GROUP 5

PTB, PNEUMONIA, HYDROPNEUMOTH

ORAX

University of Perpetual Help System - LagunaDr. Jose G. Tamayo Medical University

Sto. Niño, Biñan, LagunaCOLLEGE OF NURSING

A.Y. : 2014 – 2015, 1st SEMESTER

I. Introduction

Pulmonary TuberculosisPulmonary Tuberculosis in the past also called phthisis, phthisis

pulmonalis, or consumption, is a widespread, and in many cases fatal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. Tuberculosis typically attacks the lungs, but can also affect other parts of the body. M. tuberculosis becomes dormant before it progresses to active TB. It most commonly involves the lungs and is communicable in this form, but may affect almost any organ system including the lymph nodes, CNS, liver, bones, genitourinary tract, and gastrointestinal tract. It is spread through the air when people who have an active TB infection cough, sneeze, or otherwise transmit respiratory fluids through the air. Most infections do not have symptoms, known as latent tuberculosis. About one in ten latent infections eventually progresses to active disease which, if left untreated, kills more than 50% of those so infected. Many people who are infected with TB have few or no symptoms at all, at least in the beginning. Some people develop symptoms slowly, over time, and pay little attention to them until the disease has reached the advanced stages. When symptoms do appear, they generally include: fatigue, loss of appetite and weight loss, cough with purulent and/or bloody sputum, night sweats, low-grade fever that occurs mostly in the afternoon, and lethargy.

TB kills more people than any other infectious agent and was associated with an estimated 1.4 million deaths in 2011, second only to HIV/AIDS among infectious diseases. Approximately one third of the global population is infected. According to WHO data, there were 8.7 million new cases of TB worldwide in 2011, and 1.1 million new cases of TB in people infected with HIV.

Tuberculosis (TB) is a major public health concern in the Philippines, ranking as the sixth (previously fifth) leading cause of morbidity and mortality based on recent local data. In 2011, the Philippines with an estimated population of 94,852,000,recorded a total of 28,000 deaths from tuberculosis, at the turn of the century. In worldwide, Tuberculosis is the second leading cause of death among developing countries. Standard medical treatment with antibiotics is usually effective in managing TB.  Successful treatment depends on close cooperation between the patient and physicians and other health care workers.  Patient education is essential, and many doctors opt for supervised, directly observed therapy (DOT).

• STAGES OF PTB• 1. Latent Tuberculosis – It is the stage of infection when the person who

had been exposed to the M. tuberculosis nuclei does not manifest signs and symptoms of the disease and do not have the capacity to infect other people. The nuclei just persist in the system in its necrotic form which could stay for a long time, not until that immunosuppression or a certain factor triggers it to become its virulent form.

• 2. Primary Pulmonary Tuberculosis – Since the most immediate location of pathogenesis of the organism is in the lungs, primary activation of disease in the pulmonary cavity is considered. It is usually asymptomatic and only identified through significant diagnostic examinations. Only the presence of lymphadenopathy is something that is indicative for its infection.

• 3. Primary Progressive Tuberculosis – It is the stage of the disease process when it is already considered as active. Clinical manifestations are evident and the client may reveal positive in sputum examination for presence of the organism. Sometimes, he or she may manifest cough with purulent sputum and some pleuritic chest pain because of inflammation in the parenchymal walls.

• 4. Extrapulmonary Tuberculosis – It is when tuberculosis extends its infection to other parts of the aside from the pulmonary cavity. The most fatal location is the central nervous system and its infection to the bloodstream. Other locations may include the lymphatic system, the bones and joints and at times the genitourinary system.

II. Patient’s Profile

II. Patient’s Profile• Name : M.L.S.• Address : Cabilang Bay-bay,

Carmona Cavite• Age : 38 year old• Date of Birth : February 12, 1976• Gender : Male• Religion : Roman Catholic• Nationality : Filipino• Civil Status : Married• Admission Date : August 12, 2014• Admission Time : 10:38 PM• Attending Physician : Dr. Brillantes• Initial diagnosis : TB Pneumonia

DM2 controlled• Final diagnosis : PTB, Pneumonia,

Hydropneumothorax

• A. History of Present Illness:CHIEF COMPLAINT: Difficulty of BreathingTemperature: 37.5 Pulse Rate: 112bpmRespiratory rate: 38cpmBlood Pressure: 120/80 mmHg 

Patient is diagnosed with Pneumonia last July 31, 2014.

4 days prior to admission, patient experienced difficulty of breathing and easy fatigability, patient is allegedly complaint to mediastina, and abdominal pain on the right upper quadrant when coughing, patient has difficulty of sleeping(4 days), patient has orthopnea, relieved when sleeping in lateral decubitus position, persistence of symptoms prompted consult.

B. Past Medical History(+) DM: 2012 (metformin 500mg ODAD)

(glibenclamide, OD)(+) Pneummonia: July 31 2014 – Levofloxacin

500mg/tab Azithromycin

500mg/tab HRZE tab Mucolytic/

Antihisamine Prednisone 30mg OD

C. Family History of Illness(+) HPN: maternal & paternal side(+) Heart Dse: Paternal side(+) DM: Maternal & Paternal(+) PTB: Paternal side

D. Personal/Social DataSmoking: 5-6 sticks/ dayAlcoholic drinker: 100ml of 1liter of emperador

every other day

E. Environmental HistoryThe patient is presently residing at Cabilang Bay-

bay Carmona Cavite. Patient Place is quiet crowded. Their house located near highway. The patient and his family are exposed to pollution he said, especially our patient that worked as Traffic enforcer.

III. Physical Assessment

BODY PARTS TECHNIQUE NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Skin          Hair and scalp

InspectionPalpation         Inspection

- Light to dark brown- No swelling- Good skin turgor      

- No lesion- Color black

-Pale   - No swelling-Poor skin turgor -emaciated   - No lesion- Black

Indicates poor oxygenation in the body. 

-indicates of Dehydration -may be sign of dehydration and weight loss

Head  Neck  Lymphnodes  Shoulders

Inspection  Inspection  Inspection/Palpation 

Inspection

- Face is symmetrical 

- No lesion- No swelling -No palpable nodes -Normal

-face is symmetrical 

- No lesion- No swelling -Bilateral palpable nodes

    Normal  

Eyes     Eye brows   Eye lids  Sclera Pupil

Inspection           

- Symmetrically align-Blinking symmetrically   -Evenly distributed -Eyelid margins are moist - White in color - Equally round and reactivated to light accommodation

- Symmetrically align-Blinking symmetrically-Sunken Eyeballs -Evenly distributed -Eyelid margins are moist - White in color - Equally round and reactivated to light accommodation

    -indicates dehydration

Ears PalpationInspection

- Equal in size- Symmetrically align- No lesion- No swelling

- Equal in size- Symmetrically align- No lesion- No swelling

 

Nose Inspection - Color is same as face- No lesion- No swelling

- Color is same as face- No lesion- No swelling

 

Mouth  Lips   Buccal mucosa  Tongue    Gums    Nails

InspectionPalpation                  Inspection

- No lesion- No swelling - Red to pink in color- No lesion - Smooth with no lesion - Red to pink in color- No lesion- No swelling - Pink and moist    -Capillary refill of <2-3 secondas

- No lesion- No swelling - Pale- No lesion -Pale- Smooth with no lesion - Pale & dry color- No lesion- No swelling 

- Pale    -Capillary refill of more than 3 seconds

   May be related to low RBC level count.    May be Sign of Dehydration   May be related to low RBC level count.  -inadequate oxygenation

Upper Extremities       Muscle tonicity

InspectionPalpation     

 Palpation

- Symmetrically align- No lesion- No swelling- No mumps  

 - Even and firm muscle tone

- Symmetrically align- No lesion- No swelling- No mumps  

 - Weak

muscle tone

       

 Possibly related to decreased appetite causing inadequate nutrients to sustain muscle strength.

Abdomen InspectionPalpation

- Smooth to touch- No lesion- No swelling- No mumps- No redness- Warm to touch- Round and symmetrical- Abdomen rises with inspiration in synchrony with chest

- Smooth to touch- No lesion- No swelling- No mumps- No redness- Warm to touch- Round and symmetrical- Abdomen not in synchrony with inspiration

        

 Indicates ineffective airway breathing

Lower Extremities

Inspection - Bilaterally symmetrical and equal- Right foot has complete fingers- Left foot has complete fingers 

- Bilaterally symmetrical and equal- Right foot has complete fingers- Left foot has complete fingers 

        

Gordon’s 11 Functional PatternFUNCTIONAL HEALTH

PATTERNPATTERN DESCRIBES ACTUAL FINDINGS

Health Perception/Health Management

Client’s perceived pattern of health and well being and how health is managed.

We observed that he was aware about his conditions, He showed compliance in his medication regimen.

Nutritional - Metabolic Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of local nutrient supply.

Before he was hospitalized, he takes 3 time meals. He consumes almost 1 cup of rice per meal and 1 serving of vegetables, he drinks 4-5 glasses of water a day, he smoked 5-6 sticks of cigarettes a day and drink alcoholic beverages occasionally. During hospitalization the doctor ordered DM diet.

Activity -Exercise Patterns of exercise, activity, leisure and recreation

On the first day of hospitalization , he was assisted by his brother

Elimination Pattern of excretory function (bowel, bladder and skin).

Client has no problem in terms of urination, bowel elimination

Cognitive - Perceptual Sensory perceptual and cognitive patterns

Client appeared to be oriented in time, place, and date. He was cooperative during our interview, he answered some of our questions.

Sleep – Rest Patterns of sleep, rest and relaxation

Before hospitalization, client usually sleeps about 5-6 hours a day but due to his condition he cannot sleep caused by his cough.

Self-Perception/Self Concept

Client’s self concept pattern and perceptions of self

Client is contented with his family and friends.

Role relationship Client’s pattern of role engagements and relationships

There is a problem in terms of financial support about his hospitalization

Sexuality – Reproductive Patterns of satisfaction with sexually pattern; reproductive pattern

Client is married, has 3 children and has no problem in sexual relationships with her wife.

Coping / Stress Tolerance General coping pattern and effective of the pattern in terms of stress tolerance

Demonstrates techniques to cope up by diverting his attention towards watching tv.

Value – Belief Pattern of Values, beliefs and goals that guide clients choices and decisions

Client is Roman Catholic, going to church every Sunday with his family according to him he prays for his fast recovery.

IV. Anatomy and Physiology

Respiratory System

Functions of the Respiratory System

• Gas exchange – the respiratory system allows oxygen from air to enter the blood and the carbon dioxide to leave the blood and enter the air.

• Regulation of blood pH – the respiratory system can alter blood pH by changing blood carbon dioxide levels.

• Voice production – air movement past the vocal cords makes sounds and speech possible.

• Olfaction – the sensation of smell occurs when airborne molecules are drawn into the nasal cavity.

• Innate immunity – the respiratory system provides protection against some microorganism by preventing their entry into the body and by removing them from respiratory surfaces.

 UPPER RESPIRATORY TRACT

• Respiration is defined in two ways. In common usage, respiration refers to the act of breathing, or inhaling and exhaling. Respiration strictly means the uptake of oxygen by an organism, its use in the tissues, and the release of carbon dioxide.

• Respiration has two main functions:• To supply the cells of the body with the oxygen needed for metabolism• To remove carbon dioxide formed as a waste product from metabolism.

 • The upper respiratory tract conducts air from outside the body to

the lower respiratory tract and helps protect the body from irritating substances. The upper respiratory tract consists of the following structures:•  Nose – consists of the external nose and the nasal cavity.• External Nose – is the visible structure that forms a prominent feature of

the face.• Nasal cavity – extends from the nares to the choane.• Esophagus- leads to the digestive tract.

• Mucociliary Apparatus - one of the features of both the upper and lower respiratory tracts that protects the airways from irritating substances, and is composed of the ciliated cells and mucus-producing glands in the nasal epithelium.

 • The glands produce a layer of mucus that traps unwanted particles as they are inhaled.

These are swept toward the posterior pharynx, from where they are either swallowed, spat out, sneezed, or blown out.

• Air passes through each of the structures of the upper respiratory tract on its way to the lower respiratory tract. When a person at rest inhales, air enters via the nose and mouth. The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a tube like structure that connects the back of the nasal cavity and mouth to the larynx, a passageway for air, and the esophagus, a passageway for food. The pharynx serves as a common hallway for the respiratory and digestive tracts, allowing both air and food to pass through before entering the appropriate passageways.

 • Pharynx – is the common passageway of both the respiratory and the digestives system. It

receives air from the nasal cavity and air, food and water from the mouth. It contains a specialised flap-like structure called the epiglottis.

• Epiglottis – it differs from the other cartilages in that it consists of elastic cartilage rather than hyaline cartilage.

• that lowers over the larynx to prevent the inhalation of food and liquid into the lower respiratory tract.

• larynx, or voice box - is a unique structure that contains the vocal cords, which are essential for human speech. Small and triangular in shape, the larynx extends from the epiglottis to the trachea. It helps control movement of the epiglottis. The larynx has specialised muscular folds that close it off and also prevent food, foreign objects, and secretions such as saliva from entering the lower respiratory tract.

LOWER RESPIRATORY TRACTThe lower respiratory tract begins with the trachea, which

is just below the larynx.  • Trachea 

• Trachea, or windpipe - is a hollow, flexible, but sturdy air tube that contains C-shaped cartilage in its walls. The inner portion of the trachea is called the lumen.

• THE LUNGS• are the principal organs of respirations. Each lung is cone – shaped with

is based resting on the diaphragm and it is apex extending superiorly to a point of 2.5cm above the clavicle. The right lung has 3lobes called the superior, middle and inferior lobes. The left lung has 2 lobes called the superior and inferior lobes. The lobes of the lungs are separated by deep, prominent fissures on the surface of the lungs.

• Bronchi• The first branching point of the respiratory tree occurs at the lower end

of the trachea, which divides into two larger airways of the lower respiratory tract called the main bronchus: left bronchus and right bronchus.

• Left main bronchus – is more horizontal than the right bronchus because it is displaced by the heart.

• Right main bronchus – is more vertical than the left main bronchus and therefore more in direct line with the trachea.

• The wall of each bronchus contains substantial amounts of cartilage that help keep the airway open. Each bronchus enters a lung at a site called the hilum.

• Lobar (secondary)Bronchi – two in the left ling and three in the right lung conduct air to each lobe. 

• Segmental (tertiary) bronchi – is give rise ti the lobar bronchi which extends to the bronchopulmonary segments of the lungs.

• Bronchioles - subdivide numerous times to give rise to terminal bronchioles and which then subdivide into respiratory bronchioles.

• Alveolar ducts – are like long, branching hallways with many open doorways. The doorways open into the alveoli which are small air sacs. 

• The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity. There are two lungs that occupy a significant portion of this cavity.

• Diaphragm- is a broad, dome-shaped muscle that separates the thoracic and abdominal cavities and generates most of the work of breathing. The inter-costal muscles, located between the ribs, also aid in respiration. The internal intercostal muscles lie close to the lungs and are covered by the external intercostal muscles.

• Pleural CavitiesTo facilitate the movements associated with respiration, each

lung is enclosed by the pleura, a membrane consisting of two layers, the parietal pleura and the visceral pleura.

• Parietal pleura - comprise the outer layer and are attached to the chest wall. • Visceral pleura - are directly attached to the outer surface of each lung.

• Pleural cavity - The two pleural layers are separated by a normally tiny space. A thin film of serous or watery fluid called pleural fluid lines and lubricates the pleural cavity. This fluid prevents friction and holds the pleural surfaces together during inhalation and exhalation.

 • Mechanics of Breathing

• To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways.

• Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax).

• Physiology of Gas Exchanges

• Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveoli in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over.

• Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients.

• CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.

V. Pathophysiology

VI. Medical Management

Date Doctor’s Order Rationale

8/12/1411:15pm

Refer admit to isolation room

TPR q shift and record To have a baseline data

For ECG > A test that records the electrical activity of the heart.

NPO Temporarily For observation

>Labs: CBC, EAPC, APX, TBC, HBHC, Lipid function, BUN, AST, PFT

It is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases.

Meds Piptaz 4.5 IVq8 (-) ANSTFlummucilHRZE 4 tabs ODApidra

Refer to drug study

CTT plain Bottle #1 Pf count, diff count, LDH, proteinBottle #2 PF G5/C5/AFBBottle #3cytologyPlain dx serum LDH, protein

for chest drain insertion.

8-13-142am

IVF PNSS 1Lx80cc/hr > to hydrate the patient prevent hypovolemic shock or hypotension

>Schedule for CTT insertion

>Reschedule CTT under sedation tomorrow 10 pm

8-13-144am

>Inform OR/ROD

>NPO post midnight

8-13-144:10pm

>Refer acordingly

8-13-145pm

>PNSS 1Lx40cc > to hydrate the patient prevent hypovolemic shock or hypotension

>Paracetamol 500 mg/tab q4 T37.8>Paracetamol 300mg IV T38. 4

>Refer to drug study

>Place in moderate to high back rest To promote lung expansion

8-13-1411:30pmWith chestpainWith SOBBP 110/80HR 84RR 28T 36. 4

>WOF presence of dyspnea, chest pain >Maintain on o2

>Position patient to semi fowlers positon.and give O2

To support the oxygen in the body

>PNSS 1Lx40cc > to hydrate the patient prevent hypovolemic shock or hypotension

8-14-143am

>VS q2

To have a baseline

>WOF dyspnea, SOB

>Position patient to semi fowlers positon.and give O2

8-14-147am

>THOC note>AP updated>Refer

8-14-14 >Start tramadol 50mg IV q8 >Refer to drug study

>For STAT post-op x-ray > Test that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs of the chest.

>Refer accordingly

8-14-146pm

>May go back to room

>Refer

>May resume regular diet

>Refer

>Continue medication >Refer to drug study

>Continue incentive spirometry To help practice taking deep breaths, which can help open your airways, prevent fluid or mucus from building up in your lungs, and make it easier for you to breathe.

8-14-1411pm

>For daily CTT bottle care To prevent infection

>Refer

>For changing of CTT To prevent infection

8-15-145:45am

>Kindly prepare PNSS/H2O For irrigation and to hydrate the patient prevent hypovolemic shock or hypotension

8-15-146:30am(-)DOB(-)Fever(-)Sub Q Emphysema

Moderate to High Back Rest To promote lung expansion

Moderate to High Back Rest To promote lung expansion

Deep Breething Exercise

To controlled

>Start Incentive spirometry q1x10 To help practice taking deep breaths, which can help open your airways, prevent fluid or mucus from building up in your lungs, and make it easier for you to breathe.

8-15-1410am

>AP updated

>Refer accordingly

>D/C Hydrocortisone >Refe to drug study

>Repeat CBC tomorrow To check the blood component

8-15-14

8-15-143:10pm

>Deep breathing exercise >Continue incentive spirometry

To promote and to the know lung capacity

>Refer

>Lantus to 8 units >Refer to drug study

>Start metformin 500mg/tab BID

Refer to drug study

>D/C Combivent

>Refer to drug study

8-15-145:45

>Continue incentive spirometry >CTT bottle daily care

>Refer accordingly

>to prevent the contamination of microorganism and inection

8-16-142:20pm 5pm 8-17-144am

>Resure incentive spirometry q1 x4hrs

>Repeat CXR > Test that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs of the chest.

>ok for repeat chest x-ray > Test that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs of the chest.

>Deep breathing exercise

> to expand the lung

>Cont. incentive spirometry >refer

>AP updated >Repeat CXA

>> Test that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs of the chest.

8-17-147:45am

>Cont. deep breathing >incentive spirometry >refer

>>For lung expansion and easy breathing

>PNSS 1L x60cc/hr >Monitor I and O evey shift

> to hydrate the patient prevent hypovolemic shock or hypotension > To monitor patients fluid status.

8-17-14

>lantus 10cc >CBG monitoring >O2 to 2L

>Refer to drug study > > To assess patient's oxygenation, and determining the effectiveness of or need for supplemental oxygen

8-17-146:30pm

>D/C vitamin K >Repeat chest x-ray >Cont. incentive spirometry >For CTT bottle change >Kindly have PNSS at bedside >refer

>Refer to drug study > Test that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs of the chest.  >to prevent the contamination of microoganism and infection > For irrigation and to hydrate the patient prevent hypovolemic shock or hypotension

8-17-14

>Continue medication >AP’s updated >PNSS 1L x60cc/hr

>Refer to drug study >to hydrate the patient prevent hypovolemic shock or hypotension.

8-18-146am

>Declogging CTT done >For CTT change >Position patient to semi fowles >Kindly reserve PNSS at bedside >Cont. incentive spirometry >refer

>To prevent the infection to the patient >for lung expansion and easy breathing > For irrigation and to hydrate the patient prevent hypovolemic shock or hypotension

8-18-14 1:10pm 5:50pm

>Ok 3 way bottle >Ok for piptaz >For 3way bottle system >CTT bottle >Place patient to semi fowlers >IVF PNSS1Lx 40cc/hr

>refer to drug study > To promote lung expansion. > to hydrate the patient prevent hypovolemic shock or hypotension.

VII. Laboratory and Diagnostic

Name: S.M.L. Date: August 12, 2014Age: 38yrs OldDiagnostic Exam: CHEST PA (14x17) 

INTERPRETATION

CHEST PA (14x17) There is homogenous density in the right lower hemi thorax with an air fluid level in the midportion of the right hemithorax. Right upper hemithorax hyperlucent devoid of lung markings. There are reticulonodular opacities noted in the left lung. Heart size cannot be properly evaluated. Other visualized structures are unremarkable.IMPRESSION:

Consider PNUEMOHYDROTHORAX, RIGHT Findings are suggestive of extensive PTB left,

bacteriologic correlation is suggested.

Diagnostic Exam: CHEST

INTERPRETATIONCHEST Ultrasound of the right hemithorax done on sitting and supine positions show moderate amount of pleural fluid with an appropriate volume of 1083.3colThere are thin septations and some loculations seen, There are collapsed lung segments noted.Chest mapping done.No evidence of fluid noted in the pleural cavity. 

• Name: S.M.L. Date: August 17, 2014

• Age: 38yrs Old  CBC & PLATELET

Test Result Reference Value Interpretation

Hemoglobin 111 120-150 Low level of hemoglobin represents anemia. This can be iron deficiency anemia

Hematocrit 0.34 0.40-0.54 Anemiq Bleeding Destruction of red blood cells

RBC 4.13 4-5.6 Normal

WBC 7.71 5.0-10.0 Normal

SEGMENTERS 0.83 0.50-0.70 High Indicates presence of bacterial infection

Lymphocytes 0.12 0.20-0.40 Low Meaning, there is an increased risk for infection

Monocytes 0.04 0-0.05 Normal

Eosinophile 0.01 0-0.06 Normal

MCV 82.8 80-98 Normal

MCH 26.8 26-32 Normal

MCHC 325 320-360 Normal

Platelet Count 430 150-400 High indicates infection

RDW 12.8 11-15 Normal

• Name: S.M.L. Date: August 13, 2014

• Age: 38yrs Old Clinical ChemistryTEXT NAME RESULT NAME REFERENCE VALUE INTERPRETATION

SGPT(ALT) 40.10 0.0-41.0 Normal

SGOT (AST) 47.90 0.5-37 High due to a viral infection

CREATININE 50.70 .4-1.2 High indication of decreased kidney function 

SODIUM 123.70 137-145 Normal

POTASSIUM 4.45 3.5-5.1 Normal

• Name: S.M.L. Date: August 14, 2014

• Age: 38yrs OldEXAMINATION ( LDH, TP)

SPECIMEN: PLEURAL FLUID

TEST RESULT INTERPRETATION

LDH( lactic acid dehydrogenase) 2,796.OOU/L Indicates of tissue and cellular damage. It’s also indicating conditions such as lung diseases.

 

TOTAL PROTEIN 73.58g/L  

• Name: S.M.L. Date: August 14, 2014

• Age: 38yrs OldClinical Chemistry

Specimen: SERUMTEST NAME RESULT REFERENCE VALUE INTERPRETATION

CHOLESTEROL 115.54mg/dl 150-200mg/dl Low due to acute infections

HDL 14mg/dl 30-85 Low

LDL 77.90mg/dl 45-150 Normal

VLDL 25.10mg/dl 19.3-46.3 Normal

URIC ACID 3.83mg/dl 3.49-7.19 Normal

FASTING BLOOD SUGAR 213.15mg/dl 70-100 High indicates the patient has increase sugar in blood

TRIGLYCERIDES 127.43mg/dl 60.17-166.37 Normal

• Name: S.M.L. Date: August 14, 2014

• Age: 38yrs OldArterial blood Gas analysis

  NORMAL VALUES RESULTS INTERPRETATION

pH 7.35-7.45 7.459 ---

pCO2 35-45mmHg 40.2 mmHg Normal

pO2 80-100mmHg (for <60y.o)

132 mmHg Increased oxygen levels in the inhaled air

HCO3 22-26mmol/ L 26.0 mmol/ L Normal

BE +2/-2 1 When Base Excess is negative, it only indicates that the there is a negative base deficit in the blood, which will be an equivalent to acid excess.

02 sat 95-100% 99% Normal

TCO2 Content 30    

CBG MONITORING

8/13     8/14   8/15    8/16    8/17    8/19

MN-BB- 186BL- 166BS- 201 –apidra 4unit given SC MN- 226 hold apidra NPO for CTT insertionBB-BL- NO STRIPBS- 211 MN- 250 apidra 4 units givenBB- 229 apidra 4 unit givenBL- NO STRIPBS- 309 MN- 290 apidra 4units givenBB- 180BL- 217BS- 158 MN- 143BB- 153 apidra 4 units given SCBL- 189BS- 149 BB- 167BS-

VIII. Drug Study

Drug Name Action Indication Contraindication

Adverse Effect

Nursing Consideration

GENERIC NAME:Insulin glargine  BRAND MAME:Lantus CLASSIFICATION:Antidiabetics and glucagon

DOSAGE, ROUTE AND FREQUENCY:

 

Insulin glargine lowers glucose levels by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production.

Management of type 1 (insulin dependent) diabetes mellitus is patients who need basal (long acting) insulin for the control of hyperglycemia.Management of type 2 (non-insulin dependent) diabetes mellitus in patients previously treated with oral antidiabetics. 

Contraindicated in patients who are hypersensitive to insulin glargine or its excipients.

Metabolic hypoglycemia, skin lipodystrophy, pruritus, rash.Other allergic reactions, pain at injection site.

• Use cautiously in patients with renal or hepatic impairment.

• Drug isn’t intended for I.V. use it’s only for S. C. use

• Prolonged duration of activity is dependent on injection into S. C. space.

• Because of prolonged duration, this isn’t the insulin of choice for diabetic ketoacidosis.

• Lantus must not bediluted or mixed with other insulin or solution.

Drug name Action Indication Contra indication

Adverse effect

Nursing consideration

GENERIC NAME:piperacillin sodium/ tazobactam sodium BRAND MAME: piptazCLASSIFICATION:Penicillins DOSAGE, ROUTE AND FREQUENCY: 

Piperacillin is an extended-spectrum penicillin that inhibits cell-wall synthesis during microorganism multiplication. Tazobactam increases piperacillin’s effectiveness by inactivating beta-lactamases, which destroy penicillins. 

Appendicitis complicated by rupture or abscess and peritonitis caused by Escherichia coli, Bacteriodes fragilis, B. ovatus, B. thetaiotaomicron, or B.vulgatus; skin and skin-stracture infections caused by staphylococcus aures;

Contraindicated in patients hypersensitive to drug or other penicillins. 

CNS: headache, insomnia, agitation, dizziness, anxiety, seizures.CV: hypertension, tachycardia, chest pain, edemaEENT: rhinitisGI: diarrhea, nausea, constipation, vomiting, dyspepsia, stool, changes, abdominal pain. 

• Use cautiously in patients with bleeding tendencies, uremia, hypokalemia, and other drug allergies, especially to cephalosporins

• Obatain specimen for culture and sensitivity tests before giving first dose. Therapymy begin pending result.

•

DRUG NAME ACTION INDICATION CONTRAINDICATION

SIDE EFFECTS NURSING CONSIDERATION

 Generic: paracetamol  Brand: Aeknil Classification: Analgesics, Anti pyretics Dosage& Route: 300mg/amp Frequency: PRN

 Inhibition of cyclooxygenase (COX), and recent findings suggest that it is highly selective for COX-2. While it has analgesic and antipyretic properties comparable to those of aspirin or other NSAIDs, its peripheral anti-inflammatory activity is usually limited by several factors, one of which is the high level of peroxides present in inflammatory lesions.

  to relieve fever

  Hypersensitivity to drug Liver disease Anemia

 fever with nausea, stomach pain, and loss of appetite;dark urine, clay-colored stools; orjaundice

 Warn patient long term use of paracetamol will cause liver damage.   Take with food or milk to minimize GI upset. Advise patient to report N&V, cyanosis, shortness of breath and abdominal pain as these are signs of toxicity. Monitor Vital Signs especially temperature

DRUGNAME ACTION INDICATION CONTRAINDICATION

SIDE EFFECT NURSING CONSIDERATION

Generic name:Acetylcysteine Brand name: Fluimucil Dosage:600mg tab in 75cc water OD

Exerts mucolytic action through its free sulfhydryl group which opensup the disulfide bonds in the mucoproteins thus lowering mucous viscosity. The exactmechanism of action in acetaminophen toxicity is unknown. It is thought to act by providingsubstrate for conjugation with the toxic metabolite

Treatment of respiratory affections characterized by thick and viscoushypersecretions: acute bronchitis, chronic bronchitis and its exacerbations; pulmonaryemphysema, mucoviscidosis and bronchiectasis.

MAO inhibitor therapy within 14 days initiating therapy; severehypertension; severe. Coronary artery disease, hypersensitivity to pseudoedephrine,acrivastine or any component; renal impairment.Form:Solution, as Sodium: 10%; 20% Identified hypersensitivity to N-acetylcysteine.

Hypersensitivity reactions have been reported in patients receivingacetylcysteine, including bronchospasm, angioedema, rashes and pruritus, may occur. Other adverse effects reported include nausea and vomiting, fever, syncope, sweating, arthralgia, blurred vision, disturbances of liver function.

You should also watch for increased blood pressure and hypoxia. Monitor effectiveness of therapy and advent of adverse/allergic effects. Instruct patient in appropriate use and adverse effects to report.

DRUG NAME ACTION INDICATIONCONTRAINDICATI

ONADVERSE EFFECT

NURSING CONSIDERTION

 GENERIC NAME:Lactulose  BRAND MAME:Lilac CLASSIFICATION:hyperosmotic laxative DOSAGE, ROUTE AND FREQUENCY:30cc/ ODHS 

 Reduces blood ammonia; appears to involve metabolism of lactose to organic acids by resident intestinal bacteria.

 Constipation, salmonellosis.  Treatment of hepatic encephalopathy.

 Patient who require a low lactose diet. Galactosemia deficiency. Intestinal obstruction.

  Abdominal discomfort associated with flatulence and intestinal cramps. Nausea, vomiting, diarrhea on prolonged used

 Assess patient’s condition before therapy and reassess regularly thereafter to monitor drug’s effectiveness. Identify cause of constipation. Monitor for possible adverse GI reaction: nausea, vomiting, abdominal cramps, belching, diarrhea, flatulence and distension.  Monitor fluid and electrolyte status: urine output, input-output ratio to identify fluid loss, hypokalemia and hypernatremia.  Monitor for increased glucose levels in diabetic patients.  Assess patient’s and family’s knowledge of drug therapy.

DRUG NAME ACTION INDICATION CONTRAINDICATION

ADVERSE EFFECT NURSING CONSIDERATION

Generic Name:insulin glulisine Brand Names:Apidra CLASSIFICATION:Insulin DOSE,ROUTE,AND FREQUENCY:4units sq for CBG>180mg/dl tab   

Regulation of glucose metabolism is the primary activity of insulins and insulin analogs, including insulin glulisine. Insulins lower blood glucose by stimulating peripheral glucose uptake by skeletal muscle and fat, and by inhibiting hepatic glucose production. Insulins inhibit lipolysis and proteolysis, and enhance protein synthesis. The glucose lowering activities of APIDRA and of regular human insulin are equipotent when administered by the intravenous route. After subcutaneous administration, the effect of APIDRA is more rapid in onset and of shorter duration compared to regular human insulin.

ndicated to improve glycemic control in adults and children with diabetes mellitus.

During episodes of hypoglycemia.

Hypoglycemia, allergic reactions, inj site reactions, lipodystrophy, pruritus, rash, hypokalemia, weight gain, peripheral edema.

Ensure uniform dispersion of insulin suspensions by rolling the vial gently between hands; avoid vigorous shaking.· Give maintenance doses subcutaneously, rotating injection sites regularly to decrease incidence of lipodystrophy; give regular insulin IV or IM in severe ketoacidosis or diabetic coma.· Monitor patients receiving insulin IV carefully; plastic IV infusion sets have been reported to remove 20%–80% of the insulin; dosage delivered to the patient will vary.· Do not give insulin injection concentrated IV; severe anaphylactic reactions can occur.

DRUGNAME ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING CONSIDERATION

GENERICNAME: TheophyllineBRANDNAME:Nuelin SRCLASSIFICATION: BronchodilatorDOSE,ROUTE,AND FREQUENCY:SR250MG /TAB BID

Possible effects include bronchial smooth muscle relaxation; anti-inflammatory effects; increase in diaphragm contractility and CNS stimulation

Maintenance treatment in severe asthma and chronic obstructive airways disease

Contraindicated to any constituent or to xanthines. 

The most commonly reported side effects when taking Nuelin tablets 250mg include nausea, vomiting, gastric irritation, palpitations, tachycardia, arrhythmias, headache, insomnia and restlessness.

Caution patient not to chew or crush enteric-coated timed-release preparations. · Give immediate release, liquid dosage forms with food if GI effects occur. · Do not give timed-release preparations with food; these should be given on an empty stomach, 1 hr before or 2 hr after meals. · Advise patients that this drug should not be used during pregnancy; use of barrier contraceptives is recommended. · Monitor results of serum theophylline level determinations carefully, and reduce dosage if serum levels exceed therapeutic range of 10–20 mcg/mL. · Monitor carefully for clinical signs of adverse effects, particularly if serum theophylline levels are not available. · Maintain diazepam on standby to treat seizures.

Drug name Action Indication Contra indication Adverse effect Nursing consideration

Generic Name Tramadol Brand name Ultram Classification Analgesic Dosage, route, and frequency 50mg IV q8

Binds to mu-opioid receptors and inhibits the reuptake ofnorepinephrine and serotonin; causes many effects similar to theopioids--dizziness, somnolence, nausea, constipation--but does not have the respiratory depressant effects.

relief of moderate to moderately severe pain

Contraindicated with pregnancy; allergy to tramadol; acute intoxication with alcohol, opioids, psychotropic drugs or other centrally acting analgesics; lactation.

.

sedation, dizziness/vertigo, headache, confusion, dreaming, sweating, anxiety, seizures, Hypotension, tachycardia ,bradycardia, Sweating, pruritus, rash, pallor, urticaria, Nausea, vomiting, dry mouth, constipation, flatulence, Potential for abuse,anaphylactoid reactions

 Provide environmental control (temperature, lighting) if sweating, CNS effects occur. Use cautiously with seizures, concomitant use of CNS depressants or MAOIs, renal or hepatic impairment

DRUGNAME ACTION INDICATION CONTRAINDICATION

ADVERSE EFFECT NURSING CONSIDERATION

GENERIC NAME: HRZEBRAND NAME: MyrinCLASSIFICATION: Anti-infectiveDOUSE,ROUTE,AND FREQUENCY:4TABS ODBB

Appears to inhibit cell-wall Biosynthesis by interfering with lipidand DNA synthesis

Actively growing tubercle bacilli>prevention of tubercle bacilliin those exposed to tuberculosis or those with positive skin test results whose chestx-rays and bacteriologic studies are consisten with non-progressive tuberculosis

Contraindicated in patients with acute hepatic disease or isoniazid-related liver damage

peripheralneuropathy,fluiddiscoloration,optic neuritis,hepatitis

Use cautiously in elderly patients>peripheral neuropathy is more common inpatients who are slow acetylators or who are malnourished, alcoholic or diabetic, Monitor hepatic function closely for changes

IX. Nursing Care Plan

CUES PROBLEM SCIENTIFIC REASON

DESIRED OUTCOME

INTERVENTION/

RATIONALE

EVALUATION

 Subjective:“Kinakapos ako sa paghinga kahit wala akong ginagawa” as verbalized by the patient. Objective: (+)

Dyspnea

Tachypnea

Fatigue

(+) crackles at right upper lobe

 

 

 Ineffective airway clearance related to inability to expectorate phlegm

 Coughing is the main mechanism for clearing the airway. However the cough may be ineffective in both normal and disease states secondary to factors such respiratory muscle fatigue,   

 Short term goal: After 8 hours of nursing intervention the patient will able to expectorate/clear secretions readily. 

 1. Assess vital

signs, noting rate of respiration and sounds. To determine the presence of respiratory distress.

2. Maintain accurate I&O. To monitor accurate fluid intake and output.

 

 

STANDARD The client will maintain effective airway clearance.

CRITERIA The client demonstrated behavior to improve or maintain clear airway.

>Productive cough without phlegm(+) >hemoptysis(approx. 4tsp) RR = 25

 

or neuromuscular weakness that may affect the ability to expectorate secretions, too. Aside from that, difficulty of breathing signifies that there may be an accumulation of secretion in the bronchial cavity of the lungs.  References: http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick03.html 

Long term goal: After 1-2 days of nursing intervention patient will be able to demonstrate behaviors to improve or maintain clear airway.

 3. Position the patient by elevating head of the bed To take advantage of gravity decreasing on diaphragm and enhancing drainage of/ ventilation to different lung segments. 4.Encourage deep breathing and coughing exercises. To maximize effort. 5.Increase fluid intake. Hydration can help liquefy viscous secretions and improve secretion clearance. 

6.Administer IV fluids as indicated. To replace fluid losses. 7.Administer medication as ordered. - Sinecod forte 1tab TID- Levopront syrup 2tsp P.O TID

X. REFERENCES

• Books:• Health Assessment by Lippincot Williams and Wilkins• Introductory Medical-Surgical Nursing Tenth Edition, B. Timby and N. Smith

Lippincot Williams and Wilkins• Pathophysiology for Health Professions by: Barbara E. Gould• Lippincotts’s Drug Hand book 2010 edition • Pearson’s Drug Handbook 2010 edition• Nurse’s Pocket Guide 12th edition by : Marilyn E. Doenges • Medical-Surgical Assessment and Management 8th Edition by Lewis Dirksen

and Camera • Medical-Surgical Assessment and Management by Brunner and Suddarth• Medical-Surgical Nursing Twelfth Edition, Brunner & Suddarth• Health Assessment in Nursing by Webber and Kelley• Nursing Assessment by Janis Bellack and Penny A. Bamford• Fundamentals of Nursing by Kozier, Erb, Berman, Snyder

• Online