I.

Introduction
A. Background of the study
The case study that is to be presented features a patient who has emphysema. Emphysema is a
chronic obstructive pulmonary disease (COPD). It is often caused by exposure to toxic
chemicals, including long-term exposure to tobacco smoke or cigarette smoking. The lungs
become damaged because of reactions to irritants entering the airways and alveoli.

Cigarette smoking is the major cause of emphysema, accounting for more than 80 percent of all
cases. Emphysema occurs most often in people older than age 40 who have smoked for many
years. Long-term exposure to secondhand smoke may also play a role. Smoking stresses the
natural antioxidant defense system of the lung, allowing free radicals to damage tissue down to
the cellular level. When cigarette smoke is inhaled, 80 to 90 per cent remains in the lungs and
causes irritation, increased mucus production and damage to the deep parts of the lungs.
Eventually mucus and tar clog up the air tubes, causing chronic bronchitis and emphysema.
Among other causes of emphysema are industrial pollutants, aerosol sprays, non-tobacco smoke,
internal-combustion engine exhaust, and physiological atrophy associated with old age (senile
emphysema).

It was verbalized by the wife of the patient that he used to work at the farm in Morong. this could
be one factor that caused the patient’s disease.

Emphysema is characterized by loss of elasticity (increased pulmonary compliance) of the lung

tissue caused by destruction of structures feeding the alveoli, owing to the action of alpha 1
antitrypsin deficiency. This causes the small airways to collapse during forced exhalation, as
alveolar collapsibility has decreased. As a result, airflow is impeded and air becomes trapped in
the lungs, in the same way as other obstructive lung diseases. Symptoms include shortness of
breath on exertion, and an expanded chest. However, the constriction of air passages isn't always
immediately deadly, and treatment is available.
Emphysema is often the result of smoke that has triggered the immune system to produce more
harmful enzymes. Although these harmful enzymes are normally prevented from causing any
significant damage by a protective protein, smoking reduces the protein’s protective effect. Even
if someone has plenty of the protein in their system, smoking generates certain substances that
keep the protective protein from doing its job.

We as nurses are involved in learning what type of nursing interventions we are to apply to this
type of patient. Beyond understanding the relevant health issue, this case study will also explore
other factors that can enhance our knowledge in the field of our nursing practice. This is also the
primary reason why we choose this case study because we know that it is highly beneficial aside
from it being considered distinctive or unique.

Included with the case study are the discussions of the anatomical parts, through physical
assessment of the patient, laboratory results and their corresponding findings, a reapplied
framework theory by Florence Nightingale. Added to this we also have a corresponding plan for

1
the patients discharge arrangement and finally a discussion of the patient’s daily activities and
nursing care plans.

B. Objectives
General objectives

After exposure in the medical ward of Queen Mary Hospital the promotion of health and the
prevention of illness should have been applied through the use of effective nursing care.
Wellness should be met through the implementations that have been done with regards to the
application of the nursing process. That is after developing and implementing an intervention,
and monitoring the impact of that intervention to the patient. This is to know whether the
treatments given to him were effective or not.

Specific Objectives

Our objective is to develop our skills in identifying and assessing the health problems, how to
utilize and render quality health service in the care of an individual who has emphysema.
Other objectives would include the establishment of rapport for the patient to fully cooperate
with his treatment and so as to assess him with his health related problem.

C. Significance of the study

The importance of this study is that the case on this subject and especially in this area is still very
rare.

D. Scope and limitation

The whole study is all about emphysema, its risk factors and progress, how it affects daily living,
and how it is treated and managed.
Our study is limited only to our patient who has the said disease, his manifestations and how it
was managed up to now.

2
 E. Theoretical framework
Ore
m ’s

Theory of Self Care

• Each person has a need for self care in order to maintain optimal health and wellness.
• Each person possesses the ability and responsibility to care for themselves and
dependants.
• Theory is separated into three conceptual theories which include: self care, self care
deficit and nursing system.

Theory of Self Care

• Self care is the ability to perform activities and meet personal needs with the goal of
maintaining health and wellness of mind, body and spirit.
• Self care is a learned behaviour influenced by the metaparadigm of person, environment,
health and nursing.
• Three components: universal self care needs, developmental self care needs, and health
deviation.

3
 II. Nursing Assessment
A. Personal Data
o Name: Mr. LP
o Address: G. Robles Maybangkal Street, Morong, Rizal
o Age: 61 years old
o Birth date: March 30, 1948
o Religion: Roman Catholic
o Civil Status: Married
o Nationality: Filipino
o Occupation: Former Farmer
o Admitted on: June 21, 2009
o Time: 9:10 p.m.
o Admitting Diagnosis: COPD in exacerbation, Plural Effusion, Pneumonia, t/c Electrolyte
imbalance
o Chief Complaint: D.O.B. (Difficulty of Breathing)

B. History of Past illness

Patient has undergone, thoracentesis last June 15 at Queen Mary Help of Christians hospital prior
to that admission he was diagnose with plural effusion, thoracentesis was perform and after 5
days of admission he was discharge home.

C. History of Present Illness

After the patient was discharge home around 8:50pm (June 15, 2009) after 3 days at home he
experienced DOB and he was rush to the hospital accompanied by his wife and cousins.

-COPD
-Questionable Pneumonia
-Electrolyte Imbalance

D. Family History

According to patients wife they can not recall any illness in the family of his husband except
from asthma.

E. Patient’s Concept of Health Illness and Hospitalization

He didn’t expect that this would happen to him, doctors doesn’t have any idea of the source of
his illness but the patient says, that it might be from the work, he thought that it would just be a

4
simple cough due to tiring day but it lasted for about a month and he needs to be admitted and
undergone some procedures.

F. Physical Examination/Assessment
Area Normal Finding Actual Finding Analysis
I. Head
1. Hair - black, evenly - black slightly -Aging
distributed and grayish , thick.
covers the whole
scalp, thick, shiny,
free from split ends
2. Scalp - white, clean, free - without dandruff - normal
from masses, lumps,
scars, dandruff and
lesions
3. Face - Oblong or oval. - With wrinkles, - patient is still
Symmetrical. Facial symmetrical. With worried about his
expression that is expression of pain condition and
dependent on the and anxiety appearance
mood or true
feelings, smooth and
free from wrinkles,
no involuntary
muscles involved
4. Eyes - parallel and evenly - symmetrical, black - normal
placed, symmetrical, in color and can still
non-protruding, read with out
both eyes are black glasses
and clear
5. Nose - midline, - symmetrical with - patient has
symmetrical and NGT undergone surgery
patent clear pinkish
with few cilia (-)
congestion
6. Lips - pinkish, - crack and dry lips - patient wasn’t able
symmetrical, tip to eat and drink that
margin well define, much due to his
smooth and moist tracheotomy
7. Teeth and Gums - 32 permanent - with out dentures, - patient was
teeth, well aligned, gums are normal in instructed to gargle
free from carries or color bactidol
filing.

5
8. Speech -No hoarseness and Can not speak, Tracheostomy can
well – modulated. makes some block the vocal
Can able to say two moderate noise, can cords that’s why
words with meaning communicate with patient wasn’t able
sign language or by to make any sounds
writing.

9. Ears -Parallel, -Normal Findings -Aging

symmetrical, except, Enable to
proportional to the hear whisper spoken
size of the head, 2 feet away.
bean shaped, helix
is in line with the
outer canthus of the
eye, skin is the same
color as the
surrounding area,
clean, firm cartilage.
Ear canals are
pinkish with scant
amount of cerumen
and a few cilia. Able
to hear whisper
spoken 2 feet away.

10. Breath -No halitosis, foul - With minimal - Halitosis may be

odor, fruity and halitosis due to poor dental
sweet. hygiene

11. Throat -No inflammation, - No inflammation, -excessive mucus

no difficulty in Presences of cough production in his
swallowing and no with greenish lower lung due to
productive cough. yellow phlegm and impaired defense
experiencing mechanisms caused
difficulty in by prolonged years
swallowing of smoking.

12. Neck - Proportional to the - Presences of - Lymph nodes are

size of body and palpable lumps, present after
head, symmetrical sensation of pain surgery, patient’s
and straight. NO when trying to feels pain in the
palpable lumps, speak. neck due to body
masses, or areas of weakness in the area
tenderness of tracheostomy.

6
 II. Thorax
1. Breathing - Normal breath - Abnormal - Excessive phlegm
sounds are Respiration 40bpm, production blocks
bronchovesicular, a difficulty in his thorax and this
medium pitched breathing. may cause difficulty
sound or medium Experiencing cough in breathing.
intensity, heard after nebulization.
posyeriorly between
the scapulae. The
sound have blowing
quality with the
inspiratory phase
equal to the
expiratory phase
and Vesicular
sounds which heard
over the lung
periphery. It created
by air moving
through the small
airways. They are
soft, breezy and low
pitched and the
inspiratory phase is
about three times
longer than the
expiratory phase.
Respiration rate
ranges from 16 – 20
in normal adult.

2. chest - flat chest, tender: - a tube is inserted - to remove fluid

brownish in color. in the fifth from the
intercostals space, intrathoracic space
mid-axillary line.
3. Abdominal Exam - Color is uniform, - Unblemished skin, - normal
symmetrical uniform color,
movement caused symmetric
by respiration. Soft movement cause by
abdomen, no respiration , soft, no
tenderness, no tenderness, no
lumps, or masses, lumps or masses,
no organomegaly

7
 III. Limbs
1. Extremeties - no areas of - with IV catheter on - red spots may
tenderness, muscle his right arm and a cause itchiness in
appear with good red spots in the site the site of IV and
muscle tone of the IV catheter. also this may cause
infection or
phlebitis.

2. Nails - transparent, - pale nail beds and - poor circulation

smooth and cover peripheral last for
with pink nail beds 4seconds
and translucent

IV. Genitalia -No discharges or -There are no -Patients urinate on

bleeding, no discharges or any the bed pan
difficulty in bleeding.
urinating.

V. Mental State - Can be able to - He can - Slightly anxious

responds from any answer/respond to about his condition,
questions and can us a little bit slowly. and tries to think
still be familiar to about what when
his environment wrong before he
experience his
illness.

VI. Hygiene and - Full bath and able - Patients depends - Patient has a
comfort to practice simple on significant others drainage tube at his
hygiene and care for in eating, taking a chest and undergone
himself. bath (TSB) and tracheostomy,
other chores that patients
involves wide experiencing body
movement. weakness can not
move properly

8
 F.Usual Pattern of daily living/
Gordon’s Health Assessment
Pattern Before After Interpretation Analysis
Hospitalization Hospitalization
1. Health Patient X makes Patient X Patient X cannot A tracheostomy is a
Perception- sure to consult his considers himself function surgical procedure to
Health doctor with not healthy due to normally like create an opening
Management regards to his his present before because of through the neck into
condition, he goes condition. He was his confinement the trachea (windpipe).
for checkups diagnosed with and because of A tube is usually
because he knows "COPD” and he his condition. His placed through this
that there is had undergone body image opening to provide an
something wrong tracheostomy. He changed due to airway and to remove
with him. He is expecting to his disease and secretions from the
maintains a recover from his surgical lungs. This tube is
healthy body. He present condition procedure that he called a tracheotomy
easily gets bored with the help of has undergone. tube or trachea tube.
when he is not the health care This surgical
doing anything. providers procedure helps the
He has started attending to his client with his
smoking needs. breathing problem.
(Marlboro Green) All of the
since he was 36 medications
years old up to prescribed to
present. He is not patient X are
allergic to any available.
food or drug. His
family does not
have any history
of hypertension,
heart disease,
cancer, asthma,
diabetes or even
tuberculosis.

2.Nutritional Patient X’s life During Patient X’s An individual’s health

- before his pre hospitalization, nutritional and status greatly affects
Metabolic confinement stage the patient is on a metabolic status eating habits and
Management was normal, he DAT diet (Diet as has been changed nutritional status
can eat whatever tolerated). He eats due (Fundamentals of
he wants. He eats lugaw, goto, to his Nursing by Kozier p.
fruits like crushed biscuits. confinement and 1178) The patient was
apples and He said he has his medical brought to the hospital
bananas, fish and poor appetite or he health because of ruptured

9
 also vegetables easily loses his condition. His globe right eye due to
most of the time. appetite. confinement accident and burn of
He rarely eats status is totally facial area including
meats. affected. the neck.

3.Eliminatio Bowel Bowel Bowel An illness greatly

n Patient X Patient defecates There was a affects elimination
Pattern defecates once a day but not change in status due to
1-2 times a day everyday. He the frequency, immobility.
without defecates in the consistency and
Experiencing bed pan. Stool is amount of stool.
discomforts, soft, is minimal in Bladder
usually in the amount and is There was a
morning and brown in color. change in
afternoon. Bladder the frequency,
Stool is brown in Patient voids in and amount.
color and is well- the bed pan
formed. without pain and
Bladder discomfort.
Patient X voids Urinates about 3-5
usually times a day.
6-8 times a day.
Urine is yellow in
color. No pain
when voiding.

4. Activity, In the morning, Patient X’s During Patient Pain causes discomfort
Leisure Patient X’s daily activities in X’s and may disrupt the
and include farming in the hospitals are confinement in patient’s daily
Recreation their land fields. ambulation, deep the hospital, activities.
Pattern In the afternoon breathing exercise, there is limitation
after lunch, Patient taking a bath or in his activities
X likes to watch personal hygiene. of daily living
T.V. and a disruption
in his leisure and
recreation
pattern.
5. Sleep and Patient X before Patient X Patient X's sleep “Illness that causes
Rest hospitalization verbalizes that he and rest pattern pain or physical
Pattern already has has difficulty with has not changed distress can result in
difficulty in sleeping and that much before and sleep problems.
sleeping. He says he sleeps for short after admission People who are ill
he will fall asleep periods of time to the hospital. require more sleep
but will eventually about: (3-4 hours) Pain also than
wake up again and due to pain and contributes a big normal and the normal
will not be able to the environment factor for rhythm and

10
 return back to that he is in. He disturbances of wakefulness
sleeping. He does not feel his sleeping is often disturbed.”
sleeps for comfortable. pattern. (Fundamentals of
A short period of Nursing, 7th ed by
time about 4 hours Barbara Kozier, et al,
a day. p.
1117). There is
disruption of the sleep
wake
cycle because of the
patient’s disease.
6. Cognitive- Patient is an Because of Patient There was a Tracheostomy can
Perceptual elementary X’s present change in block the vocal cords
Pattern graduate. He is a condition, he has cognitive and that’s why patient
farmer. He can difficulty in perceptual wasn’t able to make
read and write. breathing. Patient pattern in terms any sounds
He can speak and is able to read and of speaking due
be understood by write at present. to his
others. He cannot speak tracheostomy.
much because of
his tracheostomy
tube, he
communicates
through hand
gestures but most
data that we
received came
from his wife.
7. Self- Patient X is a He does not There is a change “Events or situations
Perception- friendly person; he consider himself in his self may change the level
Self-Concept loves to socialize as a holistic esteem. of self concept over
Pattern with his friends in person. He has time. Illness and
their many regrets in trauma can also affect
neighborhood. He his life like his the self concept.”
considered himself smoking habits
as a holistic before. He thinks
human being as that he can't
long as his function well than
complete, healthy before.
and his family are
always there for
him. He wants
to have good
health and live his
life to the fullest.

11
8. Role Patient can speak Patient X's family He cannot Illness can cause
Relationship and understand still supports him perform his changes in one’s role.
English, Tagalog. despite of the previous
He can clearly change in his role activities or even
express himself. due to his illness. support his
He has 8 siblings family but still,
and they are all despite of that,
close to each his wife is still
other. Patient is there beside him
very active and taking care of
usually socializes him and loves
with his him.
neighbors.

9. Sexuality- Patient and his The patient does Patient does not Illness can cause loss
Reproductive wife perform this not perform any want to talk of interest in sexual
Pattern when he is still sexual activity. about it. activities.
healthy.

10. Coping When he is The recent Even though it’s According to Folkman
and anxious, patient hospitalization hard for the and Lazaruz, coping is
Stress wants to be alone. was a shocking patient to cope, is “the cognitive and
Tolerance He does not show experience for wife is there behavioral effort to
his emotions. patient X, there beside him to manage specific
When he is has been many support him and external and/or
stressed, he changes that has give him strength internal
prefers to rest. occurred which and hope. demands that are
When it comes to made it difficult appraised as taxing or
problem, he lets for him to adjust. exceeding the
himself think He cannot resources of the
immediately for a communicate person”(Fundamental
solution. effectively due to s
the procedures on Of Nursing by Kozier
his neck which is P.
open to direct 1020).
airway through an
incision in the
trachea.
11. Values- Patient X is a According to the After what Due to illness, it
Belief Roman Catholic. patient, there are happened, patient makes the patient
Pattern According to the no practices that is now seeking become closer to God.
client, he goes to affect his for medical
mass every sunday hospitalization. He assistance.
with his family. follows Religious effort
therapeutic is still a part of
regimen and has patient’s life.

12
 strong faith in God
accounts for his
fast progress.

III. ANATOMY
The Respiratory System

13
Parts of the Respiratory System
Structurally, the respiratory system consists of two parts:
1. Upper Respiratory Tract
2. Lower Respiratory Tract
Functionally, the respiratory system consists of two parts:
1. The conducting portion
2. The respiratory portion
Respiratory Tract
The respiratory tract is the path of air from the nose to the lungs. It is divided into two sections:
Upper Respiratory Tract
Lower Respiratory Tract

Upper respiratory tract

1. Nose
2. Pharynx (throat)
3. Associated structures

Lower Respiratory Tract

1. Larynx (voice box)
2. Trachea (windpipe)
3. Bronchi
4. Lungs

IV. PHYSIOLOGY
Upper respiratory tract
Nose
The nose, whether “pug” or “ski-jump” in shape, is the only externally visible part of the
respiratory system. During breathing, air enters the nose by passing through the external nares, or

14
nostrils. The interior of the nose consists of the nasal cavity, divided by a midline nasal
mucoseptum. The olfactory receptors for the sense of smell are located in the mucosa in the slit
like superior part of the nasal cavity, just beneath the ethmoid bone.

Pharynx
The pharynx is a muscular passageway about 13 cm long that vaguely resembles a short length
of red garden hose. Commonly called the throat, the pharynx serves as a common passageway
for food and air.
Air enters the superior potion, the nasopharynx, from the nasal cavity and then descends
through the oropharynx and laryngopharynx to enter the larynx-below.

Lower Respiratory Tract

Larynx
The larynx, routes air and food into the proper channels and plays a role in speech. The largest of
the hyaline cartilages is the shield shape thyroid cartilage, which protrudes anteriorly and is
commonly called the Adams’s apple.

Trachea
Air entering the trachea or windpipe from the larynx travels down its length (10-12 cm, or about
4 inches) to the level of the fifth thoracic vertebra, which is approximately midchest. The trachea
is lined with a ciliated mucosa.

Primary Bronchi
The division of the trachea forms the right and left primary bronchi. The right primary bronchus
is wider, shorter, and straighter than the left. By the time incoming air reaches the bronchi, it is
warm, cleansed of most impurities, and well humidified.

Lungs
The paired lungs are fairly large organs. They occupy the entire thoracic cavity except for the
most central area, the mediastinum, which houses the heart, the great blood vessels, bronchi,
esophagus, and other organs. The surface of each lung is covered with a visceral serosa called the
pulmonary,or visceral, pleura, and the walls if the thoracic cavity is lined by the parietal pleura.

Alveoli (site of gas exchange)

An alveolus (plural: alveoli, from Latin alveus, "little cavity"), is an anatomical structure that has
the form of a hollow cavity. In the lung, the pulmonary alveoli are spherical outcroppings of the
respiratory bronchioles and are the primary sites of gas exchange with the blood. The lungs
contain about 300 million alveoli, representing a total surface area of 70-90 square metres, each
wrapped in a fine mesh of capillaries. It has a radii of about 0.1 mm and wall thicknesses of
about 0.2 µm. It consists of an epithelial layer and extracellular matrix surrounded by
capillaries. In some alveolar walls there are pores between alveoli. There are three major
alveolar cell types in the alveolar wall (pneumocytes): Type I cells that form the structure of an

15
alveolar wall. Type II cells that secrete surfactant to lower the surface tension of water and
allows the membrane to separate thereby increasing the capability to exchange gases. Type III
cells that destroy foreign material, such as bacteria. The alveoli have an innate tendency to
collapse (atelectasis) because of their spherical shape, small size, and surface tension due to
water vapor. Phospholipids, which are called surfactants, and pores help to equalize pressures
and prevent collapse.

Pulmonary gas exchange

Pulmonary gas exchange is driven by passive diffusion and thus does not require energy for
exchange. Substances move down a concentration gradient. Oxygen moves from the alveoli
(high oxygen concentration) to the blood (lower oxygen concentration, due to the continuous
consumption of oxygen in the body). Conversely, carbon dioxide is produced by metabolism and
has a higher concentration in the blood than in the air.
Oxygen in the lungs first diffuses through the alveolar wall and dissolves in the fluid phase of
blood. The amount of oxygen dissolved in the fluid phase is governed by Henry's Law. Oxygen
dissolved in the blood may diffuse into red blood cells and bind to hemoglobin. Binding of
oxygen to hemoglobin allows a greater amount of oxygen to be transported in the blood.
Although carbon dioxide and oxygen are the most important molecules exchanged, other gases
are also transported between the alveoli and blood. The amount of a gas that is exchanged
depends on the water solubility of the gas the affinity of the gas for hemoglobin. Water vapor is
also excreted through the lungs, due to humidification of inspired air by the lung tissues. Red
blood cells transit the alveolar capillaries in about 3/4 of a second. Most gases (including carbon
dioxide and nitrous oxide) reach equilibrium with the blood before the red blood cells leave the
alveolar capillaries. Gases that reach equilibrium before the blood leaves the alveolar capillaries
are perfusion limited, since the amount of the gas exchanged depends solely on the volumetric
flow rate of blood past the alveoli. However, carbon monoxide is stored in such high
concentrations in the blood, due to its strong binding to hemoglobin that equilibrium is not
reached before the blood leaves the alveolar capillary. Thus, the concentration of carbon
monoxide in the arterial system can be used to assess the resistance of the alveolar walls to gas
diffusion. Transport of carbon monoxide is thus termed diffusion limited. Oxygen is normally
perfusion limited, but in disease conditions it can be diffusion limited.

V. Laboratory Examination
Microbiology Date: 6-19-09
Specimen: Pleural Fluid
Result: No Pathogenic Organism isolated after 3 days
Of intebation.

Dr. Noel C. Santos MD

16
 FPSP

Chemistry Test Date: 6-22-09

Na 142.6 (137-145mmol)
Mg .90 (.66-.95mmol/L)
BUN 6.5 (3.2-7.1mmol/L)
Creatinine 93 (71-133mmol/L)
SGPT(ALT) 45 (13-61mmol/L)
SGOT 19 (14-50mmol/L)
K 3.62 (3.5-5.1mmol/L)
Total CHON 62 (63-82G/L)
Albumin 31 (35-50 G/L)
Globulin 31
A/G Ratio 1.0

Histopathology Date: 6-22-09

-Negative for Malignancy, Pleural Fluid ,Cytology

-Gross/Microscopic descriptions submitted for cytology is a 1L

& 40ml dirty yellow fluid.

-Micro show reactive mesothelial cells, lymphocytes, occasional polys.

No malignant cell seen.

Mennen A. Alsol M.D.

Pathologist

Hematology Date: 6-23-09

Hgb - 157 (120-150g/L)
Hematocrit - 0.48 (0.37-0.47)
WBC - 15.8 (5.0-10.0x10/L)
Segmenters - 0.90 (0.42-0.75)
Lymphocyctes - 0.07 (0.20-0.51)
Monocytes - 0.03 (0.02-0.09)

17
Interpretation: Polycythemia with infection related to pleural effusion

Protime Date: 6-23-09

Control = 10.2 sec.
Pt = 7.8 sec.
IVR = 0.80
%activity = 131%

Serology & Immunology Date: 6-23-09

Test: Prostate specific antigen
Specimen: Serum
Result: 1.30 mg/ml
Normal Values: Less than 4.0mg/ml
Pls. Note: Colerate clinically

Noel C. Santos MD
FPSP

ECG Date: 6-26-09

Rhythm: Sinus
QRS axis 70
Rate: Auricular 120/min.
Ventricular: 120/min.
PR interval 0.16 sec.
QRS interval 0.10 sec.
QT interval 0.36 sec.

Interpretation: Sinus tachycardia Left atrial enlargement, persistent fever, diffuse nonspecific T-
wave changes.

Urinalysis Date: 06-28-09

Color: Yellow
Transparency: Turbid
Reaction: 5.0
Specific Gravity: 1.015
Sugar: negative
Protein: positive
Puss: 4.5/hpf
RBC: Few

18
Epithelial: Few
Urates: Few
Mucus threads: Few
Dr. Mennen Alsol MD

Histopathology Date: 6-29-09

Specimen: Vocal cord masses

Pathologic Dx
-Squamous papillomas showing chronic non-specific inflammation, Right and Left vocal cords.

Gross/micro description
-Specimen consist of grayish white tissue fragments measuring as labeled A. 1x0.6cm and B.
1.1x0.5cm Entire specimen submitted. Microsecretions A and B disclosed tissues lined by
thickened stratified squamous epithelium set in a fibrovascular stroma with Coci of chronic
inflammation. There is no evidence of malignancy.

ECG Date: 6-30-09

QRS – 75
Rhythm: Sinus
Rate Auricular: 110/min.
Ventricular: 110/min.
PR Interval: 0.16/sec.
QRS: 0.09/sec.
QT int. 0.36/sec.

Interpretation: Sinus tachycardia. Incomplete Right bundle branch block

And persistent fever.

Dr. Ma. Imelda L. Balajadia

Cardiologist

Chest AP Sitting Date: 6-30-09

-Follow-up Chest Film 6-30-09 when compared to previous film dated 6-17-09
showed increase in previously noted PE in both hemithoraces suggest clinical
cerrelation and follow-up.

Dr. Rufely S. Laron MD FRAMS

Sonographic Date: 7-1-09

19
Chest Ultrasound

-Pleural Effusion is present in both Right and Left hemithoraces w/ estimated

volume of 1,182 ml & 519 ml respectively. No No loculation or cenoolidation seen.

Ma. Clarita D. Espanol MD, FPCR

Radiologist

Hematology Date: 7-3-09

Hgb - 128 (120-150 gm/L)
Hematocrit - 0.39 (0.37-0.47)
WBC - 11.5 (5.0-10.0x10/L)
Segmenters - 0.91 (.42-.75)
Lymphocytes - 0.06 (.20-.51)
Monocytes - 0.03 (.02-.09)

Interpretation: Prior to his last hematology result the patient has infection related to presence of
water in his lungs(Pleural effusion).
Dr. Anne Paulette C. San Antonio MD

Hematology Date: 7-4-09

Hgb - 128 (120-150 gm/L)
Hematocrit - 0.39 (0.37-0.47)
WBC - 11.5 (5.0-10.0x10/L)
Segmenters - 0.91 (.42-.75)
Lymphocytes - 0.06 (.20-.51)
Monocytes - 0.03 (.02-.09)

Interpretation: Prior to his last hematology result the patient has infection related to presence of
water in his lungs(Pleural effusion).

Dr. Anne Paulette C. San Antonio MD

Chest Ap Sitting Date: 7-4-09

-Follow-up chest film when compared w/ the one done on June 30, 2009 show decrease in the
amount of pleural effusion, bilaterally. There is a rightsided chest tube in place w/ its tip at the
level of the 8th posterior rib. Tracheostomy tube is again seen in place. There is minimal
subcutaneous in the right chest wall.

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 Chest Ap Sitting Date: 7-7-09
-Follow-up chest film 7-7-09 when compared to previous film dated 7-4-09 shows resolutions of
previously noted right sided pleural effusion. However, no significant interval change in
previously noted left sided pleural effusion other finding remain unchanged. Suggest clinical
correlation & follow-up.

ECG Date: 7-7-09

Rhythm: Sinus
QRS Axis: 88
Rate: Auricular 110/min.
Ventricular 110/min
PR interval: 0.16 sec.
QRS interval: 0.10 sec.
QT interval: 0.32 sec>

Interpretation: Sinus Tachycardia

VI. DRUG STUDY

NAME OF ACTION
DRUGS
Chemically related to
atropine, it antagonizes the
Atrovent effect of acetylcholine. It
causes a local and site
>anticholinergic, specific bronchodilatation by
bronchodilator preventing the increase in
INDICATION NSG.CONSIDERATION
Acute exacerbations Teach patient and/or family:
of COPD. Used in >that the drug may induce
junction with B- visual disturbances, sleepiness,
adrenergic stimulant or dizziness, and to use care
for acute asthmatic when performing tasks that
attacks. require mental alertness.

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>1 neb + 2cc NSS intracellular cyclic guanosine >to increase fluid intake, as
QID monophosphate w/c is drug causes dry mouth, throat
produce by the interaction of irritation, and a bad taste of the
acetylcholine with the mouth.
muscarinic receptors of the
bronchial smooth muscles.
Pharmacokenetics
Absorption: Minimal
Distribution: none
Metabolism: liver (small
Amount of absorption)
Excretion: kidneys absorbed
amount
Half life: 2hrs.
Pharmocodynamics
Inhalation
Onset: 5-15 mins.
Peak: 1-2hrs.
Duration: 3-6hrs.

NAME OF DRUGS ACTION INDICATION NSG.CONSIDERATION

Glucocorticoid w/ the high
topical anti inflammatory
potency. It has a strong
Flixotide affinity for and agonist
activity at human
>anti inflammatory glococorticoid receptors.
>1/2 neb + 1cc NSS Pharmacokenetics
q12 Absorption: limited,
(bioavailability <2%)
Prophylactic >Monitor for possible drug
management in mild, induced adverse reactions:
moderate and severe Dryness of mouth, and throat;
asthma. hoarseness; paradoxical
bronchospasm.
> assess for pulmonary and
cardiac status.
>assess the pt. and families
knowledge on drugs therapy.

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 distribution: minutes traces
metabolism: liver excretion
liver halflife: 8 hrs
Pharmacodynamics
Onset unknown
peak: 1-2 hrs
duration: unknown.

NAME OF DRUGS ACTION INDICATION NSG.CONSIDERATION

Immediately and Allergic and >obtain baseline wt. blood
completely inflammation pressure and electrolyte level and
Prednisone converted to active conditions, in monitor periodically during
prednisolone in the bronchial asthma therapy.
>adrenocorticosteroids liver. The anti- >assess for “k” depletion. Fatigue,
, synthetic. inflammatory effects nausea, vomiting, depression,
>10 mg 1 tab TID may be due to polyuria, weakness, edema,
inhibition of hypertension.
prostaglandin >monitor for possible induce
synthesis. reactions: CNS: insomnia CV:
Pharmacokinetics: heart failure or HPN. GI: peptic
Absorption: well ulcerations musculoskeletal:
Distribution: wide muscle weakness.
Metabolism: liver
Excretion: kidney
Half life: 18-36hrs

NAME OF DRUGS ACTION INDICATION NSG.CONSIDERATION

Decreases pre-load Treatment of acute Teach patient and/or family:
and after-load w/c angina. >to apply only as directed
Nitroglycerine thus decreases left >to remember to remove old pad
ventricular end >to rotate sites of application
>coronary vasodilator diastolic pressure >not to disturb or open patch
>5mg OD and systemic >Evaluate therapeutics
vascular resistant: effectiveness cardiac status and
dilates coronary adverse response: e.g.
arteries and improve hypotension, arrhythmias, GI

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 blood flow through disturbance.
coronary
vasculature, dilates
arterial, venous beds
systemically.

Pharmacokinetics
Absorption: well
absorbed (PO buccal
and SL)
Distribution:
unknown
Metabolism: liver
extensively
Excretion: kidney
Half life: 1-4mins.
Pharmacodynamics
Onset: 30 mins.
Peak: unknown
Duration: 2-12 hrs1

NAME OF DRUGS ACTION INDICATION NSG.CONSIDERATION

Norvasc Inhibits influx of Treatment: >assess for cardiorespirartory

calcium ion across hypertension, chronic status: angina pain, B/P, pulse,
> cell membranes to stable angina; respiration, ECG.
>5mg 1tab q4 until produce relaxation vasospastic angina. >assess hydration and fluid volume
febrile of coronary vascular status, input and output ratio,
smooth muscle extended neck vein, lung crackles,

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 dilatation of adequate pulses and skin turgor.
coronary artery,
decrease peripheral
vascular resistance
of smooth muscle
decrease b/p and
increases myocardial
O2 delivery in
patient’s w/
vasospatic angina.
pharmacokinetics
Absorption: well
absorbed up to 90%
Distribution: 95%
bound in plasma
protein crosses
placenta
Metabolism:
extensively in liver
Excretion: kidneys
Half life: 30-50hrs.
increases in elderly
hepatic disease.
pharmacodynamics
Onset: unknown
Peak: 6-10hrs
Duration: 24 hrs

VII. Discharge Planning

Medication

The patient has home medication to continue the following instructions:

• Atravent 1 Neb + 2cc NSS every 4 hours for Nebulization
• Cefadox 200mg 1 tablet twice a day for complete 10 days

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 • Vastarel MR 35mg twice a day 1 tablet
• Mepirocin Ointment apply to Tracheal Stoma twice a day
• Prednisone 5mg ½ tablet for twice a day in 2 days then 5mg ½ tablet for once a day in 2
days then disc
• Ansimar 400mg 1 tablet for twice a day

Exercise
• Mild exercise can increased oxygen utilization and re-train muscle to help improve the
tissue.
• Encouraged the patient to pursed-lip breathing to prolong exhalation and increase airway
pressure during expiration, thus reducing the amount of trapped air and the amount of
airway resistance.
• Instructed the patient to Inhale through the nose while slowly counting to 3 then blow it
slowly and evenly against pursed lips while tightening the abdominal muscles.
• Pursing the lips increases intratracheal pressure; exhaling through the mouth offers less
resistance to expired air.
• Turn side by side to prevent bedsore.
• Instructs the patient to flexion and extension or rotate his foot.

Treatment
• Nebulization
• Tracheal Suction
• Oxygen Therapy

Health Teaching

• Placed in a semi-Fowler’s position to facilitate ventilation, promote drainage and prevent

strain on the suture lines.
• Instruct the family to encourage breathing exercise to promote lung expansions.
• The member of the family keeps paper and pencil or a Magic Slate within the patient’s
reach at all times to ensure a means of communication.

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 • Instruct the family to avoid air pollutants such as smoke, dust or aerosol sprays which
may initiate brochospasm.

Nebulizer Therapy
• Instructed the patient to breath through the mouth, taking slow, deep breaths and then
to hold for a few seconds then breathing out. At end of inspiration to increase
intrapleural pressure and reopen collapsed alveoli.
• Instructed the family to avoid replacing the nebulizer cup and the tube to the dust and
smoke area, away from open window.
• Avoid putting the equipments in the dishwasher area.
• Instructed the family to wash the mouthpiece in a warm water and mild detergent.
They can also use vinegar solution by soaking for 30 minutes then rinse through
water, allow drying with a paper towel and put it in a zipper plastic bag.

Tracheal Suctioning
• Instructed the patient to perform hand hygiene and use glove before performing to
prevent contamination and spread of.
• Do not suction for longer than 10 seconds to prevent suctioning air in the lungs.

Oxygen Therapy
• Instructed the patient to keep oxygen tank at least15 feet away from matches, candles,
gas stove or other source of flame. Also keep away from TV, radio, and other
appliances at least 5 feet.

Out-Patient Follow-up

• Instruct the patient to follow-up check up on July 23, 2009 at room 106B at 4 pm.
• Instruct family to return to their attending physician for scheduled check-up and
consultation.
• Advise family to report to the physicians any complaints.

Diet

Diet as Tolerated but be careful and be selective to the foods.

• Encourage the patient to increase fluid intake to keep the mucus thin and help clear
airway.
• Eat meals when their energy levels are at their highest which is usually in the morning.

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 • Eat slowly and chewed food thoroughly to avoid becoming breathless while eating and to
prevent choking.
• Limit salty food, consuming too much can cause the body to retain water and make
breathing become difficulty.
• Eat food with balance nutritious food.
• Eat food with contains Vitamin C for development and maintenance of the blood vessels
and scar tissues.

Spiritual
• Encourage the family to pray together.
• Encouraged the patient to think positive to all happen to his life.
• Instructed the family to build up his spiritual fighting to help himself treating.

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