance
of
caffeine and high
sugar foods and
beverages,
as
ordered
12.Refer
to
occupation
or
physical therapy for
programmed daily
exercise, as ordered
12.To
stamina,
and muscle
to enhance
well-being
improve
strength,
tone and
sense of
13.Provide
supplemental
oxygen, as ordered
13.To
reduce
oxygen available for
cellular uptake and
contributes
to
fatigue
14.Review
medication
use/regimen
14.To
determine
medications
that
cause
and/or
exacerbate fatigue
194
C. IMPLEMENTATION
1. MEDICAL MANAGEMEN
a. IVF, OXYGEN THERAPY, NEBULIZATION, INSULIN DRIP, DOPAMINE DRIP, CTT,
NEPHROSTERIL, FOLEY CATHETER, BT
Medical
Date ordered
General Description
Indications
Clients Response to
Management
Date Performed
Treatment
Date Changed
PNSS 1L x 80
DO: 11/03/13
An aqueous solution of 0.9
It can be used for hydration
The intravenous fluid was
cc/hr
11/04/13
percent sodium chloride,
since it has minimal or no
administered properly, with
11/05/13
isotonic with the blood and
effect to tissues and as a
expected effects achieved,
tissue fluid, used in medicine
solvent for drugs that are to be no untoward reactions, and
DP: 11/03/13
chiefly for bathing tissue and,
administered parenterally.
11/04/13
in sterile form.
the patient neither

experienced dehydration
11/05/13
nor fluid overload.
DC: 11/05/13
The fluid was shifted to D5
After shifting the fluid
Shifted to D5 LRS
LRS, a dextrose (5%)
from PNSS to D5 LRS and
1L x 80cc/hr
containing fluid, because the
holding mixtard, the
patients CBG level was 97
patients CBG level
mg/dL (11/05/13; 9:00 am)
reached 286 mg/dL.
and the patient was on NPO
195
status which may further

result to decrease in blood
The doctor changed the
glucose levels. Furthermore,
patients fluid from D5
the client was scheduled for
LRS to PNSS because the
surgery on this given date,
CBG level of the latter
additional glucose will be
suddenly went up to
needed in order to supply
abnormally high levels.
caloric demands of the body
11/06/13
during stressful events
6:00 am = 28
(surgery).
4 mg/dL
8:00 pm = 335 mg/dL
11:00 pm = 237 mg/dL
PNSS 1L x 100
DO: 11/06/13
A day after surgery, PNSS
cc/hr
11/07/13
was resumed to maintain fluid
administered properly,
11/08/13
volume stability without
without signs of infiltration
11/10/13
causing significant changes in
and phlebitis. There were
11/11/13
clients serum glucose level
no untoward reactions. The
since there is now a decrease
patient manifested pitting
196
DP: 11/06/13
need for additional glucose.
edema on both upper
11/07/13
extremities, I/O of
11/08/13
868/80cc, and (-) crackles.
11/10/13
11/11/13
DC: 11/11/13
Shifted to PLRS
1L x 100 cc/hr
Prior the procedure:
Read the doctors order
Check IV label
During the procedure:
Check for patency of tubing
Regulate as ordered
197
After the procedure:

Check IV infusion and amount every 2 hours
Monitor patient for evidence of IV infiltrations and thrombophlebitis.
Check for presence of air in the tubing if there is, remove immediately.
Monitor patient for fluid overload
Medical
Date ordered
Management
Date Performed
General Description
Indications
Clients Response to
Treatment
Date Changed
D5LRS 1L x 80
DO: 11/05/13
cc/hr
DP: 11/05/13
These products are sterile,
The IVF of the patient
The Hgt level of the
nonpyrogenic solutions each
was shifted from PNSS 1L patient increased from
containing isotonic
x 80 cc to D5 LRS 1L x
97mg/dL to:
concentrations of electrolytes
80 cc while the on NPO
8pm = 335mg/dL
(with or without dextrose) in
because the patients CBG
11pm= 237mmg/dL
DC: 11/06/13
water for injection. The solutions level decreased to 97
Shifted to PNSS
containing dextrose and
mg/dL. It was shifted o a
1L x 100 cc/hr
electrolytes are hypertonic; those
Dextrose (5%) containing
containing only electrolytes are
fluid because of its
On 11/06/13 (a day after
isotonic.
glucose content which is
surgery), it was again
6am= 284mg/dL
198
still needed by the patient
shifted to PNSS 1L x 80
during surgery and to
cc/hr.
prevent hypoglycemia
from occurring.
Check IV label
Regulate as ordered
Monitor patient for fluid overload.
Record all procedure done
199
Medical
Date ordered
Management
Date Performed
General Description
Indications
Clients Response to
Treatment
Date Changed
PLRS 1L x 100
DO: 11/11/13
Lactated Ringer's is sterile,
cc/hr
11/12/13
nonpyrogenic and is used to
Lactated Ringer's provides The intravenous fluid was

electrolytes and is a
supply water
source of water for
with expected effects
and electrolytes (e.g., calcium,
hydration. It is capable of
achieved, no untoward
potassium, sodium, chloride). It
inducing diuresis
reactions, and the patient
DP:
contains no bacteriostatic or
depending on the clinical
neither experienced
11/12/13
antimicrobial agents. This
condition of the patient.
11/13/13
intravenous administration in a
dehydration nor fluid

This solution also contains overload with intake of
lactate which produces a
2640cc and output of
single dose container. It is also
metabolic alkalinizing
DC: 11/13/13
used as a mixing solution
effect.
Shifted to PNSS
(diluent) for other IV
1L x KVO
medications
11/13/13
product is intended for
2620cc.
200
PLRS 1L x 100
DO: 11/13/13
cc/hr
DP: 11/13/13
PNSS was terminated and
administration of PLRS
was resumed for the same
with expected effects
purpose.
achieved, no untoward
reactions, and the patient
DC: 11/14/13
neither experienced
Terminated IVF
dehydration nor fluid

overload.
Check IV label
Regulate as ordered
Monitor patient for fluid overload.
201
Medical
Management or
Treatment
OXYGEN
Date Ordered
Date Given
Date Change
DO: 11/05/13
THERAPY (3
LPM via face
mask)
DP: 11/05/13
General Description
Indication or Purpose
Oxygen therapy is the delivery

of extra oxygen to the lungs. It is
done to increase the level of
available oxygen in the body.
It is to improve oxygen
flow to major organs and
tissues, such as the heart,
lungs and brain, and to
decrease the work of
breathing. Oxygen is used
in situations such as
shortness of breath,
cardiac arrest and heart
attacks.
DC: 11/08/13
Clients Response
As a standard operating
procedure, supplemental
oxygen is given to patients
undergoing any surgical
operation mainly because
anesthesia depresses
respiration thus justifying
he need for oxygen
therapy. As a result, the
patient did not manifest
any signs of cyanosis.
Nursing Responsibilities for Oxygen Therapy

Before:
Identify the patient by asking his name. Identify oneself to allow for a good working relationship.
Explain the importance of the procedure to the significant other.
202
During:
Assess the general condition of the patient.
Review recorded vital signs.
Administer nebulization to liquefy secretions, as ordered.
Position client in a comfortable position, preferably sitting or in an orthopneic position.
Ready an emesis basin for expectoration.
Instruct client to inhale as much air as possible, then, exhale forcefully, allowing secretions to be expectorated.
Instruct client to practice coughing whenever secretions are about to be expelled.
After:
Document the time the exercises were performed.
Note color of secretions to note the progress of the disease. Report hematuria, and the like as soon as possible.
If specimen is needed, obtain specimen and send to laboratory for testing immediately.
Allow client to practice oral hygiene after exercising.
203
NEBULIZATION
Medical
Date ordered
Management
Date Performed
General Description
Indications
Clients Response to
Treatment
Date Changed
Nebulization with
DO: 11/04/13
Nebulization is the process of
Nebulization therapy is
The treatment was
medication administration via
used to deliver
administered properly and
inhalation. It utilizes a nebulizer
medications along the
effectively. The patient
which transports medications to
respiratory tract and is
did not manifest any
the lungs by means of mist
indicated to relieve
untoward reaction and no
inhalation. It aids bronchial
clients chest tightness
signs and symptoms of
DC: 11/11/13
hygiene by restoring and
and respiratory congestion
respiratory distress were
terminated
maintaining mucus blanket
due to excessive and thick
further noted. During the
continuity, hydrating dried
mucus secretions, and
entire course of therapy,
secretions, promoting secretion
bronchiectasis.
crackles, chest pain (on
duavent/combivent
every 6 hours
DP: 11/04/13 to
11/10/13
expectoration, humidifying
inspired oxygen, and delivering
drugs
surgical site) and use of

Combivent is a
combination of albuterol
and ipratropium.
Albuterol and ipratropium
accessory muscles upon

inspiration and expiration
were noted. On 11/11/13,
the patient did not
204
are bronchodilators that
manifest any signs and
relax muscles in the
symptoms of respiratory
airways and increase air
distress or difficulty of
flow to the lungs.
breathing (respiratory rate

within normal range), no
Duavent is given as
management of reversible
bronchospasm associated
crackles were noted, and

chest pain (on surgical
site) was minimal.
w/ obstructive airway
diseases e.g. bronchial
asthma, COPD.
Verify the doctors order
Check clients identity, drug label, and dosage
Prepare necessary equipment
Assess patients vital signs and respiratory status
Assist patient in a sitting or high-fowlers position
Turn on machine and check for outflow port for proper misting
205

Encourage the patient to take slow, even breath to derive maximum benefit
Monitor for over hydration, especially in patients with delicate fluid balance
Stay with the patient during the procedure
Watch out for any untoward reaction
Depending on the equipment, adjust flow rate, or change the nebulizer cup or tubing according to hospital policy

Reassess patients vital signs and respiratory status
Perform suctioning as ordered or chest physiotherapy as appropriate
Encourage the patient to cough
206
INSULIN DRIP
Medical Management
Date ordered
General Description
Indications
Date Performed
Clients Response to
Treatment
Date Changed
Insulin drip 100 u HR
DO: 11/6/13
Humulin R (HR) is a rapid Insulin drip was ordered
The CBG levels of the
in 100 cc of PNSS @ 10
DP: 11/6/13
acting insulin. The
to provide continuous
patient was persistently
primary activity of insulin
control of CBG level.
elevated, so the doctor
is regulation of glucose
8:00 pm = 423mg/dL
ordered increase in
metabolism. Insulin binds
9:00 pm = 369mg/dL
regulation of insulin drip
to insulin receptors on
10:00 pm = 341mg/dL
from 10 u /hr to
muscle and adipocytes,
11:00 pm = 312mg/dL
12u/hr
u per hour.
and lowers blood glucose

by facilitating the cellular
uptake of glucose. Insulin
simultaneously inhibits
output of glucose from the
liver
207
DO: 11/07/13
This was ordered because
The CBG levels of the
in 100 cc PNSS at 15
DP: 11/07/13
the CBG level of the
patient went down to:
patient was persistently
12:00mn= 254mg/dL
elevated, the regulation
1:00am= 208mg/dL
was increased from 10
2:00am= 181md/dL
u/hr to 15 u/hr
The drug was temporarily
u/hr
stopped at 3:00 am
because the CBG of the
patient went down to
114mg/dL
Insulin Drip 100 u
DO: 11/07/13
The insulin drip was
The result of the CBG
HR in 100 cc of PNSS x
DP: 11/07/13
resumed to 5 u/hr
levels went down from
because of the CBG level
226 to 210mg/dL with
was elevated, from
continuous insulin drip at
114mg/dL from time of
5 u/hr.
5 u/hr
holding the drip to:

4:00 am = 147mg/dL
5:00 am = 137mg/dL
6:00 am = 226mg/dL
208
Insulin drip 100 u/hr
DO: 11/07/13
The regulation was
in 100cc PNSS x 12
DP: 11/07/13
increased from 5 u to 12 patient at 11:00 am went
u/hr
The CBG result of the
u because the CBG
up to 178mg/dL with the
result of the patient went
help of administration of
downt to:
D50-50 1 vial + HR 10
8:00 am = 199mg/dL
u x 3 hours, 1 hour
9:00am = 165mg/dL
interval.
8:00 am = 144mg/dL
DO:11/07/13
The regulation was
The CBG result of the
+ 100 cc PNSS x 5
DP: 11/07/13
decreased from 12 u to
patient at 12:00 MN was
u/hr
(11am,1pm,2pm)
5 u because D50-50 1
182mg/dL
vial + HR 10 u x 3
doses was also given to
help the patient manage
CBG level within normal
limits and prevent sudden
drop in CBG levels.
209
DO: 11/07/13
+ 100 cc PNSS x 13
DP: 11/07/13
The regulation was
After changing regulation,
u/hr
(3pm to 5pm)
increased from 5 u/hr to
the CBG went down to:
13 u/hr because the
3:00 pm = 185mg/dL
CBG of the patient at 2:00
4:00 pm = 146mg/dL
pm went to 265mg/dL
DO: 11/07/13
in 100 cc PNSS at 8
DP: 11/07/13
u/hr
The regulation was
The CBG of the patient
decreased from 13 u to
went up from 86 to 132
8 u because the CBG of
mg/dL
the patient at 9:00 pm was

86mg/dL
After 6 hours of
Hold Insulin Drip
DO: 11/08/13
Insulin drip was
terminating insulin drip,
DP: 11/08/13
temporarily stopped due
the patient Hgt level
to sudden decline in
increased to 200mg/dL
clients Hgt level, 78mg/d
After 6 hours of
This was ordered due to
administration, the Hgt
increased Hgt level,
level slightly declined to
223mg/dL
221mg/dL
210
Check clients identity, drug label, and dosage and have another nurse to countercheck
Have a baseline blood glucose level
Ensure proper regulation upon administration
Check BP, I & O ratio, and blood glucose level every hour
Monitor for hypoglycemia during the time of its peak of action
Secure IV Glucagon at bedside in case of severe hypoglycemia
Check IV site and observe for infiltration of medication

Reassess clients BP, I & O ratio, and blood glucose level
211
D5050
Medical
Date ordered
Management
Date Performed
General Description
Indications
Clients Response to
Treatment
Date Changed
D5050
DO: 11/06/13
This fluid is considered to be
Mainly indicated for
From 03/05/13 to 03/07/13,
patients who are
the clients serum studies
hypoglycemic as well as
revealed hyperkalemia. In a
the blood glucose level for
with those who have an
procedure known as
emergency care to treat
altered level of
temporization where insulin
hypoglycemia and also has an
consciousness, coma of an
is given to induce a
osmotic diuretic ability.
unknown etiology and
secondary effect which is to
seizure disorders of
facilitate cellular reuptake of
DP: 11/06/13 and hypertonic, is a caloric agent

that is able to rapidly increase
11/07/13
unknown etiology also. But excess extracellular

this fluid can also be given
potassium, D5050 is given to
to reduce serum potassium
counteract its primary effect
when insulin is given
of decreasing blood sugar
subsequently by shifting
level (possible
potassium extracellularly
hypoglycemia).
into intracellularly.
212
Check IV label

Regulate as ordered

Monitor patients HGT and serum potassium
213
DOPAMINE DRIP
Medical
Date ordered
Management
Date Performed
General Description
Indications
Clients Response to
Treatment
Date Changed
Dopamine Drip
DO: 11/05/13
Dopamine Hydrochloride
This medication was used
During surgery and few
5mcg/kg/min
DP: 11/05/13
Injection, USP is a clear,
to improve kidney blood
days of post-operative
practically colorless, aqueous,
supply especially in the
period, no complications
additive solution for intravenous
case of the client who has
related to improper
infusion after dilution.
renal impairment (CKD
excretion or retention of
Dopamine (dopamine
Stage III) so as to aid in
medications/anesthetic
hydrochloride) HCl, a naturally
the elimination/excretion
agents were reported or
occurring catecholamine, is
of anesthetic by-products
noted. The patient
an inotropic vasopressor agent.
and other medications
responded by displaying
given during surgery.
BP within his normal
DC: 11/06/13
Decreased to 3
mcg/kg/min
range (140/70 mmHg), but

the patient manifested
ECG changes as
manifested by sinus
bradycardia.
214
Dopamine Drip
DO: 11/06/13
3mcg/kg/min
DP: 11/06/13
A day after the surgery,
Patient displayed vital
DC: 11/08/13
the doctor ordered a
signs within normal range.
Hold
decrease in dose due to

the possible detrimental
effects if used
continuously (sinus
bradycardia,
hypertension).
Check clients identity, drug label, and dosage and have another nurse to countercheck
Check clients Blood Pressure, Heart Rate, Urine output (and other available hemodynamic parameters)
215

Ensure proper regulation upon administration
Monitor Blood Pressure, Heart Rate, and Urine Output
Monitor for any untoward reaction
Assess IV site for possible infiltration

Reassess clients BP, I & O ratio, and blood glucose level
Do not abruptly discontinue drug, begin downward titration as ordered by the physician
216
HAESTERIL
Medical
Date ordered
Management
Date Performed
General Description
Indications
Clients Response to
Treatment
Date Changed
Haesteril
DO: 11/05/14
Haesteril is a brand name for
Therapy and prophylaxis
With the surgical
DP: 11/05/14
Pentastarch, a subgroup of
of volume deficiency
procedure made, the client
hydroxyethyl starch that is used for
(hypovolemia) and shock
did not manifest any signs
fluid resuscitation.
(volume replacement
of hypovolemia or
therapy) in connection
dehydration and the
with surgery (lobectomy).
standby order for blood

transfusion was not
initiated because it was
necessitated.
Check IV label
217

Regulate as ordered

Monitor patient for fluid overload
218
NEPHROSTERIL
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
medication and actual
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
Generic Name:
Date ordered:
500ml
12 Nephrosteril
Nephrosteril
11-07-13
OD single Dose
is Nephrosteril was given The patients creatinine
parenteral nutrition for to
the
kidney function
facilitate
patient
to level
goes
parenteral (3.61md/dL)
up
and
Brand Name:
Date given:
The amino acids
nutrition in kidney and abnormal
Nephrosteril
11-07-13
contained in
in haemofiltration and (3200/880) with doctor
Nephrosteril are all
haemodialysis.
naturally occurring
the patients creatinine cause of CKD @ Nov.
physiological
level on 11/07/13 (6:27 7 (10:40am).
compounds. As with
am) is 3.29mg/dL.
infusion 7%
500ml
11-09-13
OD
(8:15am)
12 from the ingestion and
of
Patients
the amino acids derived

Date changed:
Also, notes
I&O
Unknown
creatinine
Nephrosteril is given level was within the
assimilation of food
because the patient has normal
proteins, parenterally
low
output
range
level (1.54mg/dL) and I&O
219
administered amino
compare to the intake of
acids enter the body
level.
2030/2000.
The
patient did not manifest
pool of free amino
any
signs
acids and all
symptoms
subsequent metabolic
insufficiency but the
pathways.
drug is still continued.
of
and
renal
PRIOR:
Prepare all equipment needed.
Assess for renal impairment.
Check doctors order and follow appropriate administration.
DURING:
May take with or without meals
Obtain regular weight to monitor fluid changes
Note for sign and symptoms of toxicity
Maintain proper drop rate.
AFTER:
Instruct pt to immediately report any nausea, vomiting and chills
220
BLOOD TRANSFUSION
Medical
Date ordered
Management
Date Performed
General Description
Indications
Clients Response to
Treatment
Date Changed
4 u of Full
DO: 10/28/13
Is the introduction of whole blood
Transfusion of whole
The order was not
Blood Type O
DP: Was not
or component of the blood, e.g.
blood from one individual
administered, instead,
properly cross-
administered
plasma or erythrocytes into venous
to another is indicated for
Haesteril, a plasma volume
circulation.
two main reasons: firstly,
expander, was used during
when the volume of blood
the surgical procedure. Hitt
within the circulation
(2012) and Liumbruno et al
system of the patient is
(2009) explains that BT is
less than that required to
indicated if hemoglobin
sustain life and, secondly,
level has reached below 60-
when the red blood cells
70 mg/dL where in the
are deficient either in
lowest level of hemoglobin
quantity or quality.
concentration this client had
matched
was 107 mg/dL that did not

necessitate the order to be
executed.
221
Nursing Responsibilities
Before the procedure:
Verify the physicians written order and make a treatment card according to hospital policy
Explain the procedure/rationale for giving blood transfusion
Secure consent.
Get patient histories regarding previous transfusion.
Ensure proper blood typing and cross matching.
Using a clean lined tray, get compatible blood from hospital blood bank.
Wrap blood bag with clean towel and keep it at room temperature.
Have another nurse countercheck the compatible blood to be transfused against the crossmatching sheet noting the ABO
grouping and RH, serial number of each blood unit, and expiry date with the blood bag label and other laboratory blood exams
as required before transfusion.
Get the baseline vital signs before transfusion.
Give pre-meds 30 minutes before transfusion as prescribed.
Do hand hygiene before procedure
Prepare equipment needed for BT (IV injection tray, compatible BT set, IV catheter/ needle G 19/19, plaster, torniquet, blood,
blood components to be transfused, Plain NSS 500cc, IV set, needle gauge 18 (only if needed), IV hook, gloves, sterile 22
gauze or transplant dressing, etc.)
222

Maintain asceptic technique
Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the needle, from BT administration ser and secure with
adhesive tape.
Close the roller clamp of IV fluid of Plain NSS and regulate to KVO while transfusion is going on.
Transfuse the blood via the injection port and regulate at 10-15gtts/min initially for the first 15 minutes of transfusion and refer
immediately to the MD for any adverse reaction.
Observe/Assess patient on an on-going basis for any untoward signs and symptoms such as flushed skin, chills, elevated
temperature, itchiness, urticaria, and dyspnea. If any of these symptoms occur, stop the transfusion, open the IV line with Plain
NSS and regulate accordingly, and report to the doctor immediately.
Ensure that blood transfusion is completed within 4 hours (from the time the blood was withdrawn from the bank)
When blood is consumed, close the roller clamp, of BT, and disconnect from IV lines then regulate the IVF of plain NSS as
prescribed.

Continue to observe and monitor patient post transfusion, for delayed reaction could still occur.
Reasses Hgb and Hct, bleeding time, serial platelet count within specified hours as prescribed and/or per institutions policy.
Discard blood bag and BT set and sharps according to hospital policy.
Fill-out adverse reaction sheet as per institutional policy.
223
Medical
Date ordered
Management
Date Performed
General Description
Indications
Clients Response to
Treatment
Date Changed
Connect
DO: 11/05/13
Chest tube thoracostomy is done to
To drain air on the
The patient responded to
Anterior and
DP: 11/05/13
drain fluid, blood, or air from the
anterior CTT and to drain
treatment well and did not
space around the lungs.
fluid and blood on the
manifest any signs and
posterior CTT; used to
symptoms of respiratory
drain secretions and air
distress.
post-lobectomy.
Intermittent fluctuation
Posterior CTT
DC: 11/08/13
bottles to
emerson pump
Removed
at 20 mmHG
Emerson pump
Chest drains are inserted to remove

pathological collections of air or
fluid in the pleural space, to allow
and periodic bubbling
the re-creation of the essential
were observed.
negative pressures in the chest, and

to permit complete expansion of
the lung, thereby restoring normal
ventilation.
Maintain
DO: 11/08/13
Good fluctuation and (-)
Anterior and
DP: 11/08/13
bubbling were observed.
Posterior CTT
DC: 11/09/13
224
Anterior CT
removed
DO: 11/09/13
Maintain
DP: 11/09/13
Good fluctuation and (-)
Posterior CTT
DC: 11/14/13
bubbling were observed.
Posterior CTT
removed
Verify consent
Prepare equipment
Assess patients knowledge on procedure; provide clarifications if there are questions.
Position client as appropriate (upright or side-lying)
Assist with tube insertion as needed
225
Apply local anesthetic as per doctors order

Instruct patient to relax and breathe slowly during inspiration
Once tube is inserted and secured, check for fluctuations and bubbling
Assess respiratory status every 4 hours
Instruct patient to perform deep breathing and coughing exercises.
Keep the collection apparatus below the level of the chest
Maintain a closed system, Tape all connections, and secure the
chest tube to the chest wall
Place CTT bottles on a secured area
Check tubes frequently for kinks or loops
Instruct patient to perform deep breathing and coughing exercises.
Measure drainage every 8 hours, marking the level on the
drainage chamber.
Periodically assess water level in the suction control chamber,
adding water as necessary.
When the chest tube is removed, immediately apply a sterile
occlusive petroleum jelly dressing
226
FOLEY CATHETER
Medical
Treatment
Date Ordered
General Description
Date Started
Clients response to
treatment
Date Removed
An indwelling urinary catheter is By
Foley Catheter
DO: 11/05/13
DS: 11/05/13
inserting
Foley The patients urine was
one that is left in the bladder. You catheter, you are gaining able to drain smoothly on
may use an indwelling catheter for access to the bladder and the foley catheter without
a short time or a long time.
DR: 11/08/13
An indwelling catheter collects
urine by attaching to a drainage
bag. A newer type of catheter has
a valve that can be opened to
allow urine to flow out.
its
contents.
Thus obstruction.
enabling you to drain

bladder
contents,
decompress the bladder,

obtain a specimen, and
introduce a passage into
the GU tract.
Urinary output is also a sensitive

indicator of volume status and
renal perfusion.
Since the patient is postsurgery, there has been a

change in the bladder
227
function of the patient

that may lead to urinary
retention.
Hence,
routine foley catheter as

per hospital protocol is
needed after surgery.
Before:
Inform patient of any interventions you intend to carry out and gain consent prior.
Offer reassurance as necessary and allow patient to verbalize concerns or queries.
Ensure good hygiene measures are taken to prevent infection ascending the Catheter tubing.
During:
Regularly check tubing to ensure no erosion, kinks or occlusions are present that could prevent good urine flow.
Ensure catheter bag is changed twice weekly to prevent infection.
Ensure catheter tubing is kept away from skin to prevent friction sores on skin.
After:
Monitor urine output frequently and document appropriately, i.e. Fluid Balance
Chart. Inform Doctor if urine output <0.5 ml/kg/hr.
Ensure catheter is replaced after 12 weeks if still in situ.
Monitor bowel movements and document frequency to ensure constipation does not affect patency of catheter
228
B. Drugs
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
Generic Name:
Date ordered:
1gm IV q 12O General Action:
Cefepime was given to With the use of this
Cefepime
11-03-13
ANST (-)
Anti-infectives
treat
Functional
Bacterial
Date given:
Classification:
caused
11-03-13
Fourth
Brand Name:
to
Cephalosporin
and
Cepiram
11-09-13
Mechanism of action:
microorganisms
well
to
further
Generation Staphylococcus aureus infections
were
other prevented and did not

like experience any adverse
has Streptococcus
Date stopped:
antibacterial
11-09-13
against
both
negative
and
including
infections responded
by treatment,
Cefepime
positive
medication, the patient
reactions of the drug.
activity pyogenes, E. coli and The

gram- Klebsiellapneumoniae.
gram- Moreover
pathogens indicated
patient
showed
improvement
in
it
was condition
AEB
for
the decreased
respiratory
those treatment of susceptible infection
such
as
229
resistant to other B infections of the lower absence of fever but

Lactam
antibiotics. respiratory tract.
WBC
High affinity for the

multiple
penicillin-
are
slightly
above the normal limits

It was given to the as evidence by WBC:
binding proteins that patient
treat 12.36x109/L
to
and
are essential for cell underlying infection in Neutropils of 0.88, and

wall synthesis.
the
lungs
prophylaxsis
upcoming
and
as within normal range in

for Eosinophil of 0.01 on
lobectomy. November 7, 2013. The
Also it is given for 7 drug was shifted into

days
to
prevent an
oral
antibiotic
infection after surgery Cefixime200

and infection on CTT BID
for
mg/tab
continuous
and to prevent micro antibiotic therapy and

organisms resistance.
prevention
of
susceptible infections.
Prior:
Assess patient for infection (vital signs, wound appearance, sputum, urine, stool, and WBC) at beginning of and throughout
therapy.
230
Obtain a history before initiating therapy to determine previous use and reactions to penicillins or cephalosporins. Persons with
a negative history of penicillin sensitivity may still have an allergic response.
Obtain specimens for culture and sensitivity before therapy. First dose may be given before receiving results.
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and
notify the physician or other health care professional immediately if these occur. Keep epinephrine, an antihistamine, and
resuscitation equipment close by in the event of an anaphylactic reaction.
During:
Instruct patient to take medication round the clock and to finish the drug completely as directed, even if feeling better. Advise
patients that sharing of this medication can be dangerous.
Advise patient to report the signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foulsmelling stools) and allergy.
After:
Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus.
Advise patient not to treat diarrhea without consulting health care professional. May occur up to several weeks after
discontinuation of medication.
Instruct the patient to notify health care professional if symptoms do not improve.
231
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
General Action:
Cefixime
Anti-infectives
was indicated for the medication,
Functional
treatment of bacterial infection was prevented
Date given:
Classification:
infections
11-10-13
Third
Brand Name:
to
Cephalosporin
of the lower respiratory evidenced by incision
Suprax
11-13-13
tractcaused by certain site intact with no signs
Generic Name:
Date ordered:
Cefixime
11-09-13
200mg/tab BID
Generation susceptible
With the use of this
and
wide
bacterial
variety
of as
adverse
such of infection. The pt. did
S.pneumoniae, not manifest adverse
infections. S.pyogenes and E.coli.
Bactericidal action of
no
infections reactions were noted as
Cefiximeis used to treat microorganisms

a
other and
further
reaction
of
the
medicine AEB absence
cefixime results from This was indicated to of GI upset such as
232
inhibition of cell-wall the patient because the nausea and vomiting,

synthesis.
patients IV antibiotic headache or dizziness.

was consumed already
and the doctor ordered
cefixime
tablet
continue
therapy
to
antibiotic
to
prevent
infection on respiratory
tract and the incision
site for the CTT.
Prior:
Assess patient for infection (vital signs, wound appearance, sputum, urine, stool, and WBC) at beginning of and throughout
therapy.
Obtain a history before initiating therapy to determine previous use and reactions to penicillins or cephalosporins. Persons with
a negative history of penicillin sensitivity may still have an allergic response.
Obtain specimens for culture and sensitivity before therapy. First dose may be given before receiving results.
233
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and
notify the physician or other health care professional immediately if these occur. Keep epinephrine, an antihistamine, and
resuscitation equipment close by in the event of an anaphylactic reaction.
During:
After:
Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus.
Advise patient not to treat diarrhea without consulting health care professional. May occur up to several weeks after
discontinuation of medication.
Instruct the patient to notify health care professional if symptoms do not improve.
234
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
Brand Name:
Date ordered:
Type of insulin:
Mixtard30 was given to Hyperglycemic events
Mixtard 30 HM
11-03-13
Premixed Insulin
control
70% Isophane
level of the patient. there were still various
the
glucose were managed however
Date given:
40 units AM
30% Regular
Since during the CBC alterations
11-03-13
22 units PM
Onset: 30 minutes
monitoring
to
SQ
Peak: 2-8 hours
persistently
Duration:18 hours
level of blood glucose . glucose
This drug is also his proper
11-05-13
there
in
the
is patients CBG results
increase indicating high blood

however
orders
and
Diabetes is a disease in maintenance Insulin at dosing of the type of

which the body does home.
insulin (Mixtard 30 or
235
not
produce
enough
Humulin R) to be given
insulin to control the
were made to manage
blood
such.
glucose.
Mixtardis
replacement
insulin
Date changed:
Hold
mixtard which is identical to the Mixtard
(Date Held)
temporarily
11-05-13
while patient is pancreas. The active because

on NPO.
hold The patients glucose
was
insulin made by the during NPO because level went down to 97

the
glucose mg/dL, thus the doctor
substance in Mixtard, level of the patient change his IVF from

insulin human (rDNA), went
is
produced
method
by
known
down
a mg/dL.
to
97 PNSS
to
D5LRS
80cc/hr while pt. is on
as
NPO the CBG of the
recombinant
patient went up to 286
technology: the insulin
mg/dL.
is made by a yeast that

( frequency):
20 units now
has received a gene Mixtard
11-06-13
20 units AM
(DNA), which makes it decreased to 20 units level went up to 287
11:06 am
20 units PM
able
to
insulin. The
replacement
produce because
level
30s The patients glucose
the
glucose mg/dL and after giving
results
of the the dose patient glucose
insulin patient is high (287 level
goes
slightly
236
acts in same way as mg/dL) and the patient down (264 mg/dL) with
naturally
insulin
produced is
and
on
insulin
drip the help also of the
helps already. A stat 20 units Insulin Drip.
glucose enter cells from mixtard was given to

the blood.
the
pt.
because
his
CBG result at this time

was 287 mg/dL. The
dose was decrease to
20 units in AM and PM
because the pt. was on
insulin drip already
(Date held)
Hold
11-06-13
temporarily
5:00 pm
mixtard
Mixtard
was
during
hold The patients glucose

the level
administration
becomes
331
of mg/dL after 1 hour.
D5050 1 vial + HR 10
units HR post meal
because
level
the
glucose
results
of the
patient is slightly high
237
(194 mg/dL).
Date resumed:
20 units AM
Mixtard30 was given to The patients glucose
11-07-13
20 units PM
control
the
glucose level of the patient was
level of the patient managed (165mg/dL @

(226mg/dL @ 6am).
9am).
( frequency):
Mixtard
Date ordered:
increased to 22 units at level went up to 181
11-08-13
PM
(7:50pm)
glucose level results of the dose patient glucose
dose
because
was The patients glucose
the mg/dL and after giving
the patient is slightly level
goes
slightly
Date given:
44 unit 8AM
high (181 mg/dL) and down
(113
mg/dL).
11-08-13 to
22 units 8PM
activity of patient is Thus,
the
patient
11-12-13
much lesser at night. glucose
level
was
And also 44 units at pm managed.

because utilization of
glucose much greater at
morning
and
consumption of food.
238
(frequency):
Date ordered:
11-12-13
Mixtard
(9:00am)
increased
dose
was The
as
to level
patient
glucose
increased
Date given:
48 units AM
maintain the glucose 267mg/dL
11-12-13
24 units PM
level of the pt. to near which made the doctor

the normal levels.
to
12nn
ordered for mixtard stat

dose.
Date ordered:
11-12-13
(1:20pm)
6 units STAT
Another
units
mixtard
was
of The
given level
Date given:
because the HGT result from
11-12-13
of
the
pt.
patient
glucose
was
managed
267mg/dL
was 12nn to 144mg/dL @
267mg/dL.
6pm.
Date ordered:
11-14-13
The CBG results of the The
(7:00pm)
50 units AM
pt.
Date given:
25 units PM
increased so the dose of
11-14-13
is
patient
glucose
persistently level was managed.
Mixtard was increased.
239
Prior:
Prepare the equipments required.
Ensure prescription is complete, correct, legible and unambiguous prior to administration.
Check the name of the insulin and dose against the insulin prescription chart in the patients record.
Confirm the identity of the patient prior to administering the insulin.
Check the insulin has not already been administered by someone else.
Wash hands and put on gloves.
Check the blood glucose level according to institutions guideline on blood glucose monitoring and record the result prior to
administering the insulin.
Check correct storage of insulin.
Check expiry date.
During:
Prepare the insulin syringe or pen device.
Select injection site - remember to rotate injection sites, never use the same site for consecutive injections.
Insulin should be injected into subcutaneous tissue or soft fat, not muscle. To avoid intramuscular injection, evidence suggests
that raising the skin is best practice and, in some cases, use of a smaller needle will be recommended by the specialist clinician.
Continue to raise the skin and hold the insulin syringe in place for a count of 10 to ensure that the insulin disperses from the
site of the injection.
240
Remove the needle and insulin syringe and dispose as per safe disposal of sharps.
After:
Record the dose, timing and site of insulin injection on the chart.
Report to a supervisor if the patient bleeds from an injection site, insulin appears at the site of an injection or the patient
complains that the injection is painful. If this is the case injection technique may need reassessment.
241
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
Brand Name:
Date ordered:
Type of insulin:
Humulin R was given Hyperglycemic events
Humulin R
11-05-13
Neutral
for the treatment of were managed however
(regular or soluble)
hyperglycemia thus, by there were still various
SHORT ACTING
controlling the blood alterations
Onset: 30 minutes
glucose, the symptoms patients CBG results
Peak: 1-3 hours
and complications of indicating high blood
Duration: 8 hours
diabetes are reduced.
glucose
proper
in
the
however
orders
and
Humulin R is a fast- It was given to the dosing of the type of

acting
form
hormone
of
the patient
insulin.
to
It decrease the patients Humulin R) to be given
works by helping your fluctuating

body
to
use
rapidly insulin (Mixtard 30 or
sugar glucose level.
high were made to manage

such.
properly. This lowers
242
the amount of glucose

in the blood, which
helps to treat diabetes.
Date given:
11-05-13
8 units SQ stat
Patients
HGT
level The
patient
was 286mg/dL so the level
increased
doctor order 8 u of 335mg/dL
(6:00pm)
HR stat SQ.
glucose
to
8pm
which made the doctor

ordered for HR IV stat
dose @ 9:10pm).
(9:10pm)
10 units IV stat
Patients
HGT
level The patients glucose
becomes
237
doctor order 10 u of mg/dL after 3 hour.

HR stat IV.
11-06-13
12 units IV stat
Patients
HGT
(12:00nn)
12 units SQ stat
went
doctor order 12 u of 264mg/dL
up
and
to
after
HR stat IV and 12 u giving the dose patient

of HR stat SQ.
glucose
down
level
(199
goes
mg/dL).
243
Thus,
the
glucose
patient
level
was
managed.
11-08-13
3 units SQ stat
(3:15 pm)
Patients
HGT
was 200mg/dL so the level slightly goes up

doctor order 3 u of (213 mg/dL) after 2
HR stat SQ.
Patients
(5:20pm)
8 units SQ stat
HGT
hours.
was 213mg/dL so the level goes down (152

doctor order 8 u of mg/dL) after 2 hours.
HR stat SQ.
11-09-13
(12:52 pm)
5 units SQ stat
Patients
HGT
level The
patient
glucose
was 207mg/dL so the level slightly increased

doctor order 5 u of to 216mg/dL @ 4pm
HR stat SQ.

ordered for additional
HR SQ stat order.
244
(5:20 pm)
6 units SQ stat
Patients
HGT
was 216mg/dL so the level was manage (187

doctor order 6 u of mg/dL) after 4 hours.
HR stat SQ.
11-10-13
6 units IV stat
Patients
HGT
level The
(12:40 pm)
6 units SQ stat
was 223mg/dL so the level slightly decreased
patient
glucose
doctor order 6 u of to 221mg/dL @ 6pm

HR stat IV and 6 u of which made the doctor
HR stat SQ.

HR SQ stat order.
(6:12 pm)
5 units SQ stat
Patients
HGT
level The
doctor
ordered
was 221mg/dL so the decreased
HGT
doctor order 5 u of monitoring to q 6 in

HR stat SQ.
which
the
patients
glucose level
shows
results
increased
230mg/dL
to
12mn
245

HR SQ stat order.
11-11-13
3 units SQ stat
(12:30 am)
Patients
HGT
level The
patient
glucose
was
managed
doctor order 3 u of (189mg/dL)

HR stat SQ.
(12:30 pm)
HGT
after
hours.
6 units SQ stat
Patients
level The
6 units IV stat
was 290mg/dL so the level slightly decreased
patient
glucose
doctor order 6 u of to 272mg/dL after 6

HR stat IV and 6 u of hours which made the
HR stat SQ.
doctor
ordered
for
additional HR SQ stat
order.
(6:43 pm)
5 units SQ stat
Patients
HGT
was 272mg/dL so the level went up to 272

doctor order 5 u of mg/dL and after giving
246
HR stat SQ.
the dose patient glucose

level goes down (130
mg/dL) with the help
also of Mixtard.
Prior:
Check the name of the insulin and dose against the insulin prescription chart in the patients record.
Confirm the identity of the patient prior to administering the insulin.
Check the insulin has not already been administered by someone else.
Wash hands and put on gloves.
Check the blood glucose level according to institutions guideline on blood glucose monitoring and record the result prior to
administering the insulin.
Check correct storage of insulin.
Check expiry date.
247
During:
Prepare the insulin syringe or pen device.
Select injection site - remember to rotate injection sites, never use the same site for consecutive injections.
Insulin should be injected into subcutaneous tissue or soft fat, not muscle. To avoid intramuscular injection, evidence suggests
that raising the skin is best practice and, in some cases, use of a smaller needle will be recommended by the specialist clinician.
Continue to raise the skin and hold the insulin syringe in place for a count of 10 to ensure that the insulin disperses from the
site of the injection.
Remove the needle and insulin syringe and dispose as per safe disposal of sharps.
After:
Record the dose, timing and site of insulin injection on the chart.
Report to a supervisor if the patient bleeds from an injection site, insulin appears at the site of an injection or the patient
complains that the injection is painful. If this is the case injection technique may need reassessment
248
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
was Patients pain on the
Tramadol
Date ordered:
Generic Name:
11-03-13
100
Tramadol
Date given:
mg
very General Action:
prescribed
for
the operative
slow IV q6O x analgesic
treatment
of
the relieved on November
11-05-13
2 days then shit Functional
patients pain on the 5-7,
Brand Name:
to
to Algesia
Classification:
operative
Ultram
11-07-13
Centrally-acting
experienced
analgesic
respiration
movement.
Binds
during noted
500mg IV stat
was
2013.
site complaints
and
No
of
pain
did
not
and experience any adverse

reactions of the drug.
u-opioid
receptors and inhibits Patient complained of Patient
Date ordered:
11-11-13
to
site
reuptake of serotonin pain on the operative from
was
pain
relived
on
the
(4:30am)
and norepinephrine in site
operative site and did
Date given:
the CNS.
not complain of such in
11-11-13
the following days.
249
IV
was Patients
pain
was
Brand Name:
Date ordered:
1 tab QID x 3
Tramadol
Algesia
11-03-13
days then PRN
shifted to algesia an managed as evidence
for pain
oral form of analgesic by the patient was able
Date given:
to control pain felt of to move slightly, no
11-06-13
the pt. in the CTT site.
guarding
reflex
and
grimace noted.
Date stopped:
Algesia
11-08-13
discontinued on Nov 8
and
was
was
shifted
to
tramadol retard because

it was given already for
3 days and no adverse
reactions of the drug
noted.
Brand Name:
Date ordered:
Tramal Retard
11-08-13
100 mg tab TID
Tramadol
was Patients pain was been
prescribed to replace managed as evidence

algesia for continuous by the patient was able
250
treatment
and to move slightly, no
Date given:
management
of
the guarding
11-08-13
patients pain on the grimace
reflex
noted
and
with
operative site that is pain scale from 7/10 to

brought about by an 3/10.
inflammation due to the
break in the skin.
Date ordered:
The doctor ordered stat The patients pain was
11-09-13
Tramal because the pt. been managed and able
(12:00 mn)
complained of pain in to sleep.

incision site.
Prior:
Assess type, location, and intensity of pain before and 23 hr (peak) after administration.
Assess blood pressure and respiratory rate before and periodically during administration. Respiratory depression has not
occurred with recommended doses.
251
Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and
with laxatives to minimize constipating effects.
Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously
received opioids for more than 1 wk; may cause opioid withdrawal symptoms.
Prolonged use may lead to physical and psychological dependence and tolerance, although these may be milder than with
opioids. This should not prevent patient from receiving adequate analgesia. Most patients who receive tramadol for pain do not
develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve
pain.Monitor patient for seizures. May occur within recommended dose range. Risk is increased with higher doses and in
patients taking antidepressants (SSRIs, SNRIs, tricyclics, or MAO inhibitors), opioid analgesics, or other drugs that decrease
the seizure threshold. Also monitor for serotonin syndrome (mental-status changes (e.g, agitation, hallucinations, coma),
autonomic instability (e.g, tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g, hyperreflexia,
incoordination) and/or gastrointestinal symptoms (e.g, nausea, vomiting, diarrhea) in patients taking these drugs concurrently.
Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse some, but not all, of the symptoms
of overdose. Treatment should be symptomatic and supportive. Maintain adequate respiratory exchange. Hemodialysis is not
helpful because it removes only a small portion of administered dose. Seizures may be managed with barbiturates or
benzodiazepines; naloxone increases risk of seizures.
During:
Do not confuse tramadol with Toradol (ketorolac).
Tramadol is considered to provide more analgesia than codeine 60 mg but less than combined aspirin 650 mg/codeine 60 mg
for acute postoperative pain
252
Explain therapeutic value of medication before administration to enhance the analgesic effect. Regularly administered doses
may be more effective than prn administration. Analgesic is more effective if given before pain becomes severe.
Tramadol should be discontinued gradually after long-term use to prevent withdrawal symptoms.
After:
Instruct patient on how and when to ask for pain medication
May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to
medication is known.
Advise patient to change positions slowly to minimize orthostatic hypotension.
Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication. Advise patient to notify
health care professional before taking other RX, OTC, or herbal products concurrently.
Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.
253
Date ordered
Route of
General action,
Indication
Client response to
Name of the drug
Date given
administration,
functional
Initial Reaction
Generic Name
Date changed
dosage and
classification,
Purpose
side effect
Brand Name
Date stopped
frequency of
mechanism of action
administration
Generic Name:
Date ordered:
50 mg IV q 8 x General Action:
Ketesse was given in Patients pain was been
Dexketoprofen
11-03-13
2 days
support of the tramadol managed as evidence
Analgesic, antipyretic
trometamol
Brand Name:
in
treatment
of the by the patient was able
Date given:
Functional
patients pain on the to move slightly, no
11-05-13
Classification:
operative site that is guarding
reflex
NSAID
brought about by an grimace
noted
Ketesse
inflammation
Date stopped:
11-07-13
The
mechanism
irritation
of
and
with
and pain scale from 7/10 to

nerve 3/10.
of ending due to the break
action of NSAIDs is in the skin.

related to the reduction
of
synthesis
inhibition
prostaglandin
by
the
of
254
cyclooxygenase
pathway. Specifically,
there is an inhibition of
the transformation of
arachidonic acid into
cyclic
endoperoxides,
PGG2
and
PGH2,
which
produce
prostaglandins
PGE1,
PGE2,
PGF2
and
PGD2
and
also
prostacyclin PGI2 and

thromboxanes
(TxA2
and
TxB2).
Furthermore,
inhibition
the
of
synthesis
the
of
prostaglandins
could
affect
other
inflammation mediators
255
eg, kinins, causing an

indirect action which
would be additional to
the direct action.
Prior:
Assess type, location, and intensity of pain before and 23 hr (peak) after administration.
Assess blood pressure and respiratory rate before and periodically during administration. Respiratory depression has not
occurred with recommended doses.
Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and
with laxatives to minimize constipating effects.
Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously
received opioids for more than 1 wk; may cause opioid withdrawal symptoms.
Prolonged use may lead to physical and psychological dependence and tolerance, although these may be milder than with
opioids. This should not prevent patient from receiving adequate analgesia. Most patients who receive tramadol for pain do not
develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve
pain.Monitor patient for seizures. May occur within recommended dose range. Risk is increased with higher doses and in
patients taking antidepressants (SSRIs, SNRIs, tricyclics, or MAO inhibitors), opioid analgesics, or other drugs that decrease
the seizure threshold. Also monitor for serotonin syndrome (mental-status changes (e.g, agitation, hallucinations, coma),
256
autonomic instability (e.g, tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g, hyperreflexia,
incoordination) and/or gastrointestinal symptoms (e.g, nausea, vomiting, diarrhea) in patients taking these drugs concurrently.
Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse some, but not all, of the symptoms
of overdose. Treatment should be symptomatic and supportive. Maintain adequate respiratory exchange. Hemodialysis is not
helpful because it removes only a small portion of administered dose. Seizures may be managed with barbiturates or
benzodiazepines; naloxone increases risk of seizures.
During:
Do not confuse tramadol with Toradol (ketorolac).
Tramadol is considered to provide more analgesia than codeine 60 mg but less than combined aspirin 650 mg/codeine 60 mg
for acute postoperative pain
Explain therapeutic value of medication before administration to enhance the analgesic effect. Regularly administered doses
may be more effective than prn administration. Analgesic is more effective if given before pain becomes severe.
Tramadol should be discontinued gradually after long-term use to prevent withdrawal symptoms.
After:
Instruct patient on how and when to ask for pain medication
May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to
medication is known.
Advise patient to change positions slowly to minimize orthostatic hypotension.
Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication. Advise patient to notify
health care professional before taking other RX, OTC, or herbal products concurrently.
Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.
257
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
General Action:
Aeknil was prescribed The patient decreased
Non-narcotic
because
analgesic, Antipyretic
episodes of fever with a 37.1C after 2 hours.
Date given:
Functional
Tempearature of 38.0C
11-06-13
Classification:
Generic Name:
Date ordered:
Paracetamol,
11-06-13
300 mg IV NOW
Acetaminophen
Brand Name:
Aeknil
pt.
had temp from 38.0C to
Analgesic, Anti-pyretic
11-07-13
May give Aeknil Mechanism of action:
This
(3:40 pm)
300mg IV Now Decreases fever by
because the patient had temp from 38.2C to
then q 4 for T inhibiting the effects of
episodes of fever with 36.4C after 2 hours.
38C
Temp of 38.2C. This
and pyrogens on the
was
also
ordered The patient decreased
Paracetamol 1 tab hypothalamus heat
was
given
to
q 4 for 37.5C
regulating centers & by
control pt temp not to
a hypothalamic action
shoot up to high levels.
258
leading to sweating &

vasodilatation. Relieves
pain by inhibiting
prostaglandin synthesis
at the CNS but does not
have anti-inflammatory
action because of its
minimal effect on
peripheral
prostaglandin
synthesis.
Brand Name:
Date ordered:
Biogesic
11-08-13
500 mg tab QID
Paracetamol
was Patients pain was been
prescribed to replace managed as evidence

algesia
and
support by the patient was able
Date given:
with Tramal Retard for to move slightly, no
11-08-13
continuation treatment guarding
reflex
and
of the patients pain on grimace noted.

the operative site that is
brought about by an
259
inflammation due to the

break
in
the
skin.
Paracetamol and tramal

was
combined
for
faster onset and longer

duration of Aeknil
Date ordered:
50mg tab NOW
The doctor ordered stat Patients pain was been
11-10-13
Biogesic because pt. managed for the whole
(4:30am)
complained of pain on day as evidence by the

incision site.
patient was able to

move
guarding
slightly,
no
reflex
and
grimace noted. Patient

was able to sleep well
also.
Prior:
Assess patients fever or pain: type of pain, location, intensity, duration, temperature, and diaphoresis.
260
Use cautiously to patients with fluid or electrolyte imbalance

Instruct the patient and SO regarding the action and side effects of the medication
During:
Monitor CBC, liver and renal functions.
Assess for fecal occult blood and nephritis.
Avoid using OTC drugs with Acetaminophen.
Take with food or milk to minimize GI upset.
Report N&V. cyanosis, shortness of breath and abdominal pain as these are signs of toxicity.
Report paleness, weakness and heart beat skips
Report abdominal pain, jaundice, dark urine, itchiness or clay-colored stools.
Report pain that persists for more than 3-5 days
Avoid alcohol.
This drug is not for regular use with any form of liver disease.
Give with food or milk if GI upset occurs
Establish safety precautions if CNS effects occur, protect patient from sun or bright lights if photophobia occurs
Monitor serum electrolytes and acid-base balance during course of drug therapy
261
After:
Assess allergic reactions: rash, urticaria; if these occur, drug may have to be discontinued.
Teach patient to recognize signs of chronic overdose: bleeding, bruising, malaise, fever, sore throat.
Advise patient or SO to take drug with meals if GI upset occurs
Arrange to have intraocular pressure checked periodically
Advise patient and SO that she may experience these side effects: dizziness, drowsiness, sensitivity to sunlight (use protective
sunglasses), GI upset
Instruct SO to report weight change for more than 3 pounds in 1 day, dizziness, fatigue, trembling
262
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
Generic Name:
Date ordered:
40 mg Tablet General Action:
Pantoprazole
11-05-13
OD x 3 days
sodium
Brand Name:
Pantoloc was given to The patient completed
Suppress gastric acid the patient to prevent the full course of the
production
the
Date given:
Functional
stomach
11-05-13
Classification:
stomach
Proton-pump inhibitor
associated with NSAID stomach
Pantoloc
of drug
ulcers
and
or manifest
pain symptom
did
not
signs
and
of
having
ulcers,
no
and because patient is complains of stomach
Date stopped:
11-07-13
occurrence
still on NPO the doctor pain,
Pantoprazole is a
ordered IV Antacid.
nausea
and
vomiting.
proton pump inhibitor

(PPI) that suppresses
the final step in gastric
acid production by
covalently binding to
263
the (H+, K+)-ATPase

enzyme system at the
secretory surface of the
gastric parietal cell.
This effect leads to
inhibition of both basal
and stimulated gastric
acid secretion,
irrespective of the
stimulus. The binding
to the (H+, K+)ATPase results in a
duration of
antisecretory effect that
persists longer than 24
hours
PRIOR:
Note reasons for therapy, onset, duration, triggers, characteristics of S&S.
264
DURING:
Assess for GI upset.
AFTER:
Advise patient or SO that drug may take with or without meal.
Instruct pt to avoid alcohol, aspirin or NSAIDs and foods that may cause GI irritation.
Instruct pt to report symptoms of liver damage (such as yellow skin or eyes, abdominal pain, dark urine, clay-coloured stools,
loss of appetite)
265
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
Generic Name:
Date ordered:
Furosemide
11-06-13
Brand Name:
Date given:
Lasix
11-06-13
20mg IV stat
Furosemide was given The patient pts I&O is
General Action:
Rapid-acting
potent to the patient because still not balance as
sulfonamide,
his output was 60cc evidenced by I and O
antihypertensive
against input of 320cc of 868/80 at the end of

and
(9:30am)
BP
of
Functional
mmHg.
Classification:
also
Loop diuretic
lower extremities.
The doctor ordered to The patient I&O was
( dose):
Furosemide is a potent
increased
11-06-13
diuretic (water pill) that Furosemide to 40mg BP of 130/70mmHg.
(4:45pm)
is used to eliminate
because pts I and O
water and salt from the
was 868/80 cc and BP
Date changed:
40mg IV stat
has
The
140/70 the shift (6-2) and a BP

patient of was 130/70mmHg.
edema
dose
on .
of still not balance and a
266
body. In the kidneys,
of 140/70 mmHg . The
salt (composed of
pt. also has edema on
sodium and chloride),
lower extremities.
water, and other small

11-07-13
was The patient pts I&O is
40mg IV now molecules normally are
Furosemide
then q 8
filtered out of the blood
increased dose of 40mg still abnormal and a BP
and into the tubules of
because pts I and O of 140/70mmHg.
the kidney. The filtered
was 3200/880 cc and
fluid ultimately
BP of 140/80mmHg.
becomes urine. Most of

( frequency):
40mg IV q 12
11-09-13
was The patient pts output
the sodium, chloride
Furosemide
and water that is
decrease
filtered out of the blood
because
Input
is reabsorbed into the
output
is
blood before the
(2030/2000) and BP of @ Nov. 10) and BP
filtered fluid becomes
130/80mmHg).
frequency improves as evidenced
urine and is eliminated
and by the patient I and O

normal are balance (2640/2620
remained
at
130/80mmHg).
from the body.

40mg IV q 24
11-12-13
Furosemide works by
Furosemide
blocking the absorption
decreased
was Thoracostomy drain is

frequency added on the total
267
of sodium, chloride,
because
Input
and output which made
and water from the
output
is
normal increased in the output
filtered fluid in the
(2310/3780).
level of the patient. No
kidney tubules, causing
signs and symptoms of
a profound increase in
dehydration was noted
the output of urine
to the patient.
(diuresis). The onset of

action after oral
administration is within
one hour, and the
diuresis lasts about 6-8
hours. The diuretic
effect of furosemide
can cause depletion of
sodium, chloride, body
water and other
minerals.
PRIOR:
Assess for renal impairment or if receiving other ototoxic drugs, observe for ototoxicity
268
With history of gout, monitor uric acid levels. Monitor BP, weight, edema, breath sounds, I&O and electrolytes; observe for
S&Sx of hypokalemia.
With rapid diuresis, observe for dehydration and circulatory collapse; monitor pulse rate.
With chronic use, assess for thiamine deficiency; if used with zaroxlyn, assess for low phosphate levels.
DURING:
Assess closely for signs of vascular thrombosis and embolism, particularly in the elderly.
AFTER:
Advise patient or SO change positions from lying to standing slowly
Instruct pt to immediately report any muscle weakness/cramps, dizziness, ringing in the ears, sore throat, fever, severe
abdominal pain, numbness, or tingling.
Instruct pt to avoid alcohol and dont exercise heavily in hot weather
Monitor weights; report any gains of > 2 lbs. per day or > 10 lbs. per week. Supplement diet with vegetables and fruits that re
high in potassium (bananas, oranges, peaches, dried dates).
269
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
Generic Name:
Date ordered:
Calcium Gluconate 11-07-13
1 vial stat
General Action:
Calcium
Replacement solution
the
antagonizes The patients potassium

effects
hyperkalemia
in
Brand Name:
Date given:
Functional
cellular
Kalcinate
11-07-13
Classification:
lower
(10:45am)
Fluid and electrolytic potassium level.

and
Date stopped:
water
level,
the
of level decreased from

the 6.03 to 5.16 with the
thus, help of Temporization
patients (D5050 + insulin).
balance
agent
11-07-13
Soluble calcium is
predominantly
absorbed from the
small intestine by
270
active transport and

passive diffusion.
Small intestines by
active transport and
passive diffusion.
PRIOR:
DURING:
Assess for cutaneous burning sensations and peripheral vasodilation, with moderate fall in BP, during direct IV injection.
Monitor ECG during IV administration to detect evidence of hypercalcemia: decreased QT interval associated with inverted T
wave.
Observe IV site closely. Extravasation may result in tissue irritation and necrosis.
Monitor for hypocalcemia and hypercalcemia.
271
AFTER:
Lab tests: Determine levels of calcium and phosphorus (tend to vary inversely) and magnesium frequently, during sustained
therapy. Deficiencies in other ions, particularly magnesium, frequently coexist with calcium ion depletion.
Instruct pt to report S&S of hypercalcemia promptly to your care provider.
Encourage to take milk and milk products are the best sources of calcium (and phosphorus). Other good sources include dark
green vegetables, soy beans, tofu, and canned fish with bones. Calcium absorption can be inhibited by zinc-rich foods: nuts,
seeds, sprouts, legumes, soy products (tofu).
272
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
General Action:
Generic Name:
Date ordered:
2 suppositories Expands intestinal fluid Ducolax
Bisacodyl
11-07-13
anus now
was
given The patient had no
volume by increasing
because patient had no bowel movement after
epithelial permeability
bowel movement for 5 the administration of

days.
the drug, which makes
Brand Name:
Date given:
Dulcolax
11-07-13
Functional
the doctor ordered for
(1:00pm)
Classification:
Lactulose.
Stimulate laxative
11-11-13
suppositories
Drug
is
given
to The patient was able to
improve
Bisacodyl acts mainly
bowel movement. The 12.
in the large intestine by
pt. still complained of
Date stopped:
increasng its motility to
problems with BM so
11-11-13
effect bowel
the doctor ordered stat
evacuation.
suppository.
anus now
patients defecate well at Nov.
273
PRIOR:
Instruct patient to have deep breathing exercise before administration to relax bowel.
DURING:
Provide privacy while giving the drug.
Instruct patient to hold the drug.
Use aseptic technique in administration of the drug.
AFTER:
Evaluate periodically patients need for continued use of drug; bisacodyl usually produces 1 or 2 soft formed stools daily.
Monitor patients receiving concomitant anticoagulants. Indiscriminate use of laxatives results in decreased absorption of
vitamin K.
Add high-fiber foods slowly to regular diet to avoid gas and diarrhea. Adequate fluid intake includes at least 68 glasses/d.
274
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
Generic Name:
Date ordered:
Lactulose
11-07-13
5 ml OD @ HS
General Action:
Lactulose was given to The patient was able to
Reduces blood
the patient to facilitate have bowel movement
ammonia; appears to
Bowel movement with and
defecate
Brand Name:
Date given:
involve metabolism of
the coordination with without straining.
Cephulac
11-08-13
lactose to organic acids
Dulcolax, Also to avoid
by resident intestinal
straining that can cause
bacteria
pain on incision site.
well
Date stopped:
11-12-13
Functional
(9am)
Classification:
Hyperosmotic laxative
Lactulose promotes
275
peristalsis by producing
an osmotic effect in the
colon with resultant
distention. In hepatic
encephalopathy, it
reduces absorption of
ammonium ions and
toxic nitrogenous
compounds, resulting
in reduced blood
ammonia
concentrations.
Prior:
Assess patients fever or pain: type of pain, location, intensity, duration, temperature, and diaphoresis.
Mix with half a glass of water, milk or fruit juice to improve taste.
276
During:
Encourage pt increase fluid intake (>=15002000 mL/d) during drug therapy for constipation; older adults often self-limit
liquids. Lactulose-induced osmotic changes in the bowel support intestinal water loss and potential hypernatremia.
After:
Laxative action is not instituted until drug reaches the colon; therefore, about 2448 h is needed.
Do not self-medicate with another laxative due to slow onset of drug action.
Notify physician if diarrhea (i.e., more than 2 or 3 soft stools/d) persists more than 2448 h. Diarrhea is a sign of overdosage.
Dose adjustment may be indicated.
May take up to 48 hours to act.
Diarrhea may indicate the dose is too high.
Evaluate therapeutic response: decreased constipation or blood ammonia level.
Assess amount, colour and consistency of stool.
277
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
General Action:
To helps in slow down
The patient was able to
Medical nutritional
the progression of
take the formula and no
supplement
chronic kidney disease
adverse
(CKD) by giving
noted.
administration
Generic Name:
Date ordered:
Neprocan
11-08-13
Brand Name:
Date given:
Nepro
11-08-13
1 can TID
Functional
complete renal
Classification:
nutrition. A fat blend
Enteral
effects
are
Nutritional rich in
formula
monounsaturated fatty
acids and omega-3 fatty
acids while CarbSteady
The protein content is
is a carbohydrate blend
adequate to replace
that helps manage
protein and amino and
blood glucose
prevent catabolism of
responseo; and kidney-
278
tissue proteins. The
friendly levels of
high quality protein
phosphorus, potassium
meets or surpasses the
and sodium appropriate
standard amino acid
for those with CKD.
profile for protein of

high biological value.
Gluten-free, Calcium,
magnesium and sodium
caseinates, milk protein
and the fat blend is
combination meets the
American Heart
Association
recommendations of
<10% of calories from
both saturated and
polyunsaturated fatty
acids.
279
Generic Name:
Date ordered:
55 mg in 210
Neprocan was changed
The patient was able to
Nutren DM
11-11-13
ml water
to Nutren DM because
take the formulas and
the pt. does not want
no adverse effects are
the taste of Neprocan .
noted.
Brand Name:
Date given:
Nutren DM
11-11-13
Prior:
If you are taking any of these enteral nutrition formulas without a prescription, carefully read and follow any precautions on
the label.
During:
Instruct patient to report GI upset (such as constipation, nausea and vomiting and diarrhea).
280
After:
Notify physician if diarrhea (i.e., more than 2 or 3 soft stools/d) persists more than 2448 h. Diarrhea is a sign of overdosage.
Dose adjustment may be indicated.
Diarrhea may indicate the dose is too high.
Assess amount, colour and consistency of stool.
Store away from heat and direct sunlight
Enteral feedings must be handled properly to protect them from bacteria.
281
Name of the drug
Date ordered
Route of
General action,
Indication
Client response to
Generic Name
Date given
administration,
functional
Initial Reaction
Brand Name
Date changed
dosage and
classification,
Purpose
side effect
Date stopped
frequency of
mechanism of action
administration
Generic Name:
Date ordered:
Linagliptin
11-11-13
Brand Name:
Date given:
Trajenta
11-11-13
5 mg Tab OD
General Action:
Linagliptin is given to
The
patient
blood
Improves glycemic
reduces blood sugar
glucose remains high
control
(glucose) levels in
(290mg/dL @ 12:30
patients. Patient blood
pm), which made the
Functional
glucose of 230mg/dL
doctor give stat order
Classification:
@ 12:30am)
of HR.
Antidiabetic Agent
Date stopped:
Untill
Discharge
Linagliptin belongs to
the group of diabetes
medications
called DPP-4
inhibitors. It works by
282
increasing the amount

of incretin released by
the intestine. Incretin is
a hormone that raises
insulin levels when
blood sugar is high
(especially after a
meal) and decreases the
amount of sugar made
by the body.
Prior:
Check the blood glucose level
During:
Instruct patient to report side effects of the drug (stuffy or runny nose, sore throat, cough and diarrhea).
After:
Instruct pt do not drug if the pt is allergic to linagliptin or any ingredients of this medication, have ketoacidosis (a complication
of diabetes associated with high blood sugar, weight loss, nausea or vomiting)
283
c. Diet
Type of Diet
Date
Ordered
Date Started
Date
Changed
General
Description
NPO
[Nothing per
orem]
This kind of diet

Date
includes nothing by
Ordered:
November 4, mouth meaning the
2013
patient is ordered not
to take any kind of
food or liquid.
Date
Started:
November 5,
2013
NPO status was ordered

because the pt. was
scheduled to undergo
lobectomy on Nov. 5
Special Food Taken
NONE
Client Response
The patient together

with the S.O.
complied with the
prescribed diet but
complained of
moderate hunger.
The pt. underwent
the surgery and no
complication were
noted.
Date
Changed:
November 5,
2013
Nursing responsibilities:
Before
Review the doctors order carefully. Note if special food are to be taken by the patient.
284
Collaborate with Dietary Services if possible.

Identify the patient by asking his name. Identify oneself to allow for a good working relationship.
Explain the importance (to prevent aspiration) of the diet to the significant other.
During
Assess the general condition of the patient.
Review recorded vital signs.
Do not allow client to take any food or fluid.
Perform needed interventions as with dyspnea.
After
Document the time when the diet was started.
Educate SO regarding the signs of dyspnea (difficulty of breathing, increased respirations, stuttering, restlessness, increased
heart rate).
Do not allow client to feed if such occurs.
285
TYPE OF
DIET
DATE
ORDERED,
DATE
STARTED,
DATE
CHANGED
GENERAL
DESCRIPTION
INDICATIONS OR
PURPOSES
SPECIFIC
FOODS TAKEN
CLIENTS RESPONSE
AND/OR REACTION TO
DIET
This diet incorporates

Soft diet
D/O:
foods that are
Designed for the
Fruit drinks, fruit
Client easily tolerated the
November 5,
moderately low in
patient who cannot
like banana and
ordered diet and was relieved
2013
fiber, have a soft
tolerate
apple, rice
with the moderate hunger he
texture and are
general diet.
porridge, soup
was complaining. No signs of
D/S:
moderately seasons.
November 5,
varies from smooth,
A transition diet for
2013
creamy foods to foods
pt. who was been on
that are slightly
NPO status.
D/C:
crispy. A diet which
November 8,
contains easy to
2013
swallow and digest
aspiration was also noted.
foods
286
NURSING RESPONSIBILITIES:
BEFORE THE PROCEDURE:

Introduce self and verify clients identity
Explain the purpose and benefits of Soft diet intake
Explain the reason for compliance for soft diet
Set goals that will make soft diet more tolerable
DURING THE PROCEDURE:

Identify what kinds of soft diet is provided
Explain to the significant others the reason including the health precaution for the diet given
Assess clients reaction
Monitor if the patient complies with the diet given
Monitor intake and output
AFTER THE PROCEDURE:

Document findings in the client record
Encourage clients SO when possible to participate in complying with soft diet
Instruct to give soft diet only
Assess clients reaction
287
Type of Diet
Date Ordered
Date Started
Date Changed
DM Diet
D/O:
November 5, 2013
General
Description
Specific Foods
Taken
A diet designed to Indicated for clients Malunggay,

control
symptoms
D/S:
Indication(s)
Or Purpose(s)
the with
of mellitus
diabetes
November 5, 2013
diabetes ampalaya,
Clients Response
and/or Reaction to
the Diet
The
client
lean tolerated
has
solid
meat, fruits, non fat foods and complied

milk
with
the
diet
prescribed.
D/S:
November 8, 2013
NURSING RESPONSIBILITIES
Prior:
Check the doctors order to know the type of diet preferred.
Explain the diet to the pt.s SO
Inform the patient and S.O. of the foods that she is allowed to eat.
Explain the purpose of the diet.
288
During:
Advise SO to note that the pt.s diet can change depending on her tolerance
Check the food that the patient is about to eat.
Implement aspiration precaution
Instruct the patient not to eat while lying to prevent aspiration.
Assist the patient in eating as necessary
After:
Assess for bowel movement
Evaluate pt.s reaction to the diet
Check if the pt. complied to the diet
Monitor the patient closely for the compliance of the diet.
Proper documentation.
289
d. Exercise
TYPES OF
EXERCISE
DATE ORDERED,
DATE
PERFORMED,
DATE CHANGED
Bed rest
D/O:
November 5, 2013
D/P:
November 5, 2013
GENERAL
DESCRIPTION
INDICATION OR
PURPOSE(S)
Restriction of a patient's To decrease O2 consumption

activities, either partially thus, decrease the workload of
or completely.
the heart because patient
undergone surgical operation.
CLIENTS
RESPONSE TO
TREATMENT
The was given O2

after the operation and
was able to rest and
sleep without any
complaints
of
difficulty in breathing.
D/C:
November 6, 2013
Check the physicians order before the exercise
Identify the patient before the exercise or activity
Explain the procedure and importance to the patient SO(s).
Ensure that the clients SO(s) understands the rationale for the said activity
290

Provide safety precaution
Provide comfort measures
Promote a quite environment conducive for rest.
Provide adequate rest periods

Monitor the position/activity of the patient every 2 hours.
Obtain initial assessment about the progress of the activity.
Encourage verbalization of feelings about the activity.
Assess for patients condition, how he responds to the activity.
Document
291
TYPES OF
EXERCISE
DATE ORDERED,
DATE
PERFORMED,
DATE CHANGED
GENERAL
DESCRIPTION
INDICATION OR
PURPOSE(S)
CLIENTS
RESPONSE TO
TREATMENT
Sit up on bed, Dangle

Legs
DO:
November 6, 2013
The patient is
encouraged to sit on bed
and dangle legs.
To improve circulation of
blood in the body system
especially on the lower
extremities. To prevent also
accumulation of secretions on
respiratory area and decrease
the presence of edema on the
upper extremities.
The patient was able

to tolerate sitting and
was able to dangle
legs. Was able to
expectorate secretion
and no presence of
edema was noted at
November 7.
DS:
November 6, 2013

292


Document.
TYPES OF
EXERCISE
DATE ORDERED,
DATE
PERFORMED,
DATE CHANGED
Ambulate
DO:
November 6, 2013
GENERAL
DESCRIPTION
INDICATION OR
PURPOSE(S)
CLIENTS
RESPONSE TO
TREATMENT
Patient should stand or
To promote good circulation
The patient was able
walk with or without
of the blood in the body
to stand and walk
assistance but should
slowly going to
have rest periods
comfort room.
293

Document.
294
2. Surgical Management
Lobectomy
A lobectomy is a surgical procedure performed to remove one of the lobes of the lungs.
The procedure may be performed when an abnormality has been detected in a specific part of the
lung. When only the affected lobe of the lung is removed, the remaining healthy tissue is spared
to maintain adequate lung function. A lobectomy is most often performed during a surgical
procedure called a thoracotomy (surgical incision of the chest). (HopkinsMedicine.Org)
Lobectomy is done to remove an infected or a diseased lobe in the lungs to prevent affecting
other parts of healthy lungs to prevent compromising optimal lung function. Diseases like
bronchiectasis and fungal infection in the lungs may require the patient to have an elective
lobectomy. The prognosis of bronchiectasis without surgical therapy is poor.
(Forsee and
Klinger) According to Lilienthal in the article of Forsee and Klinger, "Chronic pulmonary
suppurations wholly or partially of the bronchiectatic type are rarely curable without the
extirpation of the pathologic focus.
Prior to surgery the patient was:

Cleared for CP
Secured consent
NPO post midnight
Infused with #5 PNSS IL X 80 CC/HR
Pre-medicated at OR complex
Inducted at Anesthesia Room
In performing Lobectomy, the surgeon may use any of the 2 approaches which are:
Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgery. Your
surgeon will insert special instruments and a thoracoscope through three small incisions
in your chest. The thoracoscope is a thin, lighted instrument with a small camera that
transmits pictures of the inside of your body to a video screen. Your surgeon sees the
inside of your chest on the video screen while performing surgery. Minimally invasive
295
surgery generally involves a faster recovery and less pain than open surgery. This is
because it causes less trauma to tissues. Your surgeon will make small incisions instead
of a larger one used in open surgery. Surgical tools are threaded around muscles and
tissues instead of cutting through or displacing them as in open surgery. Some surgeons
use a surgical robot assist in minimally invasive surgery.
Open surgery (thoracotomy) involves making a large incision in the chest between
the ribs. Open surgery allows your surgeon to directly view and access the surgical area.
Open surgery generally involves a longer recovery and more pain than minimally
invasive surgery. Open surgery requires a larger incision and more cutting and
displacement of muscle and other tissues than minimally invasive surgery. Despite this,
open surgery may be a safer or more effective method for certain patients.
Left Upper Lobectomy
Pulmonary artery: apicoanterior, posterior, and lingular The interlobar fissure is developed
with a combination of sharp and electrocautery dissection. The posterior aspect of the fissure,
between the apicoposterior segment of the left upper lobe and the superior segment of the left
lower lobe, is completed (with a linear stapler if necessary) to expose the proximal portion of the
pulmonary artery. The left upper lobe is then retracted anteriorly and superiorly to expose the
pulmonary arteries supplying the lobe [see Figure 7]. The left upper-lobe pulmonary artery
anatomy is most variable among the lobes. The most common anatomy is three branches from
the pulmonary artery: apicoanterior, posterior, and lingular branches. However, not infrequently,
multiple posterior apical branches are encountered; in fact, as many as seven vessels supplying
the left upper lobe may be identified. Typically, the posterior segmental branch frequently arises
directly opposite the superior segmental branch to the lower lobe, as well as a more distally
situated lingular branch. These vessels should be identified, individually ligated, and divided.
Next, the whole lung is retracted inferiorly to expose the aortic arch. A large arterial branch
supplying the apicoposterior aspect of the upper lobe is usually encountered. Although the
superior and posterior aspects of this artery are easily dissected, the anterior aspect is frequently
obscured by an apical branch of the superior pulmonary vein; division of this venous branch may
296
improve exposure and facilitate control of the artery. Once the artery is encircled, it is ligated and
divided. To prevent avulsion of this vessel from the main pulmonary artery, care must be taken
not to exert excessive traction on the lung.
Pulmonary vein: superior pulmonary vein The superior pulmonary vein can then be identified
easily. If the apical branch was not previously ligated, the surgeon should make every effort not
to damage the pulmonary artery branches that lie posterior to this portion of the vein. The
majority of the superior pulmonary vein lies anterior to the left upper-lobe bronchus. Once this
vein is encircled, it is ligated and divided.
Left upper-lobe bronchus Attention is then redirected toward the fissure, and the peribronchial
nodal tissue surrounding the left upper-lobe bronchus is swept distally with blunt and sharp
dissection. The fissure between the lingula and the lower lobe is completed with serial
application of GIA staplers [see Figure 8]. The left upper-lobe bronchus is encircled and either
clamped or controlled with a TA stapler. To prevent inadvertent injury, the pulmonary artery
branches to the lower lobe should be gently retracted posteriorly during stapler placement. With
the stapler applied (or the clamp in place), the anesthesiologist ventilates the left lung to verify
that air is flowing freely to the entire left lower lobe. Once unobstructed airflow is confirmed, the
stapler is fired and the bronchus is divided.
Figure
6.
Left
Upper
Figure
Lobectomy:
Upper Lobectomy:
Interlobar Fissure
Lobectomy:
Anterior
Figure 7. Left Upper

Left
8.
Left
Left Fissure after

Division
Left
Hilum
297
NURSING RESPONSIBILITIES:
Before:
Inform patient of the procedure to be performed
Secure consent for THORACOTOMY LEFT UPPER LOBECTOMY
Review results of ECG, sodium, potassium, and blood profile
Assist patient on the way to OR complex
Teach techniques to relieve from anxiety
Maintain NPO status
Continue infusion of PNSS 1L x 80 CC/HR
Proper draping of the patient before cutting
Maintaining sterile field sterile
Proper scrubbing of hands before gloving
Proper donning of gloves and surgical gown and other PPEs
Prepare instruments to be used prior to surgery
Counting of the instruments to be use and document
Remove earring, jewelries, prosthetic teeth, and nail polish
During:
Assist surgeon on handing instruments to be used
Maintain sterility of the sterile field
WOF signs of hypovolemic shock.
Monitor respiratory effort of the patient
Measure amount of blood loss to know if there is a need for BT
Recounting of instruments that have been used
Document
After:
Position patient left lateral to promote lung expansion of the right lung.
Monitor patients vital signs and GCS.
298
Monitor patient until awaken

Document vital signs and GCS of the patient while still in the influence of anesthesia.
ACTUAL OR TECHNIQUE:
(Lifted from the Chart)
Patient in supine, induction of GETA using double lumen ET.
Placed in lateral
decubitus, performed aseptic and antiseptic technique. Left posteriolateral thoracotomy thru 5th
ICS, Dislocation of left pleural cavity, noted (+) minimal pleural adhesion left upper lobe, (+)
palpable "mass" in hilar area left upper lobe. Opening of mediastinal pleural and helium,
exposure of superior pulmonary vein, opening of oblique fissure, exposure of individual
pulmonary artery branches LUL, division and ligation of individual pulmonary artery branches
and individual pulmonary vein. Exposure of LUL bronchus, LUL bronchus divided about 2cm
distal to LMB, bronchial stump closed in 2 layers of Vicryl 3.0 sutures, LUL delivered out. LLL
expanded and checked for all leak (-). Inferior pulmonary ligament divided. Achieved
hemostasis, Placement of anterior posterior CT's, incision is closed. Proper dressing of the
incision site.
HISTOPATHOLOGIC DIAGNOSIS:
November 13, 2013
Lung LUL: Left Upper Lobectomy

CONSISTENT
WITH
INFLAMMATION WITH
BROCHIECTASIS.
FOCAL
DYSPLASIA
ORGANIZED
OF
THE
ACUTE
BRONCHIAL
EPITHELIUM. CHRONIC PASSIVE CONGESTION.
Gross/Microscopic Description:
The specimen submitted consist of a piece of dark brown rubbery to spongy tissue upper
lung lobe measuring 16.6 x 10.0 x 4.4 cm. Sections disclose branches of the bronchioles filled
299
with dark brown granular material. The lung parenchyma shows focal pale areas. No definite
mass is seen.
Representative sections are taken for microscopic studies and labeled as follows:
A bronchial margin 3 blocks
B- random sections of the lung 3 blocks
Microscopic sections disclose dilated bronchioles with focal erosion of the lining
epithelium with acute inflammation and surrounding chronic inflammation and granulation tissue
formation. Some areas shows squamous metaplasia, with focal dysplastic changes. Some
bronchioles also show atypia of the glandular cells. No definite evidence of malignant change is
seen. The surrounding parenchyma shows mixed acute inflammation with atelectasis, focal
irregular emphysema and granulation tissue formation. No granulomas and fungal infections are
seen. There are also aggregates of pigment-laden macrophages, congestion and thickening of the
small and medium-sized pulmonary arteries.
CLOSED TUBE THORACOSTOMY (Anterior and Posterior)
Closed tube thoracostomy is done to drain fluid, blood, or air from the space around the
lungs. Some diseases, such as pneumonia and cancer, can cause an excess amount of fluid or
blood to build up in the space around the lungs (called a pleural effusion). Also, some severe
injuries of the chest wall can cause bleeding around the lungs. Sometimes, the lung can be
accidentally punctured allowing air to gather outside the lung, causing its collapse (called a
pneumothorax). Chest tube thoracostomy (commonly referred to as "putting in a chest tube")
involves placing a hollow plastic tube between the ribs and into the chest to drain fluid or air
from around the lungs. The tube is often hooked up to a suction machine to help with drainage.
The tube remains in the chest until all or most of the air or fluid has drained out, usually a few
days. Occasionally special medicines are given through a chest tube.
Contraindications:
The need for emergent thoracotomy is an absolute contraindication to tube thoracostomy.
300
Relative contraindications include the following:

Coagulopathy
Pulmonary bullae
Pulmonary, pleural, or thoracic adhesions
Loculated pleural effusion or empyema
Skin infection over the chest tube insertion site
Risks:
Some of the risks of chest tube thoracostomy include:
Pain during placement Discomfort can result as the chest tube is inserted. Doctors try
to lessen the pain with a local numbing medicine (anesthetic like novocaine). The
discomfort can be severe at first but usually decreases once the tube is in place.
Bleeding During insertion of the tube, a blood vessel in the skin or chest wall may be
accidentally nicked. Bleeding is usually minor and stops on its own. Bleeding can occur
as a bruise of the chest wall. Rarely bleeding can occur into or around the lung and may
require surgery.
Infection Bacteria can enter around the tube and cause an infection around the lung.
The longer the chest tube stays in the chest, the greater the risk for infection. The risk of
infection is decreased by special care in bandaging the skin at the point where the tube
goes into the chest.
Equipments used:
Chest tube drainage device with water seal (autotransfuser unit is an option)
Suction source and tubing
Sterile gloves
Preparatory solution
301
Sterile drapes
Surgical marker
Lidocaine 1% with epinephrine
Syringes, 10-20 mL (2)
Needle, 25 gauge (ga), 5/8 in
Needle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for instilling local anesthesia
Blade, No. 10, on a handle
Large and medium Kelly clamps
Large curved Mayo scissors
Large straight suture scissors
Silk or nylon suture, 0 or 1-0
Needle driver
Vaseline gauze
Gauze squares, 4 x 4 in (10)
Sterile adhesive tape, 4 in wide
Chest tube of appropriate size
Man - 28-32F
Prior to surgery the patient was:

Cleared for CP
Secured consent
NPO post midnight
Infused with #5 PNSS IL X 80 CC/HR
Inducted at Anesthesia Room
Pre-medicated at OR complex
Technique
Obtain informed consent from the patient or patients representative.
302
Assemble the drainage system and connect it to the suction source. The appearance of
bubbles in the water chamber is a sign that the chest tube drainage device is functioning
properly.
Identify the patient using two identifiers (eg, name and date of birth). If possible, match
the patient's identifiers at his or her bed side with the identifiers present on a chest x-ray
or CT scan that was recently performed (preferably, one performed at the patient's bed
side). Clearly mark the site of chest tube insertion (right or left).
Identify the fifth intercostal and the midaxillary line.
The skin incision is made in between the midaxillary and anterior axillary lines
over a rib that is below the intercostal level selected for chest tube insertion.
A surgical marker can be used to better delineate the anatomy
Shave excessive hair and apply a preparatory solution to a wide area of the chest wall as
shown below.
Skin preparation and marking.

Wear sterile gloves, gown, hair cover, and goggles or
face shield, and apply sterile drapes to the area.
Administer analgesia.
Administer
systemic
analgesic
(unless
contraindicated).
Use the 25-ga needle to inject 5 mL of the local anesthetic solution into the skin
overlying the initial skin incision, as shown below.
Local anesthesia.
Use the longer needle (23 or, preferably, 27 ga) to
infiltrate about 5 mL of the anesthetic solution to
a wide area of subcutaneous tissue superior to the
expected initial incision. Redirect the needle to
the expected course of the chest tube (following
the upper border of the rib below the fifth
303
intercostal space), and inject approximately 10 mL of the anesthetic solution into

the periosteum (if bone is encountered), intercostal muscle, and the pleura.
Aspiration of air, blood, pus, or a combination thereof into the syringe confirms
that the needle entered the pleural cavity.
Skin incision.
Use the No. 11 or 10 blade to make a skin incision
approximately 4 cm long overlying the rib that is below
the desired intercostal level of entry. The skin incision
should be in the same direction as the rib itself.
Blunt dissection down to the intercostal muscle.

Use a hemostat or a medium Kelly clamp to bluntly
dissect a tract in the subcutaneous tissue by intermittently
advancing the closed instrument and opening it, as shown.
Further blunt dissection own to the intercostal muscle.

Palpate the tract with a finger as shown, and make sure
that the tract ends at the upper border of the rib above the
skin incision.
304
Palpation of the selected intercostal space and the superior

margin of its inferior rib.
Adding more local anesthetic to the intercostal muscles
and pleura at this time is recommended.
Use a closed large Kelly clamp to pass through the
intercostal muscles and parietal pleura and enter into the
pleural space, as sho
A closed and locked Kelly clamp is used to enter the chest

wall into the pleural cavity. Make sure to guide the clamp
over the upper margin of the rib.
This maneuver requires some force and twisting

motion of the tip of the closed Kelly clamp.
This motion should be done in a controlled manner so the instrument does not
enter too far into the chest, which could injure the lung or diaphragm.
Upon entry into the pleural space, a rush of air or fluid should occur.
The Kelly clamp should be opened (while still inside the pleural space) and then
withdrawn so that its jaws enlarge the dissected tract through all layers of the
chest wall as shown. This facilitates passage of the chest tube when it is inserted.
Once the Kelly clamp enters the pleural cavity, the clamp
should be opened to further enlarge the opening.
Use a sterile, gloved finger to appreciate the size of the

tract and to feel for lung tissue and possible adhesions, as
shown in the image below. Rotate the finger 360 to
appreciate the presence of dense adhesions that cannot be
305
broken and require placement of the chest tube in a different site, preferably under
fluoroscopy (ie, by interventional radiology).
A finger is used to palpate the tract and feel for adhesions

before insertion of the chest tube.
Measure the length between the skin incision and the

apex of the lung to estimate how far the chest tube
should be inserted.
If desired, place a clamp over the tube
to mark the estimated length.
Some prefer to clamp the tube at a distal point, memorizing the estimated
length.
Grasp the proximal (fenestrated) end of the chest tube with the large Kelly clamp and
introduce it through the tract and into the thoracic cavity as shown.
The proximal end of the chest tube is held with a Kelly clamp
that is used to guide the chest tube through the tract. The
distal end of the chest tube should always be clamped until it
is connected to the drainage device.
Release the Kelly clamp and continue to advance the chest tube posteriorly and
superiorly. Make sure that all of the fenestrated holes in the chest tube are inside the
thoracic cavity.
Connect the chest tube to the drainage device as shown (some prefer to cut the distal end
of the chest tube to facilitate its connection to the drainage device tubing). Release the
cross clamp that is on the chest tube only after the chest tube is connected to the drainage
device.
306
Connection of the chest tube to a drainage system.
Before securing the tube with stitches, look for a

respiration-related swing in the fluid level of the water
seal device to confirm correct intrathoracic placement.
Secure the chest tube to the skin using 0 or 1-0 silk or
nylon stitches, as depicted below.
A 0 or 1-0 silk or nylon suture is used to secure the chest tube

to the skin.
Securing sutures: Two separate through-and-through,
simple, interrupted stitches on each side of the chest
tube are recommended. This technique ensures tight
closure of the skin incision and prevents routine patient
movements from dislodging the chest tube.
Each stitch should be tightly tied to the skin, then wrapped tightly around the chest tube
several times to cause slight indentation, and then tied again.
Sealing suture: A central vertical mattress stitch with ends left long and knotted
together can be placed to allow for sealing of the tract once the chest tube is removed.
Place petrolatum (eg, Vaseline) gauze over the skin incision as shown.
Apply petrolatum (eg, Vaseline) gauze over the skin incision.
Create an occlusive dressing to place over the chest tube

by turning regular gauze squares (4 x 4 in) into Y-shaped
fenestrated gauze squares and using 4-in adhesive tape to
secure them to the chest wall, as shown below. Make
sure to provide enough padding between the chest tube and the chest wall.
307
Preparation of a Y-shaped fenestrated drain gauze from

regular gauze (4 x 4 in).
Apply support gauze dressing around the chest tube and secure it to the chest wall with 4in adhesive tape.
Strap the emerging chest tube on to the lower trunk with a

"mesentry" fold of adhesive tape, as this avoids kinking of the
tube as it passes through the chest wall. It also helps reduce
wound site pain and discomfort for the patient. All
connections are then taped in their long axis to avoid
disconnections.
Obtain a chest radiograph, like the one below, to ensure
correct placement of the chest tube.
Chest tube in good position.
308
3. NURSING MANAGEMENT (ACTUAL SOAPIERS)
NOVEMBER 6, 2013
S>
O> Received patient on a high fowlers position on bed with ongoing IV fluids of #7 PNSS 1L x
80cc/hr received at 650 cc level regulated at 26-27 gtts/min via soluset; with a side drip of
Dopamine 5mcg/kg/min regulated at 26 ugtts/min received at 50 cc level; with CTT anterior and
posterior hooked on an Emerson pump at 20 cm/hr, with the anterior CTT bottle at 400 cc level
draining bloody fluid while the posterior CTT bottle received at 350 cc level draining
serosanguinous fluid; with (+) fluctuations; with oxygen therapy via nasal cannula regulated at 3
LPM; with indwelling foley catheter draining well with dark yellow color of urine received at
100 cc urine ouput; with presence of pitting edema on both upper extremities;lethargic; with
the use of accessory muscles; afebrile; (-) hemoptysis; (-) episode of coughing; without signs of
respiratory distress; with regular depth and rhythm of breathing; with initial v/s taken as follows:
BP= 140/70 mmHg; T= 37.3; PR= 72 bpm; RR= 24 cpm;
A> Activity Intolerance related to post-operative thoracotomy and presence of CTT
P>After 6 hours of NI, the SO will verbalize understanding of the condition and proper
care for the patient especially care of CTT
I>
Assessed general condition
Ascertain to move about and degree of assistance needed by the patient
Assessed CTTs patency and recorded level of drainage
Plan care to carefully balance rest periods with activities
Monitored v/s every 1 hour and I/O strictly quantified
Instructed patients relative not to leave patient unattended
Assist with ADLs
Assist patient in learning and demonstrating appropriate safety measures
Regulated IV fluids and oxygen therapy as ordered
309
Provided safety and comfort measures

Clamped tube while on transport and instructed importance to SO
E>Goal met AEB the SO understood the health teachings provided and proper
therapeutic regimen and CTT care.
A>Ineffective airway clearance r/t retained secretions

P>After 6 hours of NI, the patient will expectorate/ clear secretions readily
I>
Ascertained to move about and degree of assistance needed by the patient
Planned care to carefully balance rest periods with activities
Monitored respiration and breath sounds, noting rate and sounds
Assist with ADLs
Encouraged deep breathing and coughing exercises
Positioned head appropriate for age and condition
Encouraged adequate fluid intake with strict aspiration precaution
Encouraged and provided opportunities for rest; limit activities to level of respiratory
tolerance
E>Goal met AEB the patient was able to expectorate secretions
310
A>Fluid volume excess r/t inability to maintain fluid balance AEB decreased output
P>After 6 hours of NI, the patient will demonstrate behaviors to monitor fluid status and
reduce recurrence of fluid status of fluid excess
I>
Observed skin and mucous membrane
Assist with ADLs
tolerance
Stressed need for mobility and/or frequent position changes
Reinforced diet of low salt, low fat diet
E>Goal met AEB the patient demonstrated behaviors to monitor fluid status and
311
A>Impaired urinary elimination r/t diabetic neuropathy

P>After 6 hours of NI, the patient will participate in measures to correct or compensate
for defects
I>
Determined patient usual fluid intake
Assist with ADLs
tolerance
E>Goal met AEB the patient participated in measures to correct or compensate for
defects
A>Electrolyte imbalance r/t abnormal blood profile

P>After 6 hours of NI, the patient will be free of complications resulting from electrolyte
imbalance
I>
312

Monitored heart rate and rhythm by auscultation
Monitored for physical or mental disorders impacting fluid intake
Assist with ADLs
Evaluated motor strength and function
E>Goal met AEB the patient have been free of complications resulting from electrolyte
imbalance
A>Decreased cardiac output r/t altered stroke volume

P>After 6 hours of NI, the patient will display hemodynamic stability AEB VS are within
normal range
I>
Monitored cardiac rhythm continuously
Assist with ADLs
313

Decreased stimuli; provided quiet environment
Encouraged relaxation techniques
Elevated edematous extremities and avoided restrictive clothing
Encouraged changing positions slowly
E>Goal partially met AEB the patient did not display hemodynamic stability AEB VS
are within normal range
A>Constipation r/t electrolyte imbalance

P>After 6 hours of NI, the patient will verbalize understanding of risk factors and
appropriate interventions related to individual situation
I>
Ascertained frequency, color, consistency, amount of stools
Assist with ADLs
tolerance
Encouraged adequate fluid intake with strict precaution
314
Encouraged activity within limits of individual ability

E>Goal met AEB the patient verbalized understanding of risk factors and appropriate
interventions related to individual situation
A>Impaired physical mobility r/t body weakness

P>After 6 hours of NI, the patient will maintain position of function AEB absence of
footdrop, contractures, decubitus and so forth
I>
Turned patient frequently in good body alignment
Observed skin for reddened areas
Assist with ADLs
Provided diversional activities
E>Goal met AEB the patient maintained position of function AEB absence of footdrop,
contractures, decubitus and so forth
315
A>Risk for Impaired gas exchange r/t alveolar-capillary membrane changes

P>After 6 hours of NI, the patient will demonstrate improved ventilation an adequate
oxygenation
I>
Encouraged frequent position changes
Assist with ADLs
tolerance
E>Goal met AEB the patient demonstrate improved ventilation an adequate oxygenation
A>Impaired physical mobility r/t musculoskeletal impairment

I>
316

Instructed in use of side rails, overhead trapeze and roller pads
Assist with ADLs
Encouraged participation in self-care
Provided patient with ample time to perform activities
A>Ineffective tissue perfusion r/t abnormal blood profile

P>After 6 hours of NI, the patient will demonstrate behaviors and lifestyle changes to
improve circulation
I>
Measured capillary refill
Inspected lower extremities for skin texture
317
Palpated arterial pulses

Determined pulse equality
Assist with ADLs
E>Goal met AEB the patient demonstrate behaviors and lifestyle changes to improve
circulation
NOVEMBER 7, 2013
S>
O> Received patient on high fowlers position, awake and coherent on bed, with ongoing IV
fluid of #9 PNSS 1L x 100cc/hr received at 700 cc level; with a side drip of Dopamine
3mcg/kg/min regulated at 16 gtts/min received at 50cc level; with a side drip of #1 Insulin drip
100 units HR in 100 cc PNSS regulated at 12 units/hr via soluset received at 150 cc level; with
indwelling foley catheter draining well with dark yellow color of urine received at 80 cc urine
output; with Oxygen therapy via nasal cannula regulated at 2-3 LPM; with CTT anterior and
posterior attached to Emerson pump; (+) fluctuations; Posterior CTT draining bloody fluid at 350
cc level; Anterior CTT draining serosanguinous fluid at 320 cc level; I/O ratio on 11/06/13 is
868/80; with HGT level of 199 mg/dL taken by SO; afrebile; (-) DOB; without respiratory
distress; on incentive spirometer 15 times per hour; (-) pain upon inhalation; with regular rhythm
and depth of breathing; without the use of accessory muscles; without episodes of hemoptysis; (-
318
) coughing; with initial v/s taken as follows: BP= 140/70 mmHg; T= 36.4; PR=64 bpm; RR=
22cpm
A> Fluid Volume Excess related to compromised regulatory mechanism AEB fluid retention
P>After 6 hours of NI, the patient and SO will verbalize understanding of importance of
strict fluid restrictions and health teachings provided.
I> Assessed general condition
Monitored and recorder v/s every 1 hour
Monitored and recorder HGT level every 1 hour
Monitored I/O every 1 hour
Assessed CTT bottles level and CTT patency and fluctuations
Noted presence of pitting edema on both upper extremities
Instructed patient and SO diet at tolerated (DM diet) when fully awake
Instructed SO to assist patient in performing Incentive Spirometry, 15 repetitions/ hr
at 250 ml
Instructed patient and SO patient may dangle lower extremities if tolerated
Change position gradually
Instructed SO to clamp CTT tube when going to bathroom of bed side chair
Demonstrate deep breathing exercises
Fluid of PNSS was maintained KVO
E> Goal Met AEB patient and SO verbalized understanding of importance of strict fluid
restrictions and health teachings provided.

I>
319

Assist with ADLs
E>Goal met AEB the SO understood the health teachings provided and proper therapeutic
regimen and CTT care.

I>
Assist with ADLs
Encouraged and provided opportunities for rest; limit activities to level of
respiratory tolerance
320


for defects
I>
Assist with ADLs
tolerance
defects
321

imbalance
I>
Assist with ADLs
imbalance

normal range
I>
322

Assist with ADLs
E>Goal partially met AEB the patient did not display hemodynamic stability AEB VS
are within normal range
A>Risk for constipation r/t electrolyte imbalance

I>
323
Assist with ADLs


I>
Assist with ADLs
324


oxygenation
I>
Assist with ADLs
325

I>
Assist with ADLs

improve circulation
I>
326

Assist with ADLs
circulation
NOVEMBER 8, 2013
S>Masakit ya ing tahi kuas verbalized by the patient
O>Received on high fowlers oriented to time and place, with an ongoing IVF of #9 1L PNSS x
100cc/hr. received at 100cc level infusing well on right hand with SD1 of Dopamine drip
3mcg/kg/min regulated at 16mgtts/min received at 210cc level and SD2 of insulin drip 100 units
HR in 100cc PNSS via soluset received at 65cc level with anterior and posterior CT bottle with
(+) fluctuation, (-) bubbling, with anterior CT level of 40cc with moderate, bloody consistency,
with posterior CT level of 30cc with serosanguinous consistency, with IFC connected to urine
bag draining well to a yellow colored urine received at 400cc level, with O2 inhalation via nasal
cannula at 3Lpm, (+) complains of pain on CT site, with deep regular rhythm of breathing
327
with use of accessory muscles, on HGT monitoring every two hours; P: pain upon movement
Q: quality is stabbing R: localized on surgical site S: 7/10 severity T: pain occurs upon
movement and relieved at rest, vital signs taken and recorded as follows: T=36 PR=64bpm
RR=18cpm BP=140/70mmHg .
A>Acute Pain related to surgical incision

P>After 4 hours of nursing interventions, the patient will repost understanding of health
teachings to relieve pain and patient will verbalize pain is relieved from 7/10 to 3/10
I>
Provided comfort measures
Provided relaxation techniques to relieve pain such as deep breathing exercises
Reiterated adequate rest periods
Reiterated to gradually change position
Reiterated to dangle legs as ordered and as tolerated
Instructed to clamp CTT tube when patient goes out of bed
Maintained fowlers position
Reiterated DM diet
Encouraged adequate fluid intake
Monitored HGT every two hours
9:00am insulin drip was stopped due to high result of 71mg/dl
9:30am patient started on bladder training but patient is unable to tolerate it
E>Goal met as evidenced by patient verbalized understanding of health teachings given
and verbalized pain has decreased from 7/10 to 3/10

I>
328

Assist with ADLs
A>Fluid volume excess r/t inability to maintain fluid balance AEB decreased output
P>After 6 hours of NI, the patient will demonstrate behaviors to monitor fluid status and
I>
Assist with ADLs
329

E>Goal met AEB the patient demonstrated behaviors to monitor fluid status and reduce
recurrence of fluid status of fluid excess

for defects
I>
Assist with ADLs
330

defects

imbalance
I>Assessed general condition
Assist with ADLs
imbalance
331

normal range
I>
Assist with ADLs
E>Goal partially met AEB the patient did not display hemodynamic stability AEB VS are within
normal range
A>Risk for constipation r/t electrolyte imbalance

I>
332

Assist with ADLs

I>
333

Assist with ADLs
A>Impaired gas exchange r/t alveolar-capillary membrane changes

oxygenation
I>
Assist with ADLs
334


improve circulation
I>
Assist with ADLs
335
circulation
NOVEMBER 12, 2013

S>Masakit ya ing sugat ku... as verbalized by the patient
O> Received patient sitting on bed, patient is oriented to time, place and person, with ongoing
IVF #12 PNSS 1L x 100 cc/hr received @ 50 cc level infusing well with no signs of infiltration
noted with posterior CTT received @ 3500 ml level with light yellow output with fluctuation, (-)
bubbling, with regular depth and rhythm of breathing without use of accessory muscles, (-)
guarding behavior, (+) grimace, patient complaints of pain on CTT site pain occurs during
movement and coughing, characterized as sharp pain, with pain scale of 7/10, presence of
crackles on both lung fields upon auscultation,with stable vital signs of BP: 130/70 mmHg,
Temp: 36.1, RR:22, PR:60.
A>Acute Pain related to surgical incisions.

P>After 3-4 hours of NPI the patient will be relieve from pain AEB pain scale of 7/10
(moderate) to 3/10 (mild)
I>
Monitored and recorded Vital signs
Provided comfort and safety measures
Provided adequate rest periods
Instructed to clamp CTT tube when patient goes out of bed
Maintained fowlers position
Encourage adequate fluid intake
Provided relaxation techniques such as deep breathing and diversional activities
Reinforced NPO @ 10 am for 12pm GHT then DM diet with SAP
Maintained CTT below patients chest area
E> Goal met as evidenced by the patient was relieved from pain.
336

I>
Assist with ADLs

imbalance
I>
337

Assist with ADLs
imbalance

I>
Assist with ADLs
338


oxygenation
I>
Assist with ADLs
339

I>
Assist with ADLs
NOVEMBER 13, 2013

S>Mapapagalkupatsemagsalitaku as verbalized by the patient
O> received patient in sitting position, oriented to time, place and person; with an ongoing IVF
of #14 PLRS 1L received @100cc level, regulated @33-34gtts/min, infusing well over right
hand; with CTT on posterior part left thorax, attached to drainage bottle, draining well patent to a
340
yellow fluid @320cc level, with fluctuations, (-) bubbling; afebrile;(-) DOB at rest, no signs of
respiratory distress, with regular depth and rhythm of respirations; (-) coughing, needs
assistance with changing position and activity; with good muscle strength, needs assistance
with ADLs, with complains of DOB after activity and talking; presence of crackles on both
lung fields upon auscultation; with the following VS taken and recorded as follows: T-36.4C
P-64bpm R-23cpm BP:140/80
A> Fatigue related to altered oxygen supply and demand

P>After 8hrs of nursing interventions, the patient will identify basis of fatigue and will
demonstrate ways to conserve energy during activity
I>
Noted age, ascertained patients belief about what is causing the fatigue
Assessed factors that may affect reports of fatigue level
Interviewed SO regarding the changes of patients activities
Monitored VS periodically especially during and after activity
Provided health teachings on how to conserve energy like having rest periods
between activity, changing of position gradually
Instructed SO to clamp CT tube when transferring patient from bed to chair
Planned for adequate rest periods, included SO in planning of activities.
E> Goal met as evidenced by patient identified basis of fatigue and demonstrated ways to
conserve energy

I>
341

Assist with ADLs
E>Goal met AEB the SO understood the health teachings provided and proper therapeutic
regimen and CTT care.

I>
Assist with ADLs
342


improve circulation
I>
Assist with ADLs
circulation
343

I>
Assist with ADLs
344
D. EVALUATION
1. Clients Daily Progress Chart
DAYS
Nursing care Plan

1. ACUTE PAIN
2. HYPERTHERR
MIA
3. INEFFECTIVE
AIRWAY
CLEARANCE
4. INEFFECTIVE
BREATHING
PATTERN
5. DECREASED
CARDIAC
OUTPUT
6. INEFFECTIVE
TISSUE
PERFUSION
7. FLUID AND
ELECTROLYTR
IMBALANCE
8. FLUID
VOLUME
Admiss
ion
Nov. 3,
2013
Nov.
4,
2013
Nov
. 8,
201
3
Nov.
9,
2013
Nov.
10,
2013
Nov.
11,
2013
Nov.
12,
2013
Nov
. 13,
201
X
X
Nov.
5,
2013
Nov.
6,
2013
Nov.
7,
2013
X
X
Nov
. 14,
201
3
Discharg
e
Nov. 15,
2013
345
EXCESS
9. IMPAIRED
URINARY
ELIMINATION
10. IMPAIRED
SKIN
INTEGRITY
11. RISK FOR
INFECTION
12. CONSTIPATION
13. IMPAIRED
PHYSICAL
MOBILITY
14. RISK FOR
IMPAIRED GAS
EXCHANGE
15. ACTIVITY
INTOLERANCE
16. FATIGUE
X
X
X
X
346
DIAGNOSTIC
AND
LABORATORY
DAYS
Admission
Nov. 3,
2013
Nov.
4,
2013
Nov.
5,
2013
Nov.
6,
2013
Nov.
7,
2013
COMPLETE
BLOOD COUNT
Hemoglobin
128
Hematocrit
0.35%
107
0.31
%
112
0.31%
White Blood Cell
6.48 x 10
9
/L
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Platelet
Creatinine
Blood Urea
Nitrogen
Nov
. 8,
201
3
Nov.
9,
2013
Nov.
10,
2013
Nov.
11,
2013
Nov.
12,
2013
Nov
. 13,
201
Nov
. 14,
201
3
Discharg
e
Nov. 15,
2013
12.36
x 10
9
/L
0.70
0.88
0.13
0.10
0.04
0.02
0.02
0.01
172 x10 9/L
122
3.29
mg/d
l
3.61
mg/dl
46.27
mg/dl
2.23
mg/d
l
1.54
mg/d
l
47.39
39.38
347
mg/d
l
138
meq/L
5.13
5.43
mEq/
mEq/
L
L
Serum Sodium
Serum Potassium
Electrocardiogra
phy
Sinus
Brad
ycard
ia
First
Degre
e AV
Block
X
5.96
mEq/
L
Sinus
Brad
ycar
dia
6.03
mEq/
L
mg/d
l
5.16
mEq
/L
4.41
mEq/
L
Sinus Sin
Brady us
cardia Bra
dyc
ardi
a
Random Blood
Sugar (RBS)
URINALYSIS
Light
yellow
Slightl
y
turbid
Acidic
Specif
ic
348
gravit
y
1.010
Sugar
Trace
Albu
min
Trace
Pus
cells
35/HPF
RBC
02/HPF
Epith
elial
Cells
Rare
349
IVF
DAYS
PNSS 1L x 80
cc/hr
Admission
Nov. 3,
2013
Nov.
4,
2013
Nov.
5,
2013
PNSS 1L x 80
cc/hr
Nov.
6,
2013
Nov.
7,
2013
Nov
. 8,
201
3
Nov.
9,
2013
Nov.
10,
2013
Nov.
11,
2013
Nov.
12,
2013
PNSS 1L x KVO
(40 cc/hr)
PLRS 1L x 100
cc/hr
PLRS 1L x 100
cc/hr
Discharg
e
Nov. 15,
2013
PNSS 1L x 100
cc/hr
D5LRS 1L x 80
cc/hr
Nov
. 13,
201
Nov
. 14,
201
3
X
X
350
OXYGEN
THERAPY
3 LPM via face
mask
Nov.
4,
2013
Nov.
5,
2013
Nov.
6,
2013
Nov.
7,
2013
Nov
. 8,
201
3
Nov.
9,
2013
Nov.
10,
2013
Nov.
11,
2013
NEBULIZATIO
N
DAYS
Nebulization
with
duavent/combive
nt every 6 hours
Admission
Nov. 3,
2013
Nov.
12,
2013
Nov
. 13,
201
Nov
. 14,
201
3
Discharg
e
Nov. 15,
2013
INSULIN DRIP
Insulin drip 100
u HR in 100 cc
of PNSS @ 10
u per hour.
X
Insulin drip 100
351
u/hr in 100cc
PNSS x 12 u/hr
Insulin drip 100
u HR in 100 cc
PNSS at 15
u/hr
X
Insulin Drip 100
u HR in 100 cc
of PNSS x 5
u/hr
X
Insulin drip 100
u HR + 100 cc
PNSS x 5 u/hr
Insulin drip 100
u HR + 100 cc
PNSS x 13 u/hr
Insulin drip 100

u HR in 100 cc
PNSS at 8 u/hr
Haesteril
352
DOPAMINE
DRIP
DAYS
Admission
Nov. 3,
2013
Nov.
4,
2013
Dopamine Drip
5mcg/kg/min
Nov.
5,
2013
Nov.
6,
2013
Nov.
7,
2013
Nov
. 8,
201
3
Nov.
9,
2013
Nov.
9,
2013
Nov.
10,
2013
Nov.
11,
2013
Nov.
12,
2013
Nov
. 13,
201
Nov
. 14,
201
3
Nov
. 14,
201
3
Discharg
e
Nov. 15,
2013
Dopamine Drip
3mcg/kg/min
DRUGS
DAYS
Cefepime
Cefixime
Mixtard 30 HM
Humulin R
Tramadol
(Ultram, Tramal
Retard, Algesia)
Admission
Nov. 3,
2013
Nov.
4,
2013
Nov.
5,
2013
Nov.
6,
2013
Nov.
7,
2013
Nov
. 8,
201
3
X
X
X
X
X
X
X
X
X
X
X
Nov.
10,
2013
Nov.
11,
2013
Nov.
12,
2013
Nov
. 13,
201
X
X
X
X
X
X
X
X
X
Discharg
e
Nov. 15,
2013
353
Ketesse
Paracetamol
(Biogesic, Aeknil)
Pantoloc
Furosemide
(Lasix)
Nephrosteril)
Calcium
Gluconate
Bisacodyl
(Dulcolax)
Lactulose
(Cephulac)
Neprocan
Nutren DM
Linagliptin
(Trajenta)
X
X
X
X
354
Diet:
DAYS
NPO [Nothing per

orem)
Soft Diet
DM Diet
Admission
Nov. 3,
2013
Nov.
4,
2013
Nov.
5,
2013
Nov.
6,
2013
Nov.
7,
2013
Discharg
e
Nov. 15,
2013
Nov
. 8,
201
3
Nov.
9,
2013
Nov.
10,
2013
Nov.
11,
2013
Nov.
12,
2013
Nov
. 13,
201
Nov
. 14,
201
3
X
X
Exercises/
Activity
X
Bed rest
Sit up on bed,
Dangle Legs
Ambulate
X
X
355
2. DISCHARGE PLANNING
a. General Condition of Mr. Baga upon Discharge (lifted from the chart)
Mr. Baga was discharged on November 15, 2013 with a final diagnosis of
Recurrent Massive Hemoptysis secondary to TB Bronchiectasis, Fungus Ball, Left upper
lobe. Received patient on bed, awake and coherent; without contraptions noted; with
intact and dry dressing; (-) DOB and chest pain; (-) pain complaints; afebrile; with stable
V/S; awaiting clearance.
b. METHOD
Medications
Mixtard 50 units SC in AM; 25 units SC in PM

Insulin was prescribed as maintenance drug for the patients DM.
Inject insulin 50 units at 8am and 25 units at 8pm subcutaneously.
Linagliptin (Trajenta) 5mg OD

Trajenta was prescribed as maintenance drug for the patients DM.
Take one tablet once a day.
Cefixime 20mg 1 cap BID x 7days

Antibiotic
was
prescribed
as
to
prevent
infection.
Take one capsule once a day for 7 days.

Exercise:
Continue and maintain passive range of motion exercises gradually as

tolerated.
Treatment:
If symptoms of complications persistreport immediately and consult the
physician for further treatment.
356
Health teachings:
Stressed the importance of strict compliance to treatment regimen

specially medication intake and diet therapy.
Warned Mr. Baga and his significant others regarding the side effects and
adverse reaction of the medications.
Instructed Mr. Baga and his significant others to provide a stress-free

environment.
Instructed Mr. Baga to avoid engaging in strenuous activities.
Stressed the importance of regular medical check-up
Out-Patient-Department:
Mr. Baga was instructed to come back on November 25, 2013 at a tertiary
hospital in Angeles City, Pampanga with RBC and urinalysis results.
Diet:
Diet as Tolerated for continuity of usual diet (Diabetic Diet)
Sample 7 Days Diabetes Meal Plan
Day 1
BREAKFAST
AFTERNOON SNACK
1 Cup Skim Milk
1 Orange, medium
1 Cup Cheerios Cereal
2 Tablespoons Prepared Hummus

3 Ounces Celery Sticks
DINNER
MORNING SNACK
1 Cup Cantaloupe Melon
LUNCH
1/2 Cup Cooked Brown Rice

North African Spiced Carrots
Tomato-Herb Marinated Flank Steak
1/2 Banana, small
Grilled Shrimp Skewers

over White Bean Salad
1 Whole-Wheat Pita Bread,
small
1 Cup Skim Milk
1 Fudgsicle, no sugar added
357
Day 2
BREAKFAST
AFTERNOON SNACK
1 Cup Skim Milk
6 Ounces Nonfat Vanilla or Lemon Yogurt,
1/2 Banana, small
Sweetened with Low-Calorie Sweetener
1 Cup Bran Flakes Cereal

MORNING SNACK
1 Fruit & Nut Granola Bar
DINNER
LUNCH
1 Cup Steamed Brussels Sprouts

Chopped Greek Salad with Chicken
Grilled Shrimp Remoulade
1 Whole-Wheat Bread
1/2 Cup Cooked Couscous

1 Peach, medium
Vanilla-Orange Freezer Pops

o
Day 3
BREAKFAST
1 Whole-Wheat English Muffin
AFTERNOON SNACK
1 Cup Skim Milk
1/2 Cup Blueberries

1 Teaspoon Fat Free Cream Cheese
MORNING SNACK
DINNER
Asian Green Bean Stir-Fry
1 Apple, small
LUNCH
1 Cup Tossed Salad Mix
1 Tablespoon Fat Free Blue Cheese
Salad Dressing
Hungarian Beef Goulash
1/2 Cup Fresh Pineapple
1 Slice Reduced-Calorie Oatmeal Bran
Bread
1 Cup Skim Milk
Five-Spice Tilapia
1/2 Cup Cooked Quinoa
1 Nectarine, medium
358
Day 4
BREAKFAST
AFTERNOON SNACK
1 Cup Skim Milk
1 Cup Blackberries
1/2 Cup Hot Oatmeal
1 Cup Skim Milk

DINNER
1 Ounce Dried Fruit
1 Tablespoon Walnuts
MORNING SNACK
Maple-Glazed Chicken Breasts
1 Kiwi
1/2 Cup Steamed Summer Squash
LUNCH
1/2 Cup Mango

Manhattan Crab Chowder
1 Tablespoon Low Calorie Caesar Salad
Dressing
1 Slice Reduced-Calorie Oatmeal Bran
Bread
1 Cup Honeydew Melon
Day 5
BREAKFAST
AFTERNOON SNACK
1 Scrambled Eggs
1/2 Plain Bagel
2 Slices Reduced-Calorie Oatmeal Bran

Bread
1/2 Cup Grapefruit
1 Cup Skim Milk
MORNING SNACK
2 Tablespoons Prepared Hummus

DINNER
1/2 Cup Cooked Quinoa
Roasted Baby Bok Choy
1 Cup Strawberries
6 Ounces Nonfat Vanilla or Lemon

Yogurt, Sweetened with Low-Calorie
Sweetener
LUNCH
1 Tablespoon Fat Free French Salad
Dressing
Cheese-&-Spinach-Stuffed Portobellos
1/2 Cup Unsweetened Applesauce
359
Day 6
BREAKFAST
AFTERNOON SNACK
1 Cup Skim Milk
1 Whole-Wheat English Muffin

1 Teaspoon Creamy Peanut Butter

DINNER
Singapore Chile Crab with Spinach
1 Tablespoon Sugar-Free Jam

MORNING SNACK
1 Orange, medium
Rainbow Pepper Saute
LUNCH
1 Cup Cantaloupe Melon

Chicken Mulligatawny
1 Cup Skim Milk
1 Whole-Wheat Pita Bread, small
1 Cup Watermelon
Day 7
BREAKFAST
AFTERNOON SNACK
1 Cup Skim Milk
3 Ounces Carrot Sticks
1 Plum
1/4 Cup Salsa
Quick Breakfast Taco

MORNING SNACK
1 Apple, small
LUNCH
DINNER
1 Cup Skim Milk
1 Tablespoon Low Calorie Caesar Salad
1 Veggie Burger
Dressing
1 Whole-Wheat Roll
Bok Choy-Apple Slaw
1 Apricot
Turkish Chicken Thighs
1 Peach, medium
o
360
III. SUMMARY OF FINDINGS

The researchers were able to accomplish the task given to them. They were able
to established rapport and achieve trust with the patient and her significant others. They
were able to gain needed information for the completion of the study. Also, they were
able to identify the diagnosis of the patient and his complications. They were also able to
recognized and identified actual potential problem and his prognosis with day-to-day
basis. They were able to show patients data with the information gathered and interpret
the data. The workload is properly distributed with the patient. The work tasks are
completed on time.
After 5 days of nurse-patient interaction, the student nurses were able to

familiarized the attitude of the patients family health as well as to obtain the personal
and pertinent family health-illness history of the client and relate it to the present disease
condition. Identified the statistics and prevalence of the disease condition as well as the
latest trends in the management of the disease condition. Gathered pertinent information
about the patient regarding his personal and socio-economic histories, cultural beliefs,
environmental factors as well as his family health-illness history that may have
contributed in the development of the disease condition. Analyzed the diagnostics and
laboratory procedures performed to diagnose the condition of the patient. Identified and
prioritize appropriate nursing care plans to aid in the management of the patients
condition. Provided various therapeutic nursing interventions that are suitable with the
presenting problems experienced by the patient.
After completion of this case study, the student nurses were able to discussed
Tuberculosis, Bronchiectasis and Fungus Ball, Diabetes Mellitus Type II and
Hypertension, its definition, risk factors, sign and symptoms that had contributed to the
occurrence of the disease condition. As well as to identify the apparent sign and
symptoms manifested by the patient in relation to the mentioned disease condition.
Performed a comprehensive assessment; physical, neurological and neurovascular
assessment as to general condition of the patient; as well as its effects to the significant
361
other may be it physically, socially, mentally and spiritually to confirm the diagnosis of
Pulmonary Tuberculosis, Bronchiectasis, and Fungus ball, Diabetes Mellitus Type 2,
Hypertension;
or
to
identify other
possible causes
of
patients symptoms.
Comprehensively analyzed and interpreted the different laboratory and diagnostic

procedures in relation to the clinical manifestations of the disease condition; and the
different nursing interventions that must be done before, during and after each procedure.
Identified nursing problems and appropriate nursing care plan that involves the patient
and the significant others. Specified the various treatments modalities such as medical
management and surgical management as well as current trends in managing
Hypertension. Identified the appropriate nursing diagnosis and make corresponding
interventions and carry them out as the situation permits as to promote patient wellness.
Made daily progress chart to evaluate patients response to medical management
Formulated discharge planning and care of patient at home. Formulated conclusions
based on findings and enumerate recommendations concerning the management of
Hypertension. Evaluated effectiveness of nursing care and medical interventions rendered
After 5 days of nurse-patient interaction, the patient and relative were able to
established rapport with student nurses and will trust and cooperate with them.
Understood the purpose of the student nurse purpose for acquiring related information
about the patient with regards to the condition. Determined the level of understanding
about the disease condition. Cooperate during the interview process and gathering of data
thereby sharing of information that is significant to the present condition of the patient.
Demonstrated awareness on the activities necessary to accomplish the case study.
Willingly answered the questions of the student nurses and shared relevant information
about their health belief and practices. Shared their perceptions regarding the history of
illness their family are experiencing. Imparted their views in what the possible effects of
these health problems are and what interventions can be done to solve them.
362
After the completion of the case study the patient and his family were able to
enumerated the underlying cause of the disease and its occurrence. Participated in the
modality of the treatment given to the patient. Obtained pharmacological and nonpharmacological treatment to alleviate disease condition. Acquired palliative care and
management of pain as well as reducing the occurrence of complication from disease
condition. Participated in formulating various nursing care plans with the student nurses
to improve patients condition.
363
IV. CONCLUSION
Tuberculosis (TB) is an infectious disease that primarily affects the lung
parenchyma. It also may be transmitted to other parts of the body, including the
meninges, kidneys, bones, and lymph nodes. The initial damage to the bronchi may result
from a number of different causes; one of these is Tuberculosis, leading to
Bronchiectasis. Bronchiectasis is a disease state defined by localized, irreversible dilation
of part of the bronchial tree caused by destruction of the muscle and elastic tissue. It is
classified as an obstructive lung disease; involved bronchi are dilated, inflamed, and
easily collapsible, resulting in airway obstruction and impaired clearance of secretions.
With such manifestations, treatment depends on the underlying cause and

manifestations. Persons with this condition should be closely monitored for signs of
progression of disease. Alteration of the environment and team effort from different
members of the health care team such as the physician, the nurse and most importantly
the family of the patient is much needed to the rapid wellness and optimum level of
functioning
The following manifestations observed by student nurses may help in deciding

whether the patient condition has a poor or good prognosis. The absence of recurrent
massive hemoptysis: As explained by Knechel (2009), hemoptysis or coughing of blood
may be caused by destruction of a patent vessel located in the wall of the cavity, rupture
of a dilated vessel in a cavity, or the formation of an aspergilloma in an old cavity. In
response of the body to these alterations in the body, hematologic studies may reveal
anemia, which causes fatigue and weakness, leukocytosis will also present as response to
the infection. The socio-economic status of Mr. Baga. His financial status helped the
patients condition improved because of the surgical management, lobectomy on the left
upper lobe, which the patient complied. Medications are given and taken by the patient
during the entire length of hospitalization. Home medications, are likewise taken as
ordered after conducting home visit.
364
Prolonging and improving the patients quality of life through prescribed

medications, diet, activity, monitoring of health status and follow-up consultations is a
more realistic measure. Several factors may help in contributing to the enhancement of
quality of life of the patient. The support of the family, prescribed medical and nursing
management and other support-resources can be of additional help for the recovery of the
patient.
365
V. RECOMMENDATIONS
After conducting the case of Mr. Baga, a patient with a diagnosis of Recurrent
Massive Hemoptysis Secondary to TB Bronchiectasis Fungus Ball, Left Upper Lobe, the
student nurses came up with the following recommendations. They are divided into:
patient-based and nursing-based recommendations.
PATIENT and FAMILY-BASED:
Lifestyle modification is very important towards control of the said disease.

Modification of Mr. Baga towards health promotion activities may help prevent
further complications associated with the condition.
Maintaining a schedule that contains adequate time for rest and sleep should be
considered. Good rest and enough sleep will enhance the patients body by
reservation of energy and enhancement of muscular strength and tonicity.
Strict compliance to medical and nursing regimen is another key factor toward good
prognosis of Mr. Bagas health condition. Taking medications as instructed is just one
of the several roles he has to do diligently. The condition would be properly promoted
and controlled as the client seeks a quality of life that is worth living.
The family serves as the main support system of the patient physically, emotionally
and financially. The family therefore should realize the significance of its role and
must comply with the regimen prescribed for the patient. The family must be
involved with patients care from the beginning. Patient and family education about
disease condition begins on admission and continues through rehabilitation. It is
necessary to share information repeatedly for the patient and family to assimilate it.
The prognosis of the patient does not only depend on his own but to the members of
the family. Health care providers should also assist the patient and family in
identifying and using support systems and appropriate coping mechanisms.
366
NURSING-BASED:
The patient and family should be educated concerning the possible effects of
medications and the need to notify the physician if adverse effects develop. Mr. Baga
and family were unaware of the actions, side and adverse effects of the drugs being
given to him.
Strict monitoring and continuous assessment of patients condition is a must. Physical

assessment, and early assessment of signs and symptoms is a vital way that gives
essential status of the patient.
Continuous monitoring of urine output and bladder function should be done to

properly evaluate medical and nursing interventions provided to the patient and
revision of said interventions may be implemented to improve disease condition.
367
VI. LEARNING DERIVED

Tuberculosis may come without any sign and symptoms which may lead to
untreated until such disease will decrease the immune system of the body. In this
problem complication may occur such as blood loss due to hemoptysis and also the
presence of fungal ball because the lungs was not able to destroy micro-organism because
it was been damage. Recognition and treatment of these problems are major factors in the
care of person with TB.
As student nurses, we are given vast opportunities to handle different clients with
different diseases. As in our case, we were able to manage a client with peritonitis
secondary to ruptured appendicitis. Through handling this case, the researchers were able
to know the different modifiable and non-modifiable factors that may have contributed
the patients condition and to the signs and symptoms related to the disease. Diagnostic
procedures were also identified as equally important in order to identify or to confirm the
disease and along with the nursing responsibilities before, during, and after the procedure
is done. The researchers also learned the importance of each medical management done
to the patient, specifically, their actions, indications, nursing implications and the clients
response to the management given. Nursing care plans were formulated for the care of
the patient, and for the achievement of the goals specified in the plan for the promotion of
patients health. At the same time, knowledge regarding the latest trends on tuberculosis
were learned by the researchers.
All throughout the provision of care to the patient, the researchers were able to
see life in a different perspective. Rendering care to patients does not only mean going to
patient and give interventions physically. Provision of care also entails giving the patient
a caring environment and seeing the patient and his family in an emphatic and holistic
way.
It is without a doubt that nurses do not hold the patients life but the researchers
believe that if nurses are equipped with sufficient knowledge and skills regarding the care
of patients with fracture, nurses surely can make a difference to the life of the patients
and to his family.
~ GROUP 14
368
369

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I.

Tuberculosis (TB) is an infectious disease that primarily affects the lung

a. Current Trends about the disease condition

c. Reasons For Choosing Case Presentation

Hence, a case with Pulmonary Tuberculosis as a history, leading to Bronchiectasis

Furthermore, the analysis and synthesis of both the patient-centered

Short- Term Objectives

Analyzed the diagnostics and laboratory procedures performed to diagnose

Identified and prioritized appropriate nursing care plans to aid in the

Long- Term Objectives

neurovascular assessment as to general condition of the patient; as well as its

Bronchiectasis, and Fungus ball, Diabetes Mellitus Type 2, Hypertension; or

10. Evaluated effectiveness of nursing care and medical interventions rendered

II. NURSING PROCESS

b. Socio-Economic and Cultural Factors

during the time that he is not in his farm.

Food (rice/ fish/ pork/ vegetables)

Electricity (lights, appliances & Jetmatic)

Maintenance Drugs (Estimated amount: 1000)

Php 30,000- Php 11,500 = 18,500/ month (during non-harvest season)

b.2. Educational Attainment

b.3. Religious Affiliation

b.4. Cultural factors affecting health of the family

Mr. Baga used to be a smoker, he can consume 40 sticks a day, he started

He drinks hard liquor occasionally, such as Emperador approximately 500ml.

2. Family Health Illness History

PTB; BRONCHIECTASIS; DM;

3. History of Past Illness

4. History of Present Illness

The episodes of hemoptysis started again on July 2013 as verbalized by Alveoli,

(anti-histamine) for his allergies. He was been diagnosed of Pulmonary Tuberculosis,

November 3, 2013 (Lifted from the chart)

11:20 pm done by NOD

GENERAL APPEARANCE: patient is awake, conscious and coherent, with intravenous

November 4, 2013 done by nurse on duty

8am- BP: 120/70 PR: 60bpmRR: 20cpm Temp: 36

GENERAL APPEARANCE: patient is awake, afebrile, appears weak, conscious and

3:05 pm done by NOD (lifted from the chart)

GENERAL APPEARANCE: patient is on bed, asleep but arousable, with an ongoing

6-2pm done by the Nurse on duty (lifted from the chart)

9am- BP: 160/80 PR: 60bpm RR: 21cpmTemp:36

GENERAL APPEARANCE: patient is on moderate high back rest, awake, oriented to

@9AM endorsed to OR nurses ----------------OPERATING ROOM------------------

10 am done by the NOD (lifted from the chart)

GENERAL APPEARANCE: Patient @ OR table, conscious and coherent, hooked to

CHEST AND LUNGS

Crackles heard upon

6am: with fever T: 38.0

1:05: BP: 120/80 PR: 62 RR: 23 Temp: 36

Patient was asked to Patient must be able to Patient was able to

Fxn: Sense of smell

asked to determine the coffee grounds when of coffee grounds

was identify the scent of identify the scent

scent of the material allowed to smell it.

used which is coffee

read news paper.

or penlight clearly from see the pen or

Fxn: Sense of vision

a certain distance; must penlight from a

and visual fields

newspaper with writings and had difficulty

follow the direction of direction

Pupil the penlight and ask to movement

the able to follow the