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~A Case Presentation~
As a partial requirement for Medical-Surgical Nursing I Presented By:
Aguado, John Prose Almarra, Edrianne Paul Antonino, Jelaine Bacena, Dianne Jamaica Marpa, Ian Rafael Marquez, Charmaine Ong, Julie Ann Taguba, Neilson John Villanueva, Irish Saligumba, Emyl Cyril Soliven, Kathlene Chelo Zacarias, Andrea III-CN
Presented To:
Transudative effusions
Clear, pale yellow, watery substance Influenced by systemic factors that alter the formation or absorption of fluid Contains few protein cells Common causes: CHF and liver or kidney disease
Exudative effusions
Pale yellow and cloudy substance Influenced by local factors where fluid absorption is altered (inflammation, infection, cancer) Rich in protein (serum protein greater than 0.5) Ratio of pleural fluid LDH and serum LDH is >0.6 Pleural fluid LDH is more the two-thirds normal upper limit for serum Rich in white blood cells and immune cells Always has a low pH Common causes: tuberculosis, pneumonia, cancer, and trauma
Lights criteria
Pleural fluid protein divided by serum protein is greater than 0.5. Pleural fluid LDH divided by serum LDH is greater than 0.6. Pleural fluid LDH is greater than two-thirds the upper limit of normal for the serum LDH. If none of these criteria is met, the patient has a transudative pleural effusion
Statistics
According to WHO: The estimated prevalence of pleural effusion is 320 cases per 100,000 people in third world countries. In developed countries the common causes of pleural effusions in adults are cardiac failure, malignancy and pneumonia, pneumonia, whereas in developing countries are tuberculosis and parapneumonic effusions are more prevalent.
Statistics
According to DOH: The Philippines currently has 250,000 cases of Tuberculosis, as of Tuberculosis, the year 2009. Pleural Effusion accounts to approximately 38% of patients with Tuberculosis.
www.doh.gov.ph
www.doh.gov.ph
BIOGRAPHICAL DATA
NAME: ADDRESS: AGE: GENDER: BIRTHDATE: RELIGION: DATE OF ADMISSION: MODE OF ADMISSION: Mrs. M Brgy Cembo 42 y/o Female May 30, 1969 Roman Catholic July 17, 2011 Medicine Ward
CHIEF COMPLAINT
Normal CXR
Thoracentesis
REVIEW OF SYSTEMS
Neurological System Cardiovascular System Respiratory System none none (+) dyspnea (+) paroxysmal nocturnal dyspnea (+)chest pain (P-pain in right thorax during deep inspiration and movements Q- Sharp pain RNon-radiating S-7/10 T- relieved by shallow breathing (+) orthopnea of 2 pillows (+)night sweats none none none
FAMILY HISTORY
The client has history of cancer, specifically; her mother has been diagnosed to have breast cancer while his father has been diagnosed to have prostate cancer.
Mary 49
Maricar 45
Mrs. M 42
Mark 38
Mercy 36
Mr. Husband
Marj 16
Health Perception and Health Management Pattern: Mrs. M described a healthy person as someone without an illness and still manages to do his/her daily activities. Mrs. M rated her general health status as 6/10, She added that she still has a positive outlook in life even though she has a disease. With regards to self breast examination, the client is familiar with it but doesn t have enough knowledge on how to perform it.
Mrs. M takes care of her body through bathing, trimming of fingernails, wearing of slippers at home, brushing teeth, and using deodorant. The patient doesn t smoke and doesn t drink any alcoholic beverage.
Breakfast (7:30AM)
Lunch (12:30NN)
Snack (3:00PM)
Dinner (7:00PM)
cup of steamed rice 1 pc. Lumpiang sariwa 1 glass of milk 1-2 glass of water
Elimination Pattern:
Regarding her defecation, she usually defecates once a day and the stool is dark brown in color and the consistency is solid. The patient doesnt have any discomforts upon defecation. She seldom experiences constipation or diarrhea. Regarding her urinary elimination pattern, Mrs. M frequently urinates (4-5x/day) because she is taking Furosemide every night. She stated that she doesnt feel any discomfort or pain during micturition.
Activity-Exercise Pattern:
Mrs. M is a high school teacher. She goes to school in the morning and goes home at 1:00 pm. She said that before she felt the symptoms of easy fatigability, she exercises during weekend morning for 30 minutes using a waist twisting disc. She also considers walking to her school for work as an exercise.
Mrs. M had difficulty of sleeping in the hospital because she is not comfortable sleeping with the hospital environment and also, because of the pain she has been experiencing on the thoracostomy site upon trunk movements. She described the pain as sharp, and rated it as 7/10. During the interview, facial grimace is evident. She sometimes nods her head just to agree. She also speaks at a low-volume voice.
Sleep Diary
August 30, 2011 Hours of Sleep during Night Hours of Nap During Afternoon Quality of Sleep (12AM-5AM) 5 hours (1:30PM-3:00PM) 1 hours Continuous August 29, 2011 (11AM-4:30AM) 5 1/2 hours (4:30PM 6:00PM) 1 hours Continuous August 28, 2011 (12AM-4:30AM) 4 1/2 hours (1:00-3:00 PM) 2 hours Not Continuous.
Awakened at 3am due to pain on the thoracostomy site. Fell asleep after pain subsided.
Refreshed
Refreshed
Not Refreshed
PHYSICAL EXAMINATION
General Appearance: During the interview, the client is conscious and coherent. The client has evident facial grimace. Anthropometric Measurement: Weight: Height: BMI: Vital Sign: Temperature : Cardiac Rate: Respiratory Rate: Blood Pressure: 40 kg 1.49 cm 18
Abnormal
PHYSICAL EXAMINATION
ORGAN/ BODY PART(S) Head: Skin: METHODS USED Inspection Inspection Palpation FINDINGS normocephalic Intact (+) dry skin Warm to touch elastic skin turgor White sclera (-) sunken eyeball (-) pale conjunctiva (-) discharge Bilaterally equal in size (-) lesions (-) discharge No tenderness symmetric and straight (+) pink mucosal membrane (-) deviated septum (-) discharge (-) nasal flaring SIGNIFICANCE Normal Normal Abnormal Abnormal Normal Normal Normal Normal Normal Normal Normal Normal Norma Normal Normal Normal Normal Normal
Eyes:
Inspection
Ears:
Inspection Palpation
Nose:
Inspection
PHYSICAL EXAMINATION
ORGAN/ BODY PART(S) METHODS USED FINDINGS SIGNIFICANCE
Mouth
Inspection
(+) dry lips pinkish tongue (-) lesions pink tonsils and buccal mucosa (-) cyanotic nailbeds capillary refill more than 3secs. Symmetric and head centered Thyroid gland moves upward upon swallowing Trachea is midline (+) tender lymphnodes
Nails
Inspection Palpation
Neck
Inspection Palpation
PHYSICAL EXAMINATION
ORGAN/ BODY PART(S) Thorax and Lungs METHODS USED Inspection Palpation Auscultation Percussion FINDINGS (-) Chest wall retractions asymmetric Tactile fremitus (absent on the right thorax) asymmetric respiratory excursion (movement only on the left thorax) asymmetric breathsounds (absent breathsounds on the right) (-) adventitious breath sound dull, flat sound over the right thorax (-) heart murmur Flat abdomen (+) ascites Normal bowel sounds No bruit heard Arms bilaterally symmetric (-) edema (-) lesions or ulcerations (+) palpable distal pulse SIGNIFICANCE Normal Abnormal Abnormal Abnormal Normal Abnormal
Heart Abdomen
Extremities
Inspection Palpation
Contraptions:
IV on Right Hand (PNSS 1L x 8hrs) CTT on Right Thorax at 8th ICS connected to a one-bottle water seal system With Foley Catheter
Pathophysiology
Exposure to TB
Inhalation of TB Bacilli
Formation of Granuloma
PTB
subpleural caseous focus in the lung ruptures into the pleural space
Vigorous inflammatory response associated with an exudation of white blood cells and proteins.
Increase WBC count (16.6 x 10^9 mm/ L) Increase Monocyte count (0.13 g/L)
Vigorous inflammatory response associated with an exudation of white blood cells and proteins.
Decrease breath sounds, stony dull sound when percussed PLEURAL EFFUSION (Accumulation of fluid in the pleural cavity)
CXR: Opaque densities on the right lower lobe & blunting of costophrenic angle
Empyema
( 0.02-0.04 ) ( 10 100 )
7.48 47 23 88
Significance: The patient has respiratory alkalosis. This may be due to rapid & shallow breathing.
Procedure/Ite m
Albumin
Result
Units
Reference Range ( 34 - 50 ) ( 15 - 37 )
25 35
g/L u/L
AST (SGOT)
ALT (SGPT)
33
u/L
( 30 - 65 )
143
u/L
(50-165)
Gram Stain
(August 20, 2011) Specimen: Pleural Fluid Result: Smear shows no presence of gram (-) bacilli.
CYTOPATHOLOGY
(August 20, 2011) Specimen: Pleural Fluid Pathologic Diagnosis: Negative for malignant cells
Chest X-ray
(July 14, 2011) Impression: Consider moderate pleural effusion; right Right Lateral Decubitus: Evidence of minimal pleural fluid
Chest X-ray
CT-SCAN of Chest
Result: PTB with organizing Pneumonia, Superior and posteromedial right lower lobe with right hilar lymphadenopathies and right pleural effusion.
CT MRI
(August 11, 2011) Findings: Mediastinal lymphadenopathies Right pleural effusion with thick pleural density Heart not enlarged Pulmonary Fibrosis in Left Lower Lobes
y y y y y
y y
Drug Study
Classification Mucolytics
Dosage/Frequency 600 mg PO q4
Nursing responsibilities Evaluates clients respiratory status (respiratory rate, depth, rhythm) Check sputum for color, consistency and amount. If bronchospasm occurs, stop the treatment and notify the physician. Instruct patient to notify prescriber immediately about nausea, rash, or vomiting. Warn patient about acetylcysteines unpleasant smell; reassure him that it subsides as treatment progresses. To decrease mucus viscosity, urge patient to consume 2 to 3 L of fluid daily unless contraindicated by another condition.
Evaluation Evaluate the effectiveness of Acetylcysteine through assessing the respiratory status of the client and amount of sputum expectorated.
Liquifies mucus
Nursing responsibilities Take it continously and never skip doses to avoid multi-drug resistance. Monitor Vision of patient. Ethambutol causes optic neuritis. Examine patients at regular intervals and question about possible signs of toxicity: Liver enlargement or tenderness, jaundice, fever, anorexia, malaise, impaired vascular integrity Report to physician onset of difficulty in voiding. Keep fluid intake at 2000 mL/d if possible.
Evaluation Evaluate effectiveness of medication through observing the clients coughing and coping mechanism with the drug
Bacteriostatic
Dosage/Frequency 300 mg PO OD
Nursing responsibilities Administer on an empty stomach, 1 hr before or 2 hr after meals. Administer in a single daily dose. Give with meals because it causes gastric irritation. Prepare patient for the reddish-orange coloring of body fluids (urine, sweat, sputum, tears, feces, saliva); soft contact lenses may be permanently stained; advise patients not to wear them during therapy. arrange for follow-up visits for liver and renal function tests, CBC, and ophthalmic examinatio ns. Advise client to avoid omission of dose to prevent drug resistance
Evaluation Evaluate effectiveness of medication through monitoring hemoptysis production, liver fxn test and CXR
Cell death
Classification Antibiotic
Nursing responsibilities Perform skin test before giving the initial dose. Assess client for allergy to penicillin. Check C&S result. Monitor client for 30 mins when given parenterally; administer epinephrine if anaphylaxis occurs. Do not mix aminoglycosides with penicillin in the same IV infusion deactivates aminoglycoside Check for CBC result and Monitor for hemorrhagic manifestations because high doses may induce coagulation abnormalities.
Evaluation
Cell lysis
Nursing responsibilities Monitor for adequate intake and output and potassium loss. Monitor clients weight and vital signs esp BP Monitor for signs and symptoms of hearing loss, which may last from 1 to 24 hrs. Teach client to take Furosemide early in the day to decrease nocturia. Teach client to report any hearing loss or signs of gout. monitor for S/s of hypokalemia; such as muscle weakness and cramps Monitor for sideeffects such as dizziness, lightheadedness, or fainting spells, Signs of dehydration or low electrolytes,
Action
Nursing responsibilities Assess for infection at beginning of and throughout therapy. Ask patient for allergies to penicillin or cephalosporins. Perform skin test before the initial administration. Obtain specimens for culture and sensitivity before initiating therapy. Observe patient for signs and symptoms of anaphylaxis ( rash, pruritus, laryngeal edema, wheezing)
Binds to PBPs
Action
Nursing responsibilities Assess onset, type, location, and duration of pain. yEffect of medication is reduced if full pain recurs before next dose. y Assess drug history especially carbamazepine, CNS depressant medication, MAOIs. yReview past medical history, especially epilepsy or seizures. yAssess renal or hepatic function laboratory values. yGive without regards to meals yMonitor pulse and blood pressure. yAssist with ambulation if dizziness or vertigo occurs.
Evaluation Evaluate effectiveness of medication through monitoring vital signs of client and assessing pain recurrence.
Action
Nursing responsibilities Continuous monitoring of HR and rhythm throughout thrombolytic administration. Vital observations : record 15 minutely for at least 1 hour from onset of infusion until stable. Notify physician if allergic reactions may include fever increased liver enzymes, reduced renal function, polyarthralgia, polyarthritis and rash.
Evaluation Evaluate effectiveness of Streptokinase through checking for blood in the chest tube drainage.
Classification Anti-pyretic
Nursing responsibilities Check vital signs of the client esp temperature. Inspect IM and IVinjection sitesfrequently for signs of phlebitis. Report onset of loose stools or diarrhea Monitor I&O rates and pattern:
Evaluation Evaluate effectiveness of Paracetamol through monitoring a decrease in the temperature of the client.
Inhibits fever
DISCHARGE PLANNING
Medication: After handling the patient for one day, we advice the client and significant others that the client should continue the prescribed medications as follows: Rifampicin 300 mg PO OD, Pyrazinamide + Ethambutol 400mg + 275mg PO as ordered by the doctor. Exercise: We have encouraged the client to perform mild exercise such as jogging for 30 minutes each day after the woundcompletely healed. Treatment: Health Teaching: Teach the client to avoid omission of doses of antituberculosis drugs such as Rifampicin, Pyrazinamide and Ethambutol. We have advised the client to expect reddish to orange color of urine, sweats, etc. We have advised the client to seek for consultation if she experienced blurring of vision and jaundice. We also taught the client that Mycobacterium Tuberculosis is killed by heat and sunshine thats why appropriate lighting and ventilation of the house is important. Out-Patient Follow-up Care: Advised the client for a follow up check up and for chest xray. Diet: We advised the client to increase intake of protein to increase healing of wound brought about by chest tube thoracostomy. We also advised to take 8-10 glasses of water everyday to avoid dehydration.