This+is+It!!!!+This+is+Really+is+It

INTRODUCTION

Lung cancer is a disease of uncontrolled cell growth in tissues of the lung. This

growth may lead to metastasis, invasion of adjacent tissue and infiltration beyond the

lungs. The vast majority of primary lung cancers are carcinomas of the lung, derived

from epithelial cells. Lung cancer, the most common cause of cancer-related death in

men and the second most common in women, is responsible for 1.3 million deaths

worldwide annually. The most common symptoms are shortness of breath, coughing

(including coughing up blood), and weight loss.

The main types of lung cancer are small cell lung carcinoma and non-small cell

lung carcinoma. This distinction is important because the treatment varies; non-small cell

lung carcinoma (NSCLC) is sometimes treated with surgery, while small cell lung

carcinoma (SCLC) usually responds better to chemotherapy and radiation. The most

common cause of lung cancer is long term exposure to tobacco smoke.[6] The occurrence

of lung cancer in non-smokers, who account for fewer than 10% of cases, appears to be

due to a combination of genetic factors, radon gas, asbestos, and air pollution, including

second-hand smoke.

This is the case of Mr. B.R., 18 years old, male, who was admitted to Mary

Johnston Hospital because of joint pains. The group decided to chose this patient because

we know that through studying the patient’s case, we will learn and at the same time

enhance our knowledge and skills in rendering care to patients who are in need of prompt

nursing interventions.

In studying this case, the group came up with different nursing problems, such as:

DEMOGRAPHIC DATA

This is the data of R. B., 18 years old, male, Filipino, Methodist, born on July 14

1989, presently residing at #3 Pitugo Ext. Grp 1 area B, Brgy. Payatas QC, and was

admitted Ferbruary 26, 2008 due to low back pain.

Three months PTA, patients complained of low back pains, self medicated with

alaxan and Mefenamic acid which offered temporary relief. Patient was then consulted at

Fairview Hospital where urinalysis was done revealed normal results and the patient was

sent home with pain relievers.

Two months PTA, still with low back pains consulted to Orthopedic Center wher

lumbosacral X-ray was done. Patient was diagnosed with HNP, LSSI with radiculopathy.

Patient was given medications like Mefenamic acid, Lagiflex and Godapentin. Patient

was then advised to undergoe PT. the patient had 10 sessions.

One month PTA, still with low back pains and now with difficulty walking.

Consulted at Orthopedic center where he was prescribed with Pregabalin (Lyrica), 50

mg/tab TID for 5 days, Celecoxib, 400 mg/cap OD x 7 days and Prednisone 5 mg/tab

TID for 2 days.

Persistence of low back pain, difficulty of walking, and now with pain and

paresthesia in both lower extremitiesprompled then to seek consult and was subsequently

admitted.

Past Medical History:

No PTB, no asthma, no HPN, no DM

No allergy to foods or medicines

Family History:

Unremarkable

S/P History:

Patient is a non smoker and non alcoholic beverages drinker.

Review of Systems:

Unremarkable

PE:

Conscious, coherent, ambulatory, afebrile

V/S:

BP: 110/70 mmHg PR: 84 bpm RR: 24 cpm T: 37 C

Skin: no jaundice, no pallor, no cyanosis

HEENT:

Anicteric sclerae, pinkish palpebral conjunctivae, no nasolacrimal discharges, non

distended neck veins, no cervical lymphodenopathy.

Chest Lungs:

Symmetrical chest expansion, decreased breath sounds, right lung fields,

decreased tactile, decreased vocal femitus right lung.

Heart:

Adynamic precordium, normal rate, regular rhythm, no murmur.

Abdomen:

Flat, soft, hypoactive bowel sounds, non tender.

Extremities:

Full and equal pulses on both lower and upper extremities.

Neurologic:

CNI : N/A

CNII : pupils 2-3 mm EBRTI

CN III – IV – VI : intact EOM’s

CN V : (+) corneal reflex

CN VII : no facial asymmetry

CN VIII : gross hearing intact

CN IX – X : (+) gag reflex

CN XI : able to shrug shoulder

CN XII: midline tongue

Motor: Sensory

s/s s/s 100 100

s/s s/s 80 50

GORDON’S FUNCTIONAL HEALTH PATTERN

I. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

“Ang kalusugan ay mahalaga para mabuhay ang mga tao”

“Nung sumasakit ang baywang ko, pumunta kami sa Fairview General Hospital at

nagpacheck up. Wala naman silang nakita sa ihi ko kaya niresitahan lang ako ng gamot.

Tapos hindi pa rin nawala yung sakit. Kumonsulta kami sa orthopedic center kasi baka sa

buto naman ang problema tapos nagpatherapy ako. Pagkatapos ng 12 sessions ng therapy

hindi pa rin nawala yung sakit kaya nagpatingin na kami ditto sa Mary Johnston.

Currently under the service of Dr. R.

II. NUTRITIONAL METABOLIC PATTERN

“Nakakakain naman ako pero hindi pokatulad dati na maganang Magana. Bihira

ko lang po maubos yung pagkain ko eh.”

Eats 3x a day excluding snacks.

On DAT diet.

“Maayos naman at malakas naman ako uminom ng tubig”

Consumes 1-2 liters of water a day.

“Hindi naman po ako nahihirapan sa paglunok at pagkain.”

III. ELIMINATION PATTERN

“Pawisin po ako kaya madalas lagging basa yung gown ko o kaya naman po ay

yung damit at bed sheet ko.”

With Foley catheter to CDU bag draining yellowish urine on moderate amount.

With right chest thoracostomy tube draining on 3 way bottle.

“Ang problema naman po sa akin ngayon ay yung pagdumi ko. Nakakaisang

beses pa lang ako dumumi simula noong maadmit ako last February 26. Hindi po kasi

ako masyado naggagagalaw.”

IV. ACTIVITY AND EXERCISE PATTERN

“Andito lang po ako sa higaan ko, hindi naman ako nagtatatayo kasi baka sumakit

itong tubo ko.”

Can’t turn himself on left lateral side and partially on right lateral side because of

the CTT

Has no regular bed exercises.

“Pinapalakad lakad na nga po ako ng doctor ko eh kaso lang po kinakabahan pa

rin po ako sa tubo baka sumakit o kung anong mangyari kaya hindi pa rin ako

naglalakad.”

V. SLEEP AND REST PATTERN

“Hindi po ako makatulog disto sa ospital. Nahihirapan po ako kumuha ng tulog ko

eh, hindi kop o alam kung bakit. Siguro halu-halo na rin po kung bakit hindi ako

makatulog. Siguro po dahil sa sakit ng tubong nakakabit, o dahil po kinakabahan ako, o

siguro po dahil hindi po ako sanay sa lugar na maraming tao, parang namamahay din po

ako.

Able to sleep for only 2-3 hours at night interruptedly

“Nakakatulog at nakakaidlip naman po ako sa maghapon ng mga 2-3 oras kaso

lang po pagising gising din yun.”

VI. COGNITIVE PERCEPTUAL PATTERN

“March 3, 2005 na po ngayon. Sayang nga po patapos na sana yung isang

semester ko nabitin pa.”

Oriented to date and time.

Doesn’t use eyeglasses nor hearing aids.

“Maayos naman po ang mata, tainga, pandama pati panlasa ko.”

VII. SELF CONCEPT AND SELF PERCEPTION PATTERN

“Nanghihinayang po ako dahill nagkasakit po ako tapos hindi kop o

naipagpatuloy yung pagaaral ko.”

“Kumikirot kirot pa rin po yung nasa tobo ko lalo nap o kapag gumagalaw galaw

ako.”

With pain scale of 5.

Pakiramdam ko rin po na ang hina hina at nanlalambot ako ngayon hindi po

katulad ng dati na malakas pa ako.”

VIII. ROLE AND RELATIONSHIP PATTERN

Youngest among 3 siblings.

“Hindi pa nga ako nadadalw ng mga classmate at kaibigan ko sa school kasi

malayo sa kanila at hindi nila alam itong ospital.”

“Masayang masaya po ako kahit paano kasi nandiyan naman po ang mga

magulang ko para mag alaga saakin.”

Had lots of friends and no enemy.

IX. SEXUALITY AND REPRODUCTIVE PATTERN

Circumcised

Grossly male

Dresses appropriately to gender.

X. COPING STRESS TOLERANCE PATTERN

“Kapag nababagot na po ako dito sa higaan ko madalas po nilalaro ko na lang po

ang cell phone ko o kaya naman po ay nagtitext na lang po ako.”

“Kung minsan kapag wala naman po talagang magawa, natutulog na lang po

ako.”

He also reads newspapers and magazines.

XI. VALUE BELIEF PATTERN

“Hindi po ako regular na nagsisimba eh, paminsan minsan lang po.”

A Roman Catholic

Prays everyday

Seldomly reads his Bible.

“Hindi naman ako naniniwala sa mga pamahiin.

PHYSICAL EXAMINATION

VITAL SIGNS

TEMP: 38 C

PR: 75 bpm

RR: 28 bpm

BP: 110/70 mmhg

GENERAL APPEARANCE

Awake

Coherent and conversant

Not in CP distress

Lying supine on bed

Wearing gown

HAIR

Evenly distributed hair

Black, straight

Short-haired

Dry hair uncut hair

Without white hair

(-) pediculosis

(-) dandruff

(-) lesions

EYES

Black pupils

Clear, dark brown cornea

Whitish sclerae

Pale conjunctivae

Teary-eyed

With dark circles around the eyes

Symmetrical eyes

Eyeballs able to move freely

NOSE

Symmetrical nares

(-) nasal flaring

(-) discharges

(-) bleeding

EARS

Symmetrical to the outer canthus of

the eyes

Can hear well

(-) discharges

(-) lesions

MOUTH

Pale and dry lips

Pale tongue

Pink gums

(-) halitosis

(-) tooth decay

Not inflamed tonsils

NECK

Trachea in midline

Head is centered

Able to move neck and head without

pain

(-) lesions

(-) pruritus

(-) hypertrophy of the thyroid gland

CHEST AND LUNGS

Equal lung expansion

With right chest thoracostomy tube

via 3-way bottle

Deep breathing noted

(-) DOB

Fair complexion

Intact chest wall

ABDOMEN

Decreased abdominal sounds

(-) abdominal pain

(-) abdominal enlargement

(-) lesions

(-) masses

Intact abdominal wall

UPPER AND LOWER

EXTREMITIES

Good skin turgor

Complete set of fingers and nails

Uncut finger and toenails

With numbing felt on both lower

extremities

Flexible and movable legs and hands

With full ROM on both legs and

arms

(+) lesions

(+) scars Moist skin

RISK FACTORS

PASSIVE SMOKING

Smoking, particularly of cigarettes, is far the main contributor to lung cancer.

Smoking is estimated to account for 87% of lung cancer cases. Among men smokers, the

lifetime risk of developing lung cancer is 17.2%. Cigarette smoke contains over 60

known carcinogens including radioisotopes from the radon decay and many more.

Additionally, nicotine appears to depress the immune response to malignant growths in

exposed tissue. The length lf time a person smokes as well as the amount smoked

increases the risk of developing lung cancer. The inhalation of smoke from another’s

smoke is a cause of lung cancer in non-smokers. Studies shows it have consistently

shown a significant increase in relative risk among those who exposed to passive smoke.

The patient is a non smokers, that is why passive smoking or the inhalation of smoke

from other people trigger his body to developed lung cancer.

GENETIC FACTORS

Patients with history of lung cancer have a high risk of developing lung cancer.

Researchers have discovered that an inherited genetic region on the human chromosome

number 6 that is linked with lung and other tobacco related cancers.

ENVIRONMENT

The patient lives in a place where the garbage of a city dump in. we all know that

living on this place can cause many diseases. The patient developed lung cancer due to

his stay at this place. It is only risk factor but it can contribute in developing lung cancer.

Asbestos is linked to increased risks of lung cancer. It was also studied that city air

pollution was a bigger risk for lung cancer, yet the idea tat chemicals in the environment

are a major cause of cancer persists. Although most cancers are believed to be caused by

lifestyle choices, such as what you eat, weather you maintain a healthy weight and

weather you smoke.

LABORATORIES

A. Hematology

Blood Component Result Normal Values

Hemoglobin 123-decreased 140-170g/L

Hematocrit .38-decreased .40-.50

Leukocytes 12.8-increased 5-10g/L

Segmentars .37-normal .54-.75

Lymphocytes .25-normal .2-35

Eosinophil .02-normal .01-.04

ESR 48-increased 0-10mm/hr

Thrombocytes are adequate

Normochromic, Normocytic

INTERPRETATION:

Hemoglobin is the main intracellular protein of the red blood cell. Its primary

function is to transport oxygen to the cells and remove carbon dioxide from them for

excretion by the lungs. Hemoglobin determinations are of greatest use in the evaluation

of anemia, as the oxygen-carrying capacity of the blood is directly related to the

hemoglobin level so a decreased hemoglobin level directly affects this oxygen-carrying

capacity. Hemoglobin also functions as a buffer in the maintenance of acid-base balance,

and inadequate hemoglobin in the blood impairs this role. The data above shows that the

patient has decreased hemologin levels which implies decreased oxygen carrying

capacity of the blood.

The hematocrit (packed red cell volume) measures the proportion of red blood

cells in a volume of whole blood. Normally, hemoglobin and hematocrit levels parallel

each other and are commonly used together to express the degree of anemia. Decreased

levels suggests anemia, fluid retention and hemorrhage.

Leukocyte Count is the absolute number of WBC(s) circulating in a cubic

millimeter of blood. White cells are produced in the red bone marrow and lymphatic

tissue. After they are formed, they enter the blood, which transports them to the parts of

the body where they are needed to (1) defend against invading organisms through

phagocytosis and (2) produce or transport and distribute antibodies to help maintain

immunity. The results above shows increased leukocyte count which is usually caused by

conditions such as infection, that stimulates the bone marrow to produce WBC(s) to fight

off invading organisms.

Segmentars, also called polymorphonuclear leukocytes or neutrophils has

protective functions which includes phagocytosis. Foreign particles are degraded, and

pyrogens are released that produce fever by acting on the hypothalamus to set the body’s

thermostat at a higher level. The lab result shows no deviation from normal range.

Lymphocytes functions protectively in antibody production and humoral

immunity. The result shows normal lymphocyte count which indicates absence of viral,

bacterial or hormonal disorders.

Eosinophils play a role in allergic reactions, possibly inactivating histamine. The

results indicate no deviation from normal limits which indicates no allergic reaction due

to antigen-antibody reactions.

Thrombocytes are adequate which means no deviation from the total number of

circulating platelets in the patient’s system. It also indicates good adhesiveness or sticky

quality of the platelets which allows them to clump together or aggregate and adhere to

injured surfaces if such damage is present.

The color of the erythrocytes and its size is within normal limits and as seen with

the results, the findings are normochromic and normocytic—no deviation from normal.

ESR- erythrocyte sedimentation rate-increased levels may suggest presence ofd

tuberculosis, acute and chronic inflammation, and anemia.

B. Blood Chemistry

  Result Normal Values

26-Feb-08

Creatinine 54umol/L- LO 62-133

27-Feb-08

AST 34u/L- normal 14-59

ALT 37u/L- normal 9- 72

Total CHON 69g/L- normal 63-82

Albumin 30g/L- LO 35-50

Globulin 38g/L- HI 23-35

29-Feb-08

LDH 1397u/L- HI 313-618

ALKP 187u/L- HI 38-126

INTERPRETATION:

Creatinine is constantly released from muscle and excreted primarily by

glomerular filtration with relatively no reabsorption and some secretion. Low blood

creatinine levels can mean lower muscle mass caused by a disease, such as muscular

dystrophy, or by aging. Low levels can also mean some types of severe liver disease or a

diet very low in protein. Pregnancy can also cause low blood creatinine levels.

Aspartate aminotransferase (AST), formerly called serum glutamic-oxaloacetic

transaminase, or SGOT, is another enzyme necessary for energy production. It, too, may

be elevated in liver and heart disease. In liver disease, the AST increase is usually less

than the ALT increase. However, in liver disease caused by alcohol use, the AST increase

may be two or three times greater than the ALT increase.

Alanine aminotransferase (ALT), formerly called serum glutamate pyruvate

transaminase, or SGPT, is an enzyme necessary for energy production. It is present in a

number of tissues, including the liver, heart, and skeletal muscles, but is found in the

highest concentration in the liver. Because of this, it is used in conjunction with other

liver enzymes to detect liver disease, especially hepatitis or cirrhosis without jaundice.

Additionally, in conjunction with the aspartate aminotransferase test (AST), it helps to

distinguish between heart damage and liver tissue damage.

Albumin is made mainly in the liver. It helps keep the blood from leaking out of

blood vessels. Albumin also helps carry some medicines and other substances through the

blood and is important for tissue growth and healing.

Albumin is tested to:

Check how well the liver and kidney are working.

Find out if your diet contains enough protein.

Help determine the cause of swelling of the ankles (pedal edema) or abdomen (ascites) or

of fluid collection in the lungs that may cause shortness of breath (pulmonary edema).

Decrease in albumin can cause edema to the patient because it is responsible for

the oncotic pressure in the vascular system.

Globulin is made up of different proteins called alpha, beta, and gamma types. Some

globulins are made by the liver, while others are made by the immune system. Certain

globulins bind with hemoglobin. Other globulins transport metals, such as iron, in the

blood and help fight infection

Globulin is tested to:

Determine your chances of developing an infection.

See if you have increased globulin levels are found in multiple myeloma and

Waldenstroum's macroglobulinemia, two cancers characterized by overproduction of

gammaglobulin from proliferating plasma cells. Increased globulin levels are also found

in chronic inflammatory diseases such as rheumatoid arthritis, acute and chronic

infection, and cirrhosisa rare blood disease, such as multiple myeloma or

macroglobulinemia.

ALP is generally part of a routine lab testing profile, often with a group of other tests

called a liver panel. It is also usually ordered along with several other tests if a patient

seems to have symptoms of a liver or bone disorder. High ALP usually means that the

bone or liver has been damaged. Very high ALP levels suggests that the patient’s bile

ducts are somehow blocked. Often, ALP is high in persons who have cancer that has

spread to the liver or the bones.

Lactate dehydrogenase (LDH) is a protein that normally appears throughout the body in

small amounts. Many cancers can raise LDH levels, so it is not useful in identifying a

specific kind of cancer. Measuring LDH levels can be helpful in monitoring treatment for

cancer. Noncancerous conditions that can raise LDH levels include heart failure,

hypothyroidism, anemia, and lung or liver disease.

C. Arterial Blood Gas Analyses

26-Feb-08

Arterial Blood Gas 11PM 11:45PM

Normal

Values

pH 7.42- normal 7.42- normal 7.35 - 7.45

PCO2 37-normal 37-normal 35 - 45

PO2 129.2-increased 129.2-increased 80 - 100

HCO3 23.6- normal 23.6- normal 22 - 26

B.E. 0.4- LO 0.4- LO ± 2 meq/L

O2Sat

98.6%-

increased 98.6%- increased 97%

INTERPRETATION:

The ABG result shows there is a normal arterial blood gas. Wherein, all results had been

compensated and the oxygen has good return to the body since there is more than

adequate oxygen result. There is a balance exchange of gases in the body. While in

Partial Oxygen measures, there is an increased pressure of oxygen dissolved in the blood

and there is increased oxygen moving from the airspace of the lungs into the blood, it

happens to compensate adequacy of oxygen saturation in the blood and the carbon

dioxide as well.

D. Urinalysis

Urinalysis 27-Feb-08 28-Feb-08

Color: Yellow Dark Yellow

Specific Gravity: 1.03 1.025

Characteristic Slightly Turbid Turbid

CHON: .30g/L 0.3

Reaction: 6 6

Sugar: Trace Negative

WBC: 3-5/HPF 3-4/HPF

RBC: 2-3/HPF 2-4/HPF

Epithelial Cells: Few Few

Bacteria: Few Few

Mucus: Moderate Moderate

Other: Amorphous Materials: Few

INTERPRETATION:

Slightly turbid appearance of urine is considered normal, however, turfbidity may

suggest concentrated urine. While urine’s specific gravity is an indication of the kidneys’

ability to reabsorb water and chemicals from the glomerular filtrate. However, specific

gravity is not a true measure of the number or concentration of particles but correlates

well with osmolality. The result shows a normal specific gravity of the patient’s urine,

this indicates that the kidney is able to concentrate or dilute urine and that the renal

tubules are functioning well. Also, there’s appropriate secretion of ADH by the posterior

pituitary gland and that it is in good functioning because it is the one which controls

water reabsorption in the collecting ducts.

Urine normally contains only a scant amount of protein which derives both from

the blood and the urinary tract itself. Proteinuria may indicate serious renal or systemic

disease, its detection on routine urinalysis must always be further evaluated for possible

cause.

Normally, glucose is virtually absent in the urine, the result is abnormal having a

trace of sugar in the patient’s urine. Although nearly all glucose passes into the

glomerular filtrate, most of it is reabsorbed by the proximal tubules through active

transport mechanisms. In active transport, carrier molecules attach to molecules of other

substances and transport them across membranes. Usually there are enough carrier

molecules to transport all of the glucose from the renal tubules back to the blood. If

plasma glucose levels are very high, however such that carrier mechanisms are

overwhelmed, glucose will appear in the urine, the point which called renal threshold

from 160-200 mg/ dl, depending on the individual. That is, the blood sugar must rise to

its renal threshold level before glucose will appear in the urine. The most common cause

of glycosuria is diabetes mellitus and perhaps this is the reason why there are trace of

sugar in the patient’s urine.

Only a few white blood cells are normally found in the urine, the above result is

increased which generally indicate either renal or genitourinary tract infection.

NURSING CONSIDERATION: A higher than normal number of leukocytes

may be seen if the sample is contaminated with genital secretions, also, the nurse must

carefully remind the patient not to allow samples to stand at room temperature for more

than 1-2 hour for this too will give false result.

The presence of Red Blood Cells in the urine which is called hematuria is

abnormal because RBC’s are too large to pass through the glomerulus, this condition

indicates damage to the glomerular membrane or to the genitourinary tract. But there are

some non-renal disorders wherein hematuria occurs, this includes presence of tumor,

blood cell infection and inflammation.

Few epithelial cells in the urine are normal so as rare bacteria, unless bacteria in

the urine are accompanied by excessive number of white blood cells, it may indicate an

infectious or inflammatory process. Amorphous materials as well are not of major

clinical significance.

E. PCR Test

5-Mar-08

PCR Test- NEGATIVE

CHON

Sugar

LDh

All substances are present at the pleural fluid

INTERPRETATION:

This process is artificial DNA replication, used to make copies of DNA that may be

needed for genetic testing and other times when you lots of bits of one part of DNA.

A powerful method for amplifying specific DNA segments which exploits certain

features of DNA replication. For instance replication requires a primer and specificity is

determined by the sequence and size of the primer. The method amplifies specific DNA

segments by cycles of template denaturation; primer addition; primer annealing and

replication using thermostable DNA polymerase. The degree of amplification achieved is

set at a theoretical maximum of 2^N, where N is the number of cycles, eg 20 cycles gives

a theoretical 1048576 fold amplification.

F. Pleural Fluid AFB Smear

28-Feb-08

Pleural Fluid AFB Smear

No Acid Fast Bacilli Seen

The pleural fluid smear is a screening test for the presence of microorganisms or

abnormal cells in pleural fluid in the space around the lungs .A sample of pleural fluid is

examined under the microscope. The test is performed when infection of the pleural

space is suspected, or when an abnormal collection of pleural fluid is noticed by chest x-

ray. There were no organisms present in the pleural fluid such as Mycobacterium

tuberculosis.

G. Pleural Fluid Analysis

28-Feb-08

Specimen - Pleural Fluid Result Normal Values

Rivalta's Test Negative

Ph 7.5-decreased 7.65

Specific Gravity 1.015-normal less than 1.015

Glucose 5.0mmol/L greater than 60 mg/dL

Total CHON 62g/L-increased less 3.0 g/dL

LDH 3,533u/L- increased less than or equal to 200 U/L

WBC 486x109/L-normal less than 1000 per microliter

Differential Count:

Segmentars 0.54- increased less than 50%

Lymphocytes 0.46- normal less than 50%

Pleural fluid analysis examines fluid that has collected in the pleural space. The

pleura is a thin membrane that lines the outside of the lung and the inside of the chest

cavity. The data above ruled out the diagnosis of exudative pleural effusion based on

Light’s criteria. Rivalta reaction is still used as a puncture fluid test for differentiation of

exudate and transudate pleural effusion.

H. Pleural Fluid Gram Stain and Pleural Fluid Culture and Sensitivity

28-Feb-08

Pleural Fluid Gram Stain

WBC-positive

No definite microorganism seen

3-Mar-08

Pleural Fluid Culture and Sensitivity

No growth after 72 hours of incubation (3-1-08)

INTERPRETATION

The pleural fluid gram stain is one of the best techniques for the rapid diagnosis

of bacterial infections. The test is performed when infection of the pleural space is

suspected or when an abnormal collection of pleural fluid is noticed by chest x-ray. There

were no microorganisms seen such as Mycobacterium tuberculosis. The patient’s pleural

fluid is positive to WBC which may indicate presence of infection.

I. Others

2-Mar-08

Result Normal Values

AFP >940- increased 0.0 – 11.3 IU/ml

B-HCG 84.91- increased 0.0 - 5.0 mIU/ml

INTERPRETATION

Alpha-fetoprotein is normally elevated in pregnant women since it is produced by

the fetus. However, AFP is not usually found in the blood of adults. In men, and in

women who are not pregnant, an elevated level of AFP may indicate liver cancer or

cancer of the ovary or testicle. Noncancerous conditions may also cause elevated AFP

levels. A high level of AFP may indicate a problem with the spinal cord, brain, or

digestive system.

HCG may indicate cancer in the testis, ovary, liver, stomach, pancreas, and lung.

Marijuana use can also raise HCG levels.

PROCEDURES

I. CT Scan

It is a special imaging procedure that uses the same X-rays as in a classic X-ray

examination. CT images are much more precise, however. This is because a CT takes

pictures of millimeter-thin layers of a selected region inside the body. The word

tomography comes from the Greek and means ‘depicting in layers or slices’. Various

types of tissue, such as bones, muscles and fat as well as possible changes in tissue, can

be shown much more clearly by a CT than by a simple X-ray. Furthermore, the computer

can subsequently dimensional image, which gives the physician an exact 3D picture of

certain body regions. This can be necessary before sur4gery on a complicated fracture,

for example.

CT Scan of the Chest to include the thoracic spine (non-contrast enhance)

Date: February 27, 2008

Results:

Limited study due to lack of IV contrast. There is a heterogeneous mass lesion

with calcification which appears to be in the right paratracheal space of the mediastinum

displacing the trachea to the left and compressing the underlying right lung parenchyma

as well as the right bronchi. The right lung is opacified. Moderate amount of right side

pleural effusion is present. There is pleural thickening in the right. A subcentimeter

nodule is present in the superior segment of the lower lobe. There is no focal infiltrate

and consolidation in left lung. Parenchymal fibrosis is seen in the left lower lobe. Heart is

within normal size and configuration. Great vessels are unremarkable on the non-contrast

exam. Esophagus shows no intraluminal defects. Walls are not thickened.

Lytic change is seen in the right pedicle of T2 vertebral body. Hyppodense/lytic

change is seen in L3 vertebral body . the rest of the thoracic and visualized lumbar

vertebral bodies and posterior elements are unremarkable. The alignment and

intervertebral disc spaces are unremarkable. There is a 1.2 cm hypodense structure in the

right hepatic lobe and a 2.3 cm hypodense structure in the left hepatic lobe.

Impression:

1. Limited study due to lacking of IV contrast.

2. Heterogenous mass lesion with calcification which appears to be in the right

paratracheal space of the mediastinal mass region such as teratoma with

additional malignant components is considered. Correlation with IV Chest CT

Scan and tissue correlation is suggested.

3. Subcentimeter nodule, left lower lobe.

4. Moderate right side pleural effusion.

5. Pleural thickening, right.

6. Possible metastasis, right pedicles at T2 vertebral body. Possible lytic change, L3

vertebral body.

7. Hypodense structure in the liver. Metastasis is not ruled out. Correlation with

contrast enhance abdominal CT is suggested.

II. X -Rays

It is electromagnetic radiation of extremely short wavelength (beyond the

ultraviolet), with great penetrating powers in matter opaque to light. X-rays are used in

diagnosis in the techniques of radiography and also in certain forms of radiography. Great

care is needed to avoid unnecessary exposure, because the radiation is harmful in large

quantities.

A. Chest AP Right Lateral DEC/TLS

February 26, 2008

Results:

There is hemogenous opaqcities of the right lung obscuring the left hemi

diaphragm and sulcus.

Hazy infiltrates are seen in the left lung base.

Heart size can’t be assessed.

Impression:

Massive pleural effusion

Right Pneumonia, left

Right lateral decubitus shows layering of fluid in its dependent portion.

B. Chest AP CTT insertion

February 27, 2008

Results:

Follow up chest now shows CTT tube on the right. There is very minimal clearing

of massive right side pleural effusion.

The rest of findings are unchanged.

Interpretation:

The patient was diagnosed of having pleural effusion which revealed on the first

x-ray result. The patient undergone CTT insertion that’s why he still need to underwent

Chest X-ray for the second time to determine if he tube is inserted at the right place.

C. X-ray of Thoracolumbar spine:

Lumbar spine is strengthened which can be due to muscle spasm.

Vertebral body heights and intervertebral disc spaces are intact.

III. CTT insertion

The pleural space normally contains a thin layer of lubricating fluid that allows

frictionless movement of the lungs during respirations. An excess of fluid (hemothorax or

pleural effusion), air (pneumothorax), or both in this space alters intrapleural pressure and

causes partial or complete lung collapse.

Chest tube insertion permits the drainage of air of fluid from the pleural space.

Performed by the doctor with a nurse assisting, this procedure requires sterile technique.

The insertion site varies, depending on the patient’s condition and the doctor’s judgment.

For hemothorax or pleural effusion, the sixth to the eight intercostals spaces are common

sites because fluid settles to the lower levels of the intrapleural space. For removal of

both air and fluid, a chest tube is inserted into a high and low site. Following insertion,

the chest tube is connected to a thoracic drainage system that provides for the drainage of

air and/or fluid out of the pleural space, thus promoting lung expansion.

DRUG STUDY

1. MORIAMIN FORTEClassification: Multivitamins, Essential Amino acids, folic acid, 5 oxyanthranillic acidAction: It protects and enhances body’s immune system response against further infectionSide Effects: without any known side effects.Why is it given?: Since the patient was experiencing lung cancer, the patient undergone immune system depression, this drug is given to enhance patient’s response.

2. DEXAMETHASONE SODIUM SUCCINATE 4MG TAB BIDBrand Name: DexamethasoneClassification: An anti inflammatory DrugAction: Glucocorticoids, naturally occurring and synthetic, are adrenocortical steroids that cause varied metabolic effects. In addition, they modify the body's immune responses to diverse stimuli. Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have sodium-retaining properties, are used as replacement therapy in adrenocortical deficiency states. Their synthetic analogs including dexamethasone are primarily used for their anti-inflammatory effects in disorders of many organ systems.

Adverse Effects:

Allergic reactions: Anaphylactoid reaction, anaphylaxis, angioedema.

Cardiovascular: Bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure, fat embolism, hypertension, hypertrophic cardiomyopathy in premature infants, myocardial rupture following recent myocardial infarction (see WARNINGS, Cardio-renal), edema, pulmonary edema, syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis.

Endocrine: Decreased carbohydrate and glucose tolerance, development of cushingoid state, hyperglycemia, glycosuria, hirsutism, hypertrichosis, increased requirements for insulin or oral hypoglycemic agents in diabetes, manifestations of latent diabetes mellitus, menstrual irregularities, secondary adrenocortical and pituitary unresponsiveness (particularly in times of stress, as in trauma, surgery, or illness), suppression of growth in pediatric patients.

Fluid and electrolyte disturbances: Congestive heart failure in susceptible patients, fluid retention, hypokalemic alkalosis, potassium loss, sodium retention.

Gastrointestinal: Abdominal distention, elevation in serum liver enzyme levels (usually reversible upon discontinuation), hepatomegaly, increased appetite, nausea, pancreatitis, peptic ulcer with possible perforation and hemorrhage, perforation of the small and large intestine (particularly in patients with inflammatory bowel disease), ulcerative esophagitis.

Musculoskeletal: Aseptic necrosis of femoral and humeral heads, loss of muscle mass, muscle weakness, osteoporosis, pathologic fracture of long bones, steroid myopathy, tendon rupture, vertebral compression fractures.

Contraindication: Hypersensitivity to corticosteroids

Indication: Respiratory diseases: Berylliosis, fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculous chemotherapy, idiopathic eosinophilic pneumonias, symptomatic sarcoidosis.

Why is it given?: The patient had lung cancer and experiencing difficulty of breathing, it will help tomopen airway by dilating bronchioles for more oxygen supply. It also prevents inflammation.

3. PARACETAMOL 500MG/TAB Q4 FOR FEVER

Brand Name: Biogesic

Classification: Antipyretic drug

Action: It blocks the hypothalamus to secrete pyrogens a chemical mediator responsible for increasing thermoregulation.

Indication: This drug is indicated to patient with fever and pain

Contraindication: It is contraindicated to repeated administration in anemic patient, Cardiac, Pulmonary, Renal and hepatic disease.

Side Effects: Skin rash and GI disturbances.

Why is it given?: Due to inflammatory responses, the patient experiencing fever, thus, using paracetamol will lower it.

4. NALBUPHINE 5MG Q6 FOR PAIN

Brand Name: Nubain

Classification: Opiate Analgesic

Action: NUBAIN is a potent analgesic. Its analgesic potency is essentially equivalent to that of morphine on a milligram basis. Receptor studies show that NUBAIN binds to mu, kappa, and delta receptors, but not to sigma receptors. NUBAIN is primarily a kappa agonist/partial mu antagonist analgesic.

Indication: NUBAIN is indicated for the relief of moderate to severe pain. NUBAIN can also be used as a supplement to balanced anesthesia, for preoperative and postoperative analgesia, and for obstetrical analgesia during labor and delivery.

Contraindication: NUBAIN should not be administered to patients who are hypersensitive to nalbuphine hydrochloride, or to any of the other ingredients in NUBAIN.

Side Effects: Nervousness, depression, restlessness, crying, euphoria, floating, hostility, unusual dreams, confusion, faintness, hallucinations, dysphoria, feeling of heaviness, numbness, tingling, unreality, Hypertension, hypotension, bradycardia, tachycardia, Depression, dyspnea, asthma.

Why is it given?: The patient is experiencing severe bone pain, nalbuphine is given to reduce pain.

5. CIPROFLOXACIN

Brand Name: Ciprobay

Classification: Anti infective drugs

Action: An antibiotics that prevent and blocks further bacterial and viral infection.

Indication: Urinary Tract Infections, Lower Respiratory Tract Infections, Bone and Joint Infections

Contraindication: Ciprofloxacin is contraindicated in persons with a history of hypersensitivity to ciprofloxacin, any member of the quinolone class of antimicrobial agents, or any of the product components.

Concomitant administration with tizanidine is contraindicated.

Side Effects: palpitation, atrial flutter, ventricular ectopy, syncope, hypertension, angina pectoris, myocardial infarction, cardiopulmonary arrest, cerebral thrombosis, phlebitis, tachycardia, migraine, hypotension, restlessness, dizziness, lightheadedness, insomnia, nightmares, hallucinations, manic reaction, irritability, tremor, ataxia, convulsive seizures, lethargy, drowsiness, weakness, malaise, anorexia, phobia,

depersonalization, depression, paresthesia, abnormal gait, grand mal convulsion, dyspnea, epistaxis, laryngeal or pulmonary edema, hiccough, hemoptysis, bronchospasm, pulmonary embolism.

Why is it given?: A patient is at risk for infection, antibiotics is given to prevent entrance of microorganism that may lead to infection.

COURSE IN THE WARD

March 3, 2008

The patient was seen lying in supine position with ongoing IVF # 10 D5 NM 1L x

12 hours at 500 cc level and SD A # 7 D5 W 500 + 200 mg Tramadol x 24 hours at full

level; inserted at right metacarpal vein and infusing well. He has right CTT connected to

3-way bottle with no draining output. He also has patent and intact FC to CDU draining

dark yellow urine at 200 cc level. He is in full diet + 2 egg whites TID. “Ate, masakit

yung sa may tubo ko saka yung likod ko masakit din”, as stated. He is weak and pale

looking, with pale lips and conjunctivae noted. Facial grimacing when moving and

frequent touching of the back was also evident as observed. He had pain scale of 6 out of

10 where 10 is the highest and admitted that the pain he felt was tolerable. So Nalbuphine

50 mg q6h IV which is given PRN for pain was not given. The client was encouraged to

do relaxation technique such as deep breathing. Touch therapy was also provided. The

client was also encouraged to increase fluid intake as ordered. Spiritual care such as

praying with the client was rendered.

March 4, 2008

The patient was seen lying in supine position with ongoing IVF # 12 D5 NM 1L x

24 hours at 900 cc level inserted at right metacarpal vein and infusing well. The

Tramadol drip was removed and replaced by Morphine Sulfate tablet p.o TID. He has

right CTT connected to 3-way bottle with no draining output. He also has patent and

intact FC to CDU draining dark yellow urine at 250 cc level. “Namamanhid po yung

dalawang paa ko at di kop o masyadong magalaw at maangat”, as said. He is still weak

and pale looking. He has limited ROM and poor muscle tone at lower extremities. He

cannot ambulate and cannot do ADLs alone. The client was encouraged to eat fruits and

vegetables and foods rich in protein. He was also instructed to increase oral fluid intake.

The relatives were also encouraged to exercise the feet of the client by doing passive

ROM. They were also instructed to help the client in doing his ADL. Dr. M. R. ordered

for the client to have thoracoscopy, biopsy and talc poundage tomorrow at 5:00 PM in

OR. The relatives were informed by Dr. Q about the procedure but refused to sign until

the oldest sibling arrived.

March 5, 2008

The patient was seen lying in supine position with ongoing IVF # 12 D5 NM 1L x

24 hours at 900 cc level inserted at right metacarpal vein and infusing well. He has right

CTT connected to 3-way bottle with no draining output. He also has patent and intact FC

to CDU draining dark yellow urine at 100 cc level. “Nagbabalat na yung likod nya,

parang nagbibitak na,” as said by the mother of the client. The client has dry and scaly

skin at the back. He also doesn’t ambulate or turn from side to side. He is still with

limited ROM and dependent in doing ADLs. The client was turned from side to side.

Back rub, tapotement and effleurage was rendered. The schedule for thoracoscopy,

biopsy and talc poundage was deferred because the relatives refused to sign the consent

due to financial constraints.

March 6, 2008The patient was received lying on bed on supine position, with ongoing IVF of

#13 D5NM 1L x 24 hours at 300 cc level infusing well at right metacarpal vein. He has

right CTT to 3 way bottle with no output draining. He also has a Foley Catheter to CDU,

patent and intact with yellowish output of about 210 cc. The patient still complained with

joint pains on the lower extremities, thus, health teachings regarding pain relief were

rendered by the SN. Rest periods were provided during interventions, and the patient had

some time to sleep at frequent intervals uninterruptedly. Patient was assisted to turn from

side to side but still the patient cannot tolerate the turning schedules due to pain upon

doing so. The patient was then encouraged to do some ROM exercises to facilitate good

circulation. The patient is still for thoracoscopy and talc poundage but OR was deferred

temporarily due to refusal of patient’s relatives to sign the written consent.

NURSING THEORY

LYDIA HALL’S CORE, CARE, CURE

IMOGENE KING’S GOAL ATTAINMENT THEORY

The group utilized the theory of Lydia Hall which is the Core, Care, and Cure.

This theory was used to further enhance the rendering of care to the patient. In this theory

there had been a collaborative work done by the physicians, the nurses and the student

nurses and as well as the patient himself. The core is the patient, wherein he is the center

of both the cure and the care. The cure is when the physicians takes place. This is

wherein they give medications and procedures for the patient, may it be invasive or non-

invasive. While the nurses together with the student nurses are the care. This is the part

wherein the core is being cared of, physically, mentally, emotionally, and spiritually. In

here the student nurses focused more on the care of the patient but also assisted in

delivering cure to the patient, by means of carrying out doctor’s order, giving

medications and etc.

The group incorporated the theory of Imogene king which is the goal attainment

theory. The group also utilized this theory since the above theory that was mentioned was

collaborative; which is composed of the patient, the physicians and the nurses and student

nurses as well. In using this theory the student nurse together with the patient formulated

a goal: and that is to help the patient recover from his condition and be able to continue

his normal daily activities. The student nurses ensured that the patient is still asked for his

preference and opinion in forming the said goal.

PROBLEM #ASSESSMENT:

Subjective:

“Sobrang sakit ng paa ko. Hindi ko na kaya!” as stated

“Paano ba mawawala ‘to!” as added

Objective:

-pale and weak looking

-restless and irritable

-with limited movements noted

-with limited focus

-poor eye contact noted

-pale conjunctivae

-teary eyed

-with nasal flaring noted

-dry, pale lips

-with facial grimacing noted

-with guarding behavior on lower extremities

-with clenched fist noted

-pain scale of 9 out of 10

Nursing Diagnosis

Alteration in Comfort: Acute Pain related to nerve compression of both limbs

Nursing Goal:

At the end of 8 hours duty the patient will be able to verbalize decreased pain

from 9 to 5 as manifested by less facial grimacing and guarding behavior through the use

of relaxation skills and divertional activities to be taught by the student nurse after the

hours of duty.

Nursing Interventions with Rationale:

1. Allowed patient to verbalize pain.

R: Pain is subjective that can only be felt by the person affected.

2. Determined pain history, such as location, frequency, duration, intensity and relief

measures used.

R.: Information provides baseline data to evaluate need for or effectiveness of

interventions. Pain of more than 6 mo duration constitutes chronic pain, which may

affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic

pain, requiring increased level of intervention

3. Provided non-pharmacologic comfort measures such as repositioning, back rub and

divertional activities such as listening to music and conversing about pleasant things.

R: Promotes relaxation and helps refocus attention.

3. Encouraged use of stress management skills or complementary therapies such as

guided imagery and therapeutic touch.

R: Enables patient to participate actively in nondrug treatment of pain and enhances

sense of control. Pain produces stress and, in conjunction with muscle tension and

internal stressors, increase patient’s focus on self, which in turn increases the level of

pain.

4. Taught to do deep breathing exercise and instructed to do it along with the other

interventions when the pain starts.

R: Increases lung expansion, reduces muscle tension, enhances circulation and

decreases pain perception.

5. Regulated Tramadol drip timely and correctly.

R: to ensure that the right amount of drug is given so as to help patient cope with the

pain through pharmacologic approach.

6. Administered Nalbuphine (Nubain) 5 mg TIV as rescue pain management as

ordered.

R: To aid in controlling pain easier and faster.

7. Instructed relatives to stay with the patient at most times.

R: To reduce anxiety and enhance patient’s coping skills which in turn, decreases

pain.

Evaluation:

Goal Partially Met!

At the end of 8 hours duty the patient was able to verbalize decreased pain from 9

to 6 as manifested by less facial grimacing and guarding behavior through the use of

relaxation skills and divertional activities taught by the student nurse after the 8 hours of

duty.

PROBLEM #

ASSESSMENT

Subjective:

“Lagi lang siyang nakahiga. Hindi niya kayang tumagal ng nakatagilid kasi

sumasakit yung tagiliran niya dahil sa tubo at nanghihina kasi siya.” as stated by the

relative

“Tuyo na nga likod niya at natatanggal na ang mga balat.” As added by the

relative

Objective:

-pale and weak looking

-restless and irritable

-with limited/ reluctance movements noted

-with right CTT-3 way bottle

-with fracture board under the mattress

-stays confined on low fowler’s position

-facial grimacing noted on slight movements

-with dry, scaly, blanching of skin on the back

-redness noted on the sites affected

Nursing Diagnosis:

Impaired skin integrity: presence of reddened dry and scaly skin on the back

related to prolonged bed rest and immobility

Nursing Goal:

At the end of 8 hours duty, the patient will be able to have improved skin integrity

through participating in techniques to promote healing as manifested by decreased

redness and scaly skin.

Nursing Interventions with Rationale

1. Turned/ Repositioned patient at least every 2 hours.

R: Promotes circulation and prevents undue pressure on skin and tissues.

2. Encouraged use of soft, loose cotton clothing.

R: To promote comfort and maintain optimum circulation

3. Used preventive skin care devices such as pillows and padding.

R: To avoid discomfort and skin breakdown

4. Kept patient’s skin dry and clean.

R: These measures promote comfort and reduce risk of irritation and skin breakdown.

5. Protected bony prominences with pillows and padding.

R: Prominences have little subcutaneous fat and are prone to breakdown; using

padding and pillows may help promote skin integrity.

6. Kept linen dry, clean and free from wrinkles or crumbs.

R: Dry, smooth linens help prevent excoriation and skin breakdown.

7. Monitored nutritional intake and maintained adequate hydration.

R: Anemia and low serum albumin which the patient has are associated with the

development of pressure ulcers. Hydration helps maintain skin integrity.

8. Educated his family and the patient in preventive skin care and the essence of

frequent repositioning.

R: These measures encourage compliance with patient’s skin care regimen.

Evaluation:

Goal Met!

At the end of 8 hours duty, the patient was able to show improved skin integrity

through participating in techniques to promote healing as manifested by decreased

redness and scaly skin.

PROBLEM #

ASSESSMENT:

Subjective:

“Hindi na ako makatayo at makalakad sa sobrang sakit ng paa ko.” As stated

“Mas gusto ko pa itong nakahiga.”as added

Objective:

-pale ands weak looking

-with limited movements noted

-able to do passive and active ROM exercise

-poor muscle strength noted, RA: 5 LA: 5, RL:3 LL: 3

-poor muscle tone as observed

-prefers to stay confined on low fowler’s position

-poor attention span

-limited focus noted

-facial grimacing noted on slight movements

-guarding behavior noted on lower extremities

Nursing Diagnosis:

Impaired Physical Mobility related to generalized weakness and joint pains

Nursing Goal:

At the end of 8 hours duty, the patient will be able to achieve a slight increase in

physical mobility and show no evidence of complications such as contractures and skin

breakdown through patient’s willingness to participate in care.

Nursing Interventions and Rationale:

1. Observed patient’s functional ability daily.

R: Changes may indicate decline or improvement in underlying disorder.

2. Ensured patient comfort by padding extremities prone to skin breakdown and

repositioned patient every 2 hours and provided meticulous skin care.

R: These measures prevents skin breakdown.

3. Implemented ROM exercises from passive to active, every after pain

medication.

R: This prevents injury, joint contracture and muscle atrophy.

4. Encouraged patient’s active movement by using assistive devices and

promoted joint rest between activities.

R: To increase muscle tone and increase patient’s feelings of self-esteem

5. Promoted progressive mobilization to maximum, within the limits of patient’s

tolerance for pain.

R: This maintains muscle tone and prevents complications of immobility.

6. Discussed the use of distraction and other nonpharmacologic pain relief

methods with patient.

R: In addition to providing pain relief, nonpharmacologic techniques may help

patient achieve a sense of control.

7. Encouraged nutritional intake.

R: Necessary to meet energy needs for mobility.

8. Recommended scheduling activities for periods when patient has most energy

and decreased pain.

R: Prevents overexertion, allows for some activity within the patient’s ability.

Evaluation:

Goal Met!

At the end of 8 hours duty, the patient was able to achieve a slight increase in

physical mobility and show no evidence of complications such as contractures and skin

breakdown through patient’s willingness to participate in care.

PROBLEM #

POST OPERATIVE

Assessment

Subjective:

“Kakalagay lang ng tubo sa tagiliran ko kaya hirap akong huminga”

“Parang hinahabol yung hininga”stated by the client

Objective:

- Pale and weak looking

- Restless and irritable

- Nasal flaring noted

- Mouth breathing noted

- Pale and dry lips

- Substernal muscles noted upon respiration

- Retractions noted on inspiration

- Crakles noted upon auscultation

- With respiratory rate of 38bpm

- With CTT to 3 way bottle draining

Nursing Diagnosis:

Ineffective breathing pattern related to altered physiology secondary to opening

the pleural cavity.

Nursing Goal:

At the end of 8 hours of duty, the patient will achieve normal breathing pattern as

evidenced by eupnea and a respiratory rate within the normal limits (14-24bpm) from a

RR of 38 bpm.

Nursing Interventions with Rationales:

1. Positioned the patient on semi fowler’s with head elevated 30 to 40 degrees

R: To improve movement of diaphragm

2. Looked and listened at the patient’s open mouth as he breathes.

R: To look for evidences of obstruction

3. Auscultated chest for adequacy of air movement.

R: To detect bronchospasm, consolidation.

4. Encouraged deep breathing exercises

R. To expand the lungs for better gas exchange

5. Taught of effective coughing technique

R: To expectorate secretions and increase intrapleural pressure.

6. Administered oxygen therapy

R: It decreases the ventilatory and myocardial work; warming and humidification of

inspired gases prevents drying of secretions and loss of body heat.

7. Checked the chest drainage on frequent intervals note for the color of drain and the

level of secretion.

R: Chest tube must maintain a negative pressure to avoid mediastinal shift. Assessing

for the color and drain is necessary to assess the effectiveness of the chest tube.

8. “Milked” the tubing in the direction of the drainage bottle as often as directed.

R: To prevent the tubing becoming plugged with cloth and fibrin. It also provides

patency which will facilitate prompt expansion of the lung and minimize

complication.

Evaluation

Goal met!

The patient achieved normal breathing pattern as evidenced by eupnea and a

respiratory rate within the normal limits which is 24 bpm from 38 bpm.

PROBLEM #

ASSESSMENT:

Subjective:

“Marami pa rin po akong plema at inuubo po ako. Matagal na po ito. Di

ko na po matandaan kung kailan nagsimula.”, as verbalized

Objective:

Appears pale and weak-looking

Teary-eyed

With intermittent productive cough: sputum appears

yellowish,thick and in very small amount

With abnormal breath sounds: crackles heard upon auscultation

With slight chest indrawing noted when coughing

With RR=34

Nursing Diagnosis

Ineffective airway clearance R/T decreased mucociliary action S/T present condition:

lung cancer

Nursing goal

At the end of 8-hour duty, the patient will be able to demonstrate improved

airway clearance as evidenced by clear breath sounds and will be able to expectorate at

least 30 ml. of sputum after the interventions rendered by the student nurse.

Nursing Intervention

1. Advised to perform deep breathing exercises.

®: Promotes mobilization of secretions for better lung expansion.\

2. Encouraged to increase oral fluid intake up to 2L/day.

®: Fluids help decrease viscosity of sputum.

3. Instructed on proper coughing technique with upright position.

®:Upright position allows maximal lung expansion. Effective coughing

helps avoid stress in coughing.

4. Provided mild bronchial clap.

®: Bronchial clap helps loosen secretions from the lung fields sfor easier

expectoration.

5. Observed character of sputum upon expectoration

®: Blood-streaked sputum indicates trauma in the bronchus or lungs and

may promote development of secondary problems such as Pneumonia, etc.

6. Advised to rest every after cough for about 15 minutes.

®: To avoid overexhaustion in coughing

7. Auscultated breath sounds.

®: To determine if further interventions in removel of sputum is still

needed.

8. Encouraged to increase intake of foods rich in Vitamin C such as oranges and

calamansi juice.

®: Vitamin C helps boost immune system to avoid further respiratory

problems that can occur which can cause further increase in sputum

production.

Evaluation

Goal partially met!

At the end of 8-hour duty, the patient was able to demonstrate slight improvement

in airway clearance as evidenced by expectoration of approximately 10 to 20 cc of

yellowish, non- blood streaked sputum after the interventions rendered by the student

nurse.

PROBLEM #ASSESSMENT:

Subjective

“Medyo kinakabahan ako sa gagawin sa akin sa operasyon. Di naman daw

delikado pero unang beses ko lang kasi naranasan ang magpa-opera”, as

verbalized by patient.

Objective

Pale and weak-looking

Appears nervous; mild anxiety noted

Teary eyed

Frequently asked questions

Appears interested in knowing about the operation

Nursing Diagnosis

ANXIETY R/T POSSIBLE OUTCOME OF THE SURGICAL

PROCEDURE: CLOSED THORACOSTOMY TUBE INSERTION

Nursing goal

At the end of 8-hour duty, the patient will be able to demonstrate decreased

anxiety as evidenced by the client will appear calm before the procedure and verbalize

decreased nervousness on the procedure after the interventions rendered by the student

nurse.

Nursing Interventions

1. Encouraged verbalization of feelings.

®: Support may enable patient to begin exploring and dealing with the

reality of Cancer and its treatment. Patient may need time to begin to express their

feelings.

2. Provided therapeutic touch.

®: Establishes trust and expresses support and empathy.

3. Provided opportunities to ask questions about the procedure and answered

them honestly. Provided teachings on the advantages and disadvantages of

the procedure.

®: This will decrease misperception/ misinterpretations of the situation.

This will also help in the psychological preparation of the patient.

4. Noted behaviors indicative of increased anxiety like restlessness, anger,. And

crying episodes.

®: This will signal other necessary interventions appropriate for the

situation such as pharmacotherapy.

5. Involved significant others in the teaching and support.

®: Family and close friends are effective in helping the patient cope with

the procedure to be done if involved fully in the teachings.

Evaluation

Goal met!

At the end of 8-hour duty, the patient was able to demonstrate decreased anxiety

as evidenced by the client appeared calm before the procedure and verbalized decrease

nervousness on the procedure after the interventions rendered by the student nurse.

PROBLEM #

ASSESSMENT:

Subjective:

“Marami pa rin po akong plema at inuubo po ako. Matagal na po ito. Di

ko na po matandaan kung kailan nagsimula.”, as verbalized

Objective:

Appears pale and weak-looking

Teary-eyed

With intermittent productive cough: sputum appears

yellowish,thick and in moderate amount

With abnormal breath sounds: crackles heard upon auscultation

With slight chest indrawing noted when coughing

With RR=

Nursing Diagnosis

INEFFECTIVE AIRWAY CLEARANCE R/T DECREASED MUCOCILIARY

ACTION SECONDARY TO PRESENT CONDITION: LUNG CANCER

Nursing goal

At the end of 8-hour duty, the patient will be able to demonstrate improved

airway clearance as evidenced by clear breath sounds, noiseless respiration, and will be

able to expectorate at least 30 ml. of sputum after the interventions rendered by the

student nurse.

Nursing Interventions

1. Advised to perform deep breathing exercises.

®: Promotes mobilization of secretions for better lung expansion.

2. Encouraged to increase oral fluid intake up to 2L/day.

®: Fluids help decrease viscosity of sputum.

3. Instructed on proper coughing technique with upright position.

®:Upright position allows maximal lung expansion. Effective coughing helps avoid stress in coughing.

4. Provided mild bronchial clap.

®: Bronchial clap helps loosen secretions from the lung fields sfor easier expectoration.

5. Observed character of sputum upon expectoration.

®: Blood-streaked sputum indicates trauma in the bronchus or lungs and

may promote development of secondary problems such as Pneumonia, etc.

6. Advised to rest every after cough for about 15 minutes.

®: To avoid over exhaustion in coughing

7. Auscultated breath sounds.

®: To determine if further interventions in removal of sputum is still

needed.

8. Encouraged to increase intake of foods rich in Vitamin C such as oranges and

calamansi juice

®: Vitamin C helps boost immune system to avoid further respiratory

problems that can occur which can cause further increase in sputum

production.

Evaluation

Goal partially met!

At the end of 8-hour duty, the patient was able to demonstrate slight improvement

in airway clearance as evidenced by noiseless respiration, and expectoration of 30 ml. of

yellowish, non- blood streaked sputum after the interventions rendered by the student

nurse.

PROBLEM #

Assessment:

Subjective

“Nahihirapan akong gumalaw kasi hinihingal ako,” patient said

Objective

RR – 38cpm

Deep breathing noted

Moist crackles heard on both lung fields upon auscultation

Flaring of the nares noted.

Pale and Dry Lips

Tired and Weak-Looking

Slightly Diaphoretic

Lying in bed on a side-lying position

Has difficulty assuming a standing position

Has difficulty moving both the left and right extremities

With a muscle strength of 3/5 for both left and right lower extremities

Nursing Diagnosis:

Activity intolerance related to difficulty of breathing.

Nursing Goal:

At the end of 8 hours of duty, the patient will be able to report a measurable

increase in activity tolerance as evidenced by being able to assume a standing position

with less discomfort and preventing complications in the disease condition.

Nursing Interventions with Rationale

1. Assess patient’s response to activity, such as increased BP of >140 in systolic and

>90 in diastolic, elevated pulse of more than 20 bpm, dyspnea, chest pain,

excessive fatigue, diaphoresis, dizziness or syncope.

® - The said parameters are helpful in assessing physiologic responses to the stress of

activity, and if present, are indicators of overexertion associated with activity level

2. Put the patient’s needs and belongings closer to the patient and bedside.

® - this is to decrease too much activity in the patient to help control shooting levels

of blood pressure to lessen the exacerbation of the disease process

3. Placed comfortably on a low-Fowler’s or semi-Fowler’s position

® - to promote lung expansion for better ventilation and perfusion of the patient

4. Encouraged to assume the orthopneic position.

® - to promote drainage of secretions for better lung expansion and therefore better

ventilation and perfusion to the client

5. Provide help to the patient as needed in simple ADL’s. (e.g. eating, holding a

glass, etc.)

® - pt may have a hard time in such activities due to the feeling of numbness and

weakness on the affected site. Providing assistance as needed encourages

independence in performing such activities

6. Encouraged progressive activity to the patient and taught slight range-of-motion

exercises when tolerated (e.g. dangling of feet, assuming a standing position,

etc.).

® - to help restore normal activity and avoid total weakness or paralysis of the

affected site due to immobility.

7. Encouraged early ambulation with assistance

® - to promote activity and avoid immobility to the patient and avoid pressure sores

by staying too long in bed

8. Encouraged to rest when fatigued.

® - to not overwork the heart as it may increase the workload therefore increasing the

blood pressure and may bring about complications brought about by the disease

condition

9. Provided massage on the lower extremities

® - to provide comfort to the affected hand and stimulation through touch therapy

10. Provide a walker for walking.

® - a walker will help in assisting the patient to walk and ambulate that will, at the

same time, avoid injury.

Evaluation:

Goal Met!

At the end of 8 hours duty, the patient was able report a measurable increase in

activity tolerance as evidenced by assume a standing position for 5 minutes and ambulate

to and fro inside the patient’s room with less discomfort and preventing complications in

the disease condition as evidenced by a blood pressure of 140/90mmHg.

BIBLIOGRAPHY

Jeanette Watson, R.N., M. Sc. N., Medical-Surgical Nursing and Related Physiology, 2nd

Edition, 1979, W.B. Saunders Company

Suzanne Smeltzer R.N., Brenda G. Bare R.N., Medical Surgical Nursing, 10th Edition,

Lippincott Williams and Wilkins

Joyce Mielack R.N., Jane Hokanson- Hawks R.N., Medical-Surgical Nursing, 7th Edition,

2004, Elsevier Saunders Company

June H. Celia R.N., M.S.N., Ed.D., Juanita Watson, R.N., M.S.N., Nurse’s Manual of

Laboratory Tests, F.A. Davis Company, pp.20-40, pp.305

Sheila Sparks Ralph, R.N., D.N.Sc.,F.A.A.N., Cynthia M. Taylor, R.N., M.S., Nursing

Diagnosis Reference Manual, 6th Edition, Lippincott Williams and Wilkins

Jocelyn Yambao-Franco, M.D., Philippine Pharmaceutical Directory Review, 5th Edition,

Medicomm Pacific

Judith Hopfer Deglin, PharmD, April Hazard Vallerand, PhD, R.N., Davis’s Drug Guide

for Nurses, 9th Edition, F.A. Davis Company

TABLE OF CONTENTS

Title Page

I. Introduction

II. Demographic Data

III. Gordon’s Functional Health Pattern

IV. Physical Examination

V. Risk Factors

VI. Pathophysiology

VII. Laboratory

VIII. Procedure

IX. Drug study

X. Course in the Ward

XI. Nursing Theory

XII. Nursing Care Plan

XIII. Health Teaching

XIV. Bibliography