Case Presentation Document

8/8/2019 Case Presentation Document

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LEVEL 2.NCM102.2NDSEM SY2009-2010 P a g e | 1

Level 3

CASE PRESENTATION1st Semester SY 2010-11

I. Statement of Objectives

A. General Objectives

This case analysis aims to increase the understanding and knowledge of student nurses on how to carefor patients with Cardiomegaly with Atheromatous Aota effectively and efficiently.

B. Specific Objectives

Specifically, this case analysis aims to :1. define Cardiomegaly with Atheromatous Aota and its effects to the body as a whole;2. illustrate the pathophysiology of Cardiomegaly with atheromatous aorta and in relation to the signs and

symptoms specifically observed in the client;3. describe and identify the common signs and symptoms of Cardiomegaly with Atheromatous Aota;4. discuss the medical and surgical interventions for the management of Cardiomegaly with Atheromatous

Aota;5. formulate appropriate nursing care plans suited for the client based on the assessment findings;6. identify care measures to be given to the patient and family to promote continuity of care and

independence after discharge.

II. Clients Profile

Name : Patient FM Age : 71 years oldBirth date : January 27, 1939Sex : Female

Ethnic Background : IlokanoCivil Status : Widow Address : La Union, PhilippinesReligion : Roman CatholicOccupation : none

Admitting Diagnosis :Final/Principal Diagnosis : Cardiomegaly with Atheromatous Aota Admitting Physician : Dr. HouseDate and Time Admitted : April 05, 2009 at 2:00 am

III. Chief Complaint

Cough and Difficulty of Breathing

IV. Present History of Illness

The client had productive cough that started two weeks prior to admission. While she was watching thetelevision, she experienced sudden chest heaviness and dizziness that prompted them to seek consult andsubsequently admitted in the institution. Pain rate was with the severity of 8/10. It was not radiating to other parts ofthe body but was accompanied by difficulty of breathing, weakness, shortness of breath, and sudden hacking cough.

A few minutes after the said incident, the patient verbalized that all of the symptoms mentioned slightlyimproved and was tolerable and only rest was promoted. The patient verbalized that she didnt experienced fever.

V. Past History of Illness

The client had history of hypertension and diabetes mellitus. She had verbalized that she had already beenhospitalized for several times because of chest pain and hypertension. She had been treated and was dischargedhome after days of hospitalization. She added that she had complied well with the prescribed medications likeMetformin, Combizar and Betalac as her maintenance. Everytime she feels chest pain, she immediately seeks consultand subsequently admission to the institution. She verbalized too that she did not have known allergies for foods ormedications.


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VI. Family Health History

The client claims to have familial history of Hypertension and Diabetes Mellitus on both father andmothers family. She verbalized that her father died because of Diabetes Mellitus and her mother also died due toDiabetes Mellitus and Hypertension. Other health problems such as Asthma, Kidney Diseases and Mental illnesseswere verbalized to be absent.

VII. Developmental History

The client is the seventh daughter out of the other eight siblings composed of 3 males and 5 females.She is a 72 year old woman with the task of integrity vs. despair according to Erik Eriksons Developmental Theory.The patient seems to feel fulfilled with what her children have achieved. She is living with her youngest son and hisfamily but eventually they dont spend enough time with her because of work. She spends most of her time takingcare of her grandchildren and sharing stories at the neighborhood at times.

VIII. Social and Environmental History

The client is non-smoker and non-alcoholic beverage drinker. No verbalized vices were identified. However, sheis constantly exposed to noxious fumes from outside air pollution and from second hand smokers, because of hersons and sons-in law smoke. The family lives near the main highway where all types of vehicles frequently pass. Most

of the time, she is at home or at the neighborhood where she plays cards together with her friends.The house where they stay is made up of semi-permanent and permanent materials such as wood and

cement. It is a bungalow type with 4 separate rooms. Their everyday water supply comes from the pumped well near

the house while the source of drinking water is the water refilling stations nearby. They use a water- sealed toilet.

The client and her family are Roman Catholics and they regularly attend Holy Mass during Sundays.

IX. Lifestyle and Health Practices

Due to recurrent health conditions, every time the client experiences intolerable signs and symptoms of herillness, she seeks medical help at the nearby hospitals. Whereas her sons and daughters used to self medicate. Theyrelieve common illnesses like colds and cough with over the counter drugs.

Client is neat in appearance with a well-combed short hair. She verbalized that they frequently eat meat but withvegetables also sometimes. After the household chores, she rests for some time or takes nap after lunch if she is notwith her neighbors. She performs moderate exercises by walking going to the market.

X. Health Assessment

A. General Survey

The client was received awake, lying on bed in low fowlers position. The client has an ongoing IVFPLRS I L x 10 gtts per minute x 24 hours infusing well on the right arm. The client appears weak, needs minimalassistance when assuming activities of daily living like toileting. She wears a neat gown, hygiene is fair. Client isconversant and speech is well formulated, oriented to the self and others around him, able to determine the time anddate and is aware that she stays in a private room for 3 days now.

Client is an endomorph. She verbalized that she is 56 tall and weighs 61 kilograms.

B. Head to Toe Assessment

1. Head Normocephalic, hair evenly distributed, oiliness and flaking noted, no areas ofpain or tenderness during palpation

2. Eyes Able to distinguish colors, (+) for astigmatism, verbalized difficulty to identifyobjects 6 feet away, wears corrective lenses, sclera is anicteric, pupils are equallyround, reactive to light and accommodation, EOM is intact, able to follow penlightwith gaze, no detectable oscillations, mucous membranes are moist and light pink

3. Ears Able to understand and hear spoken language correctly, with minimal cerumenbuild up in the ear canal, sl iver and intact tympanic membrane

4. Nose and sinuses Nose is patent, septum is located midline, no flaring noted, able to distinguish thescent of alcohol and perfume, no episodes of epistaxis during the shift, sinusesare not tender on palpation

5. Mouth Complete set of adult teeth, pearly white in color, and no mal aligned tooth, hadbraces for 1 year and a half year. No dental caries noted. Oral mucosa is moistand pinkish, no lesions noted, tonsils are not inflamed, Grade 1 bilaterally present,uvula is located midline

6. Neck ROM intact, able to change direction of head slowly but with without complaints ofpain, carotid pulse are bilaterally symmetrical, full and strong pulses, 2+, jugularvein is not distended, superficial cervical lymph nodes are palpable but nontender. Thyroid is located midline, no enlargement noted, trachea is locatedmidline

7. Chest Shape of the chest is elliptical, asymmetrical chest wall expansion noted, withrespiratory excursion best appreciated on the left side of the thorax, decreased


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tactile fremitus in the right lung area, decreased breath sounds in the right, nocrackles, no wheeze, no stridor, production of hollow drum like sounds inpercussion of the right side and resonant sound appreciated on the left. Clientwith an Axillary thoracotomy, dressing intact and dry, chest tube draining to abloody discharge 300 cc in amount. With limited movement on the right shoulder.Client verbalized, mahina daw ung lungs ko, spontaneous rupture of the bleb,kaya may pneumothorax ako Masakit tlaga ung sugat, parang 8/10 din, pati ata

sa loob masakit talaga, ditto lang naman sya sa may incision, parang maytumutusok kaya binigyan nila ako ng analgesic, ngayon, ayos ng konte pero maypain pa din at 6 na cguro ung scale nya out of 10. Client is observed to guardarea and grimaces when a painful stimulus is felt. Diaphoresis noted, hands arecool to touch. Maintains the supine position with head of bed elevated to amoderate high back rest

8. Cardiac Adynamic pericardium; normal rate, regular rhythm, PMI at 50 ICS LMCL, nomurmur noted, no visible pulsations in the precordium, palpable apical pulse

9. Breast (-) for gynecomastia, skin color is similar with the rest of the body, nipple is darkcolored, no discharges

10. Abdomen Flat, with normoactive bowels sounds heard in all the quadrants, soft, no directtenderness or rebound tenderness upon palpation, tympanitic, no organomegaly.

11. Genitals Patient verbalized that he had been inserted with a catheter when he was in theOR. No complaints of dysuria or urinary retention or incontinence post operatively

12. Musculoskeletal muscle strength at the right side is 4/5 while the rest of extremities are 5/5.No visible tremors noted, no complaints of pain

13. Integumentary

XI. Diagnostics

Diagnostic

Procedure

Description of the

Procedure

Significance/Purpose

of the Procedure

Date of

ProcedureFindings & Implications

BLOODCHEMISTRY>Fasting BloodSugar (FBS)

>Blood UreaNitrogen (BUN)

>A venipuncture isperformed and thesample is obtainedin either a gray or ared-topped tubedepending uponthe laboratory

performing thetest. The sampleshould be handledgently to avoidhemolysis andtransportedpromptly to thelaboratory. Acapillary samplemay be obtained ininfants andchildren, as well asin adults for whomvenipuncture may

not be feasible.Capillary samplesalso are used forself-monitoring ofblood glucose.

>In the fasting state,the serum glucoselevel gives the bestindication of overallglucose homeostasis.Randomly drawnserum glucose levels

of greater than 200mg/dl also may bepathognomonic ofdiabetes mellitus.Used as a clinicalsymptoms ofhypoglycemia orhyperglycemia.

>Urea is anonproteinnitrogenouscompound that isformed in the liverfrom ammonia.Although urea

BLOODCHEMISTRY>FastingBlood Sugar(FBS)

>Blood UreaNitrogen(BUN)

>A venipuncture is performed and thesample is obtained in either a gray or ared-topped tube depending upon thelaboratory performing the test. Thesample should be handled gently toavoid hemolysis and transportedpromptly to the laboratory. A capillary

sample may be obtained in infants andchildren, as well as in adults for whomvenipuncture may not be feasible.Capillary samples also are used for self-monitoring of blood glucose.


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>Cholesterol

>Triglycerides

>HDLcholesterol &LDLCholesterol

>Creatinine

HEMATOLOGY

>Hemoglobin>A venipuncture isperformed and thesample collected ina lavender-toppedtube. A capillarysample may beobtained in infantsand children, as

diffuses freely intoboth extracellularand intracellularfluid, it is ultimatelyexcreted by thekidneys. Blood urealevels reflect the

balance betweenproduction andexcretion of urea.

>Altered cholesterollevels are associatedwith a variety ofdisorders. Elevatedtotal cholesterollevels are associatedwith atheroscleroticcardiovasculardisease.

>Diets high incalories, fats and/orcarbohydrates willelevate a serumtriglyceride level,which is considered arisk factor foratheroscleroticcardiovasculardisease.

>High HDL-cholesterol and lowLDL-cholesterol

levels are predictiveof a lessened risk ofcardiovasculardisease, whereashigh LDL-cholesteroland low HDL-cholesterol levels areconsidered riskfactors foratheroscleroticcardiovasculardisease.

>Temporary

alterations in renalblood flow andglomerular functioncan be compensatedby increased tubularsecretion ofcreatinine. Thusserum creatinine is amore sensitiveindicator of renalfunction than theBUN.

>Hemoglobindeterminations are ofgreatest use in theevaluation of anemia,as the oxygen-carrying capacity ofthe blood is directlyrelated to thehemoglobin level,

>Cholesterol

>Triglycerides

>HDLcholesterol &

LDLCholesterol

>Creatinine

HEMATOLOGY>Hemoglobin

>A venipuncture is performed and thesample collected in a lavender-toppedtube. A capillary sample may beobtained in infants and children, as wellas in adults for whom venipuncture maynot be feasible.


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>RBC count

>Hematocrit

>WBC count

CHEST X-RAY

well as in adults forwhom venipuncturemay not befeasible.

>The volume ofthe sample neededdepends on themethod used todetermine the

hematocrit. Withthe exception ofthe classic methodof hematocritdetermination, acapillary sample isusually sufficient toperform the test. Ifa venipuncture isperformed, thesample is collectedin a lavender-topped tube.

> A venipuncture isperformed and thesample collected ina lavender-toppedtube. A capillarysample may beobtained in infantsand children, aswell as in adults forwhom venipuncturemay not befeasible. Thecounting isperformed very

rapidly byelectronic devices.

rather than to thenumber oferythrocytes. Inorder to interpretresults accurately,the hemoglobin levelmust be examined in

combination with thehematocrit.

>Decreased numbersare seen in disorderinvolving impairederythropoiesis,excessive blood celldestruction, bloodloss, and in chronicinflammatorydiseases. Increasesin the erythrocytecount are most

commonly seen inpolycythemia vera,chronic pulmonarydisease with hypoxiaand dehydration withhemoconcentration.

>Abnormalities in redcell size andextremely elevatedwhite blood cellcounts may producefalse hematocritvalues. Elevated

blood glucose andsodium may produceelevated hematocritsbecause of theresultant swelling ofthe erythrocyte.

>Determines thenumber of

leukocytes. Increasein WBC-leukocytosis,which is seen inpatients withinfection,inflammation,leukemia andparasitic infestations.Decrease WBC-Leukopenia, which isseen in bone marrowdepression, severeinfection, viralinfections,

autoimmunediseases,malignancies, andmalnutrition.

>This is used toinvestigate theintegrity of a certainstructures, to

>RBC count

>Hematocrit

>WBC count

CHEST X-RAY

>The volume of the sample neededdepends on the method used todetermine the hematocrit. With theexception of the classic method ofhematocrit determination, a capillarysample is usually sufficient to performthe test. If a venipuncture is performed,the sample is collected in a lavender-topped tube.

> A venipuncture is performed and the

sample collected in a lavender-toppedtube. A capillary sample may beobtained in infants and children, as wellas in adults for whom venipuncture maynot be feasible. The counting isperformed very rapidly by electronicdevices.

>It is a method of noninvasive imagingof internal body structures. In thismethod, energy in the x band of theradiation spectrum is beamed throughthe body to photographic film. The x-ray photograph shows the outlines ofbones and other dense structures thatpartially absorb the x-rays.

>a urinalysis is an array of testsperformed on urine and one of the mostcommon methods of medical diagnosis.A part of urinalysis can be performed byusing urine dipsticks, in which the test

results can be read as color changes.Microscopic examination is theplacement of urine under a phase-contrast microscope using a Neubauercounting chamber. The urine is underthe cover slide, in the upper segmentformed by the H-shaped grooves.

>The sample is collected in either aplastic hat type receptacle, which isplaced under the toilet seat, or in abedpan. It is important that the hat orbedpan be clean and dry, and that thesample not be contaminated with urine

or water, gloves are worn and twoclean tongue blades are used totransfer the mid-portion of a sample toa clean, dry plastic container with atightly fitting lid. Any visible mucus,blood, pus or parasites should beincluded in the sample. The containershould be covered tightly as soon as thesample is obtained. The sample should


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URINALYSIS

FECALYSIS>Microscopic;Parasites

BLOODCHEMISTRY>Fasting BloodSugar (FBS)

>Blood UreaNitrogen (BUN)

>It is a method ofnoninvasiveimaging of internalbody structures. Inthis method,energy in the xband of the

radiation spectrumis beamed throughthe body tophotographic film.The x-rayphotograph showsthe outlines ofbones and otherdense structuresthat partiallyabsorb the x-rays.

>a urinalysis is anarray of tests

performed on urineand one of themost commonmethods of medicaldiagnosis. A part ofurinalysis can beperformed by usingurine dipsticks, inwhich the testresults can be readas color changes.Microscopicexamination is theplacement of urine

under a phase-contrastmicroscope using aNeubauer countingchamber. The urineis under the coverslide, in the uppersegment formed bythe H-shapedgrooves.

>The sample iscollected in either aplastic hat type

receptacle, which isplaced under thetoilet seat, or in abedpan. It isimportant that thehat or bedpan beclean and dry, andthat the sample notbe contaminatedwith urine or water,gloves are wornand two cleantongue blades areused to transfer the

mid-portion of asample to a clean,dry plasticcontainer with atightly fitting lid.Any visible mucus,blood, pus orparasites should beincluded in the

therapeuticallydestroy diseasetissue, and to makeradiographic imagesfor diagnosticpurposes.

>Microscopicanalysis for parasitesis usually indicated inindividuals withintestinal disorders ofunknown etiology,history of possibleexposure toparasites, oreosinophilia ofunknown cause that

could be due toparasitic infestation.

>In the fasting state,the serum glucoselevel gives the bestindication of overallglucose homeostasis.Randomly drawnserum glucose levelsof greater than 200mg/dl also may be

URINALYSIS


be sent, properly labeled, to thelaboratory within 30-60 minutes.

BLOODCHEMISTRY>Fasting

Blood Sugar(FBS)

>Blood Urea

>A venipuncture is performed and thesample is obtained in either a gray or ared-topped tube depending upon the

laboratory performing the test. Thesample should be handled gently toavoid hemolysis and transportedpromptly to the laboratory. A capillarysample may be obtained in infants andchildren, as well as in adults for whomvenipuncture may not be feasible.Capillary samples also are used for self-monitoring of blood glucose.


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>Cholesterol

>Triglycerides


>Creatinine

HEMATOLOGY

>Hemoglobin

sample. Thecontainer should becovered tightly assoon as the sampleis obtained. Thesample should besent, properly

labeled, to thelaboratory within30-60 minutes.

>A venipuncture isperformed and thesample is obtainedin either a gray or ared-topped tubedepending uponthe laboratoryperforming the

test. The sampleshould be handledgently to avoidhemolysis andtransportedpromptly to thelaboratory. Acapillary samplemay be obtained ininfants andchildren, as well asin adults for whomvenipuncture maynot be feasible.

Capillary samplesalso are used forself-monitoring ofblood glucose.

pathognomonic ofdiabetes mellitus.Used as a clinicalsymptoms ofhypoglycemia orhyperglycemia.

>Urea is anonproteinnitrogenouscompound that isformed in the liverfrom ammonia.Although urea

diffuses freely intoboth extracellularand intracellularfluid, it is ultimatelyexcreted by thekidneys. Blood urealevels reflect thebalance betweenproduction andexcretion of urea.

>Altered cholesterollevels are associatedwith a variety of

disorders. Elevatedtotal cholesterollevels are associatedwith atheroscleroticcardiovasculardisease.

>Diets high incalories, fats and/orcarbohydrates willelevate a serumtriglyceride level,which is considered arisk factor for

atheroscleroticcardiovasculardisease.

>High HDL-cholesterol and lowLDL-cholesterollevels are predictiveof a lessened risk ofcardiovasculardisease, whereashigh LDL-cholesteroland low HDL-cholesterol levels are

considered riskfactors foratheroscleroticcardiovasculardisease.

>Temporaryalterations in renalblood flow and

Nitrogen(BUN)

>Cholesterol

>Triglycerides


>Creatinine

HEMATOLOGY>Hemoglobin

>A venipuncture is performed and thesample collected in a lavender-toppedtube. A capillary sample may beobtained in infants and children, as wellas in adults for whom venipuncture maynot be feasible.


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>RBC count

>Hematocrit

>WBC count

CHEST X-RAY

>A venipuncture isperformed and thesample collected ina lavender-toppedtube. A capillarysample may beobtained in infantsand children, aswell as in adults forwhom venipuncturemay not befeasible.

glomerular functioncan be compensatedby increased tubularsecretion ofcreatinine. Thusserum creatinine is amore sensitive

indicator of renalfunction than theBUN.

>Hemoglobindeterminations are ofgreatest use in theevaluation of anemia,as the oxygen-carrying capacity ofthe blood is directlyrelated to thehemoglobin level,

rather than to thenumber oferythrocytes. Inorder to interpretresults accurately,the hemoglobin levelmust be examined incombination with thehematocrit.

>Decreased numbersare seen in disorderinvolving impairederythropoiesis,

excessive blood celldestruction, bloodloss, and in chronicinflammatorydiseases. Increasesin the erythrocytecount are mostcommonly seen inpolycythemia vera,chronic pulmonarydisease with hypoxiaand dehydration withhemoconcentration.

>Abnormalities in redcell size andextremely elevatedwhite blood cellcounts may producefalse hematocritvalues. Elevatedblood glucose andsodium may produceelevated hematocritsbecause of theresultant swelling ofthe erythrocyte.

>Determines thenumber ofleukocytes. Increasein WBC-leukocytosis,

>RBC count

>Hematocrit

>WBC count

>The volume of the sample neededdepends on the method used todetermine the hematocrit. With theexception of the classic method ofhematocrit determination, a capillarysample is usually sufficient to performthe test. If a venipuncture is performed,

the sample is collected in a lavender-topped tube.

> A venipuncture is performed and thesample collected in a lavender-toppedtube. A capillary sample may beobtained in infants and children, as wellas in adults for whom venipuncture maynot be feasible. The counting isperformed very rapidly by electronicdevices.

>It is a method of noninvasive imagingof internal body structures. In thismethod, energy in the x band of theradiation spectrum is beamed throughthe body to photographic film. The x-ray photograph shows the outlines ofbones and other dense structures thatpartially absorb the x-rays.

>a urinalysis is an array of tests

performed on urine and one of the mostcommon methods of medical diagnosis.A part of urinalysis can be performed byusing urine dipsticks, in which the testresults can be read as color changes.Microscopic examination is theplacement of urine under a phase-contrast microscope using a Neubauercounting chamber. The urine is underthe cover slide, in the upper segmentformed by the H-shaped grooves.

>The sample is collected in either aplastic hat type receptacle, which is

placed under the toilet seat, or in abedpan. It is important that the hat orbedpan be clean and dry, and that thesample not be contaminated with urineor water, gloves are worn and twoclean tongue blades are used totransfer the mid-portion of a sample toa clean, dry plastic container with atightly fitting lid. Any visible mucus,


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URINALYSIS


>The volume ofthe sample neededdepends on themethod used todetermine thehematocrit. With

the exception ofthe classic methodof hematocritdetermination, acapillary sample isusually sufficient toperform the test. Ifa venipuncture isperformed, thesample is collectedin a lavender-topped tube.

> A venipuncture is

performed and thesample collected ina lavender-toppedtube. A capillarysample may beobtained in infantsand children, aswell as in adults forwhom venipuncturemay not befeasible. Thecounting isperformed veryrapidly by

electronic devices.

>It is a method ofnoninvasiveimaging of internalbody structures. Inthis method,energy in the x

band of theradiation spectrumis beamed throughthe body tophotographic film.The x-rayphotograph showsthe outlines ofbones and otherdense structuresthat partiallyabsorb the x-rays.

>a urinalysis is an

array of testsperformed on urineand one of themost commonmethods of medicaldiagnosis. A part ofurinalysis can beperformed by usingurine dipsticks, in

which is seen inpatients withinfection,inflammation,leukemia andparasitic infestations.Decrease WBC-

Leukopenia, which isseen in bone marrowdepression, severeinfection, viralinfections,autoimmunediseases,malignancies, andmalnutrition.

>This is used toinvestigate theintegrity of a certainstructures, to

therapeuticallydestroy diseasetissue, and to makeradiographic imagesfor diagnosticpurposes.

>Microscopicanalysis for parasitesis usually indicated inindividuals with

intestinal disorders ofunknown etiology,history of possibleexposure toparasites, oreosinophilia ofunknown cause thatcould be due toparasitic infestation.

CHEST X-RAY

URINALYSIS


blood, pus or parasites should beincluded in the sample. The containershould be covered tightly as soon as thesample is obtained. The sample shouldbe sent, properly labeled, to thelaboratory within 30-60 minutes.


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which the testresults can be readas color changes.Microscopicexamination is theplacement of urineunder a phase-

contrastmicroscope using aNeubauer countingchamber. The urineis under the coverslide, in the uppersegment formed bythe H-shapedgrooves.

>The sample iscollected in either aplastic hat typereceptacle, which is

placed under thetoilet seat, or in abedpan. It isimportant that thehat or bedpan beclean and dry, andthat the sample notbe contaminatedwith urine or water,gloves are wornand two cleantongue blades areused to transfer themid-portion of a

sample to a clean,dry plasticcontainer with atightly fitting lid.Any visible mucus,blood, pus orparasites should beincluded in thesample. Thecontainer should becovered tightly assoon as the sampleis obtained. Thesample should be

sent, properlylabeled, to thelaboratory within30-60 minutes.

XII. Comprehensive Pathophysiology

PRECIPITATING FACTORS

Iincreased intake of fatty foods Height (tall person), Male, 19 years old

Chemicals (Tar) Gradient of Pleural pressure increases fromlung base to apex

Blocks airway passages and degradeelastic fibers of the lungs


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Influx of neutrophils and macrophages Alveoli of lung apex receives theis induced greater distension pressure

Imbalanced enzymes (protease & anti-protease)and antioxidant system

________________Bullae/Blebs Formation______________________ N

Accumulation of atheromatous plaques Shearing forces

aorta is calcified

narrowed and obstructed blood flow

increased pressure

pooling of blood in the ventricle

_______________Pneumothorax____________________

Disequilibrium in the intrapulmonary and intrapleural pressure

Decreased sysytemic circulation Tidal volume affected Changes in the thoracic pressurelung volume

Distortion of movement of airIncreased myocardial workload in and out of the lungs

Increased myocardial cells Air flows out of the alveoliinto the Pleural space

Lung collapse during recoil

Dyspnea Sudden, sharp, stabbing pain

Admission to the Hospital

---INEFFECTIVE BREATHING PATTERN--- Partial collapse of the affected lung

Impairment of gas conduction Air trapping in the collapsed lung Ruptured bleb and lung collapsein the lower respiratory airways activate inflammatory response

Decreased tactile fremitus Hyper resonance on percussion Lung assymetry

---------------------IMPAIRED GAS EXCHANGE-------------------

Transudation of fluid and blood from surrounding Axillary Thoracotomyblood vessels of the injured lung and Bleb Excision

-------PAIN RELATED TO TISSUE TRAUMA-------

Pleural Effusion

Transudate accumulation in the pleural space

Further restriction of lung expansion Collapse of alveoli Disequilibrium in pulmonary and pleural pressures

Increased respiratory difficulty Bleeding Surgical Incision and Insertion of CTT

Stasis of pulmonary sections Decreased Hct and Hgb Tissue trauma and injury

Growth of microorganisms Decreased oxygen carrying Pain on the incision sitecapacity of the lungs

---RISK FOR INFECTION--- ---IMPAIRED MOBILITY---

---ACTIVITY INTOLERANCE---

XIII. Treatment/Management

A. Drugs

Name ClassificationDosage

Mechanism ofActionDosage

Nursing Implication Significance

GENERIC:Spironolactone

Diuretic

25g 1 tablet daily

*Competes withAldosterone forreceptor site in the

*Educate patient toavoid hazardous activitysuch as driving until

*Use in patient withessentialhypertension, edema,


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BRAND: Aldazide distal renal tubules,increasing sodiumchloride and waterexcretion whileconserving potassiumand hydrogen ions,may block the effect

of aldosterone onanterior smoothmuscle as well.

response to drug isknown.

*Take with meals ormilk; avoid excessiveingestion of food high inpotassium or use of salt

substitute.

*Diuretic effect may bedelayed 2-3 days andmaximum hypertensivemay be delayed 2-3weeks; monitor I and Oratios and daily weight,BP, serum electrolyte (K,Na) and renal function.

and ascites ofcongestive heartfailure, cirrhosis ofthe liver, nephriticsyndrome andidiopathic edema.

GENERIC: Losartan

BRAND: Combivar

Angiotensin IIReceptor Antagonist

50mg 1 tab OD

*Blocksvasoconstrictor andAldosterone-producingeffects of Angiotensin

II at receptor sites,including vascularsmooth muscle andthe adrenal glands.

*Assess blood pressure(lying, sitting, andstanding) and pulseperiodically during

therapy. Notify healthcare professional ofsignificant changes.

*Monitor frequency ofprescription refills todetermine adherence.

*Assess patient for signsof angioedema (dyspnea,facial swelling). Mayrarely causeangioedema.

*Treatment ofhypertension; forpatient in whomcombination therapy

is appropriate.

GENERIC: Ipratropium

BRAND: Duavent

Anticholinergic

1mg every 6 hours

*Anticholinergic,chemically related toatropine, which blocksvagally medicatedreflexes byantagonizing theaction of Acetylcholine. Causesbronchodilation andinhibits secretion fromserous andseromucous glands

lining the nasalmucosa.

*Offer emotional support(high incidence ofanxiety due to difficultyin breathing andsympathomimeticresponse to drug).

*Monitor rate, depth,rhythm, type ofrespiration; quality andrate of pulse. Assesslung sounds for

wheezing(bronchoconstriction)and rales.

*instruct on proper useof inhaler. Increase fluidintake (decreases lungsecretion viscosity). Donot take more than 2inhalations at any onetime (excessive use mayproduce paradoxicalbronchoconstriction or adecrease bronchodilating

effect). Rinsing mouthwith water immediatelyafter inhalation mayprevent mouth or throatdryness. Avoid excessiveuse of caffeinederivatives (chocolate,coffee, tea, and cola,cocoa). Do not take OTC

*management ofreversiblebronchospasmassociated withobstructive airwaydisease in patientswho require morethan a singlebronchodilator.


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medication withoutphysician approval: mayincrease sympatheticstimulation. Avoidsmoking, smoke fieldareas.

GENERIC NAME:azithromycinBRAND NAME:(Zithromax)

Macrolide Antibiotics500 mg OD

Bacteriostatic orbactericidal insusceptible bacteria

*Culture and sensitivitybefore the therapy.*Administer in an emptystomach 1hr. before or2-3hr after meals as foodaffects absorption. *Takethe full course o thetherapy. Encourage toreport severe waterydiarrhea, nausea,vomiting mouth sores.

*Treatment of upperrespiratory tractinfection;Streptococcalpharyngitis andtonsillitis due tostreptococcuspyogenes those thatare sensitive topenicillins.

GENERIC NAME:ampicillin sodium and

sulbactam sodiumBRAND NAME:Unasyn

Anti- infective750mg IV q8

Inhibits bacterial cellwall synthesis; when

combined withsulbactam,degradation cantoccur sulbactamextend ampicillinsbactericidal effects toto beta-lactamase producing bacteria

*Culture and sensitivitybefore the therapy.

*Avoid administeringampicillin sodium andsulbactam sodium to pt.with mononucleosis highrisk of rash. *Encourageto report unusualsymptoms suc asdiarrhea.

*Treatment ofrespiratory infections

GENERIC NAME:esomeprazoleMagnesiumBRAND NAME:

(Nexuim)

Proton pumpinhibitor40 mg OD

Interferes with gastricacid secretion byinhibiting theHydrogen-potassium

ATPaseenzyme system, orproton pump in gastricparietal cells. Itinversely inhibits thefinal step in gastricacid production byblocking the exchangeof ICF hydrogen andECF potassium; thuspreventing hydrogenfrom entering thestomach andadditional HCL from

forming.

*Give the drug at least1hr before meals*Do not take antacidswhile taking the drug.

*Do not chew tablets, ifdifficulty of swallowingoccurs tell pt. to sprinklepellets into a tablespoon.

*Reduction inoccurrence of gastriculcers with thecurrent use of

NSAIDs use in pt. atrisk for developinggastric ulcers(60 yrs.Above)

GENERICNAME:carvidilolBRAND NAME: Coreg

Alpha- and Beta -Adrenergic Blocker25mg BID

Competitively blocksalpha1-,beta1andbeta2 adrenergicreceptors and hassomesymphatomimitecactivity at beta2-

receptors both alphaand beta blockingactions contribute toBp lowering effect,beta blockadeprevents the reflextachycardia seen inmost alpha-blockingdrugs and decreases

*Take drugs with meals.Do not stop the drugunless instructed to doso by the physician.*Diabetic pt. are

advised to reportpromptly the changes in

glucose levels.*Advised pt. to reportdifficulty in breathing,swelling, dizziness, ofextremities, changes incolor of stool.

*Hypertension ,CHF(ischemic orcardiomyopathic),left ventriculardysfunction aftermyocardial infarction


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plasma renin activity.

GENERICNAME:furosemide

BRAND NAME: Lasix

Loop diuretic 20mgIV

Inhibits reabsorptionof sodium and chloride

from the proximal anddistal tubules andascending limb of theloop of Henle ,leadingto sodium rich duiresis

*Take with meals toprevent the G.I upset.

*Take during the dayfrequency of urinationwill not disturb sleep*Advice the pt. to weighself on a daily basis todetermine weight loss orgain of 3lbs in a day.*Blood glucose maytemporarily elevated indiabetic pt.

*Oral ,IV: acutepulmonary edema,

Hypertension

GENERICNAME:clonidinehydrochlorideBRAND NAME:

(catapres

Antihypertensive,Central analgesic,sympathollytic(centrally acting)

100 mcg

Stimulates CNSalpha2- adrenergicreceptors, inhibitssympathetic

cardioacelerator andvasoconstrictorcenters and decreasessympathetic outflowfro the CNS

*Monitor intake andoutput ratios dailyweight asses for andedema.

*Monitor Bp during initialdoseInstruct pt. to stop

smoking, and usingalcohol, lose weightrestrict intake of salt andexercise regularly.*Encourage pt, to reporturinary retentionchanges I visionblanching of fingers,rash.

Treatment of mild tomoderatehypertension.

B. IV Fluids

Name Classification Component/s Use & Effects Significance

LACTATED RINGERS

SOLUTION (PLRS)

*Hypotonic

solution*Electrolyte andfluidreplenishment

Osmolarity: 275

mOsmol/liter

Sodium 130mEq/LPotassium 4mEq/LCalcium 3mEq/LChloride 110mEq/LSodium Lactate 28mEq/L

This medication is an intravenous

(IV) solution used to supplywater and electrolytes (e.g.calcium, potassium,sodiumchloride) either with or withoutcalories (dextrose) to the body.

*For fluid and

electrolytesreplacement*Foradministration ofIV medication

XIV. Nursing Care Plans

A. Prioritization of Problems1. List of Problems

1. acute pain related to2. ineffective arirway clearance related to3. activity intolerance related to generalized weakness4. risk for imbalance nutrition:less than body requirements related to5. risk for excess fluid volume related to


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2. Basis of Prioritization

B. Nursing Care Plans

XV. List of References

Case Presentation Document

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