1.

Significant Diagnostic Tests

Date Laboratory Results

Performed Test

January 18, 2018 Chest X-Ray Impression:

Shows partial regression of opacification of Left lung suggestive of Pleural Effusion at

Left side Thoracotomy tube in now noted in place

Other Diagnostic Examinations

Date Laboratory Results Normal Significance of the Nursing

Result Responsibilities
Performed Test Value

Potassium- 4.38 3.6-5.2 mmol/L The higher - Explain test

mmol/L the pH reading, the procedure.
63.6 -110.5 umol/L more alkaline and Explain that
Creatinine- 59.80 oxygen rich the fluid slight
January 26, 2018 Chem test
umol/L is. discomfort may
Sodium- 130.5 135-148 mmol/L be felt when the
mmol/L skin is
punctured.
 - Encourage
avoiding stress
if possible
because altered
physiologic
status influences
and changes
normal
hematologic
values.
- Explain that
fasting is not
necessary.
However, fatty
meals may alter
some test results
as a result of
lipidemia.
- Monitor the
puncture site for
oozing or
hematoma
formation.
- Instruct to
resume normal
activities and
diet.
January 6, 2018 Blood Gas Value pH 7.47 7.30-7.45 The higher
the pH reading, the
PCO2 24.7 35-45 more alkaline and
oxygen rich the fluid
is.

Someone who is
hyperventilating will
"blow off" more
CO2, leading
to lower pCO2 levels
 1. Nursing Care Plan
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Moderate pain on After 8 hours of nursing - Assess level of pain - Monitor degree The patient’s
Left Chest CTT area intervention, the pain of pain feeling of pain
“Medyo masakit will be lessen. - Monitor vital signs decreases.
ung tubo na - Establish
nakakabit sa akin baseline and
kapag gumagalaw serves as a
ako” as verbalized reference
by the patient.

Objective: - Observe patency of

CTT and - Determine if the
 Limited characteristic of CTT is patent
ROM drainage and if there are
 In pain any
when abnormalities in
moving
the drainage
 Pain scale
of 6 out of
10 - Encourage patient to
 With CTT perform deep - Inhibits pain
at left chest breathing
draining to exercise/technique - To lessen pain
reddish
secretion - Provide analgesics This medication is used
to help relieve
as prescribed
moderate to moderately
(Tramadol 50mg IV) severe
pain. Tramadol is
similar
to opioid (narcotic)
 analgesics. It works in
the brain to change
how your body feels
and responds to pain.

Subjective: Activity Intolerance After 8 hours of - Assessed the - Baseline of the Still with activity
“Hirap r/t presence of CTT intervention, the patient tolerance of patient endurance of intolerance.
akong will be able to in performing the patient.
gumalaw
demonstrate progress in activities
dahil dito sa - Restore
tubong naka tolerance of activity
- Encourage movement and
konekta sa
ambulation prevent
akin” as
verbalized stiffening of the
- Begin patient arm body parts
by the
and shoulder
patient
exercise - Prevent over
Objective: exertion
- Adjust activities
 With CTT
at left side according to patient - Protect client
of the chest capability of doing from injury
 Restricted the activity
ROM in - Enhance the
upper - Assist with activities ability to
extrimites participate in
- Promote comfort the activities.
measures
 Name of drug Route, Action Side Effects Indications Contraindications Nursing Responsibilities
Frequency,
Dose
Generic name: Dose: Suppresses gastric Short term -hypersensitivity Assess other medications
Omepron 40mg secretion by treatment of active -pregnancy patient maybe taking for
inhibiting duodenal ulcer, -lactation and effectiveness and
Brand name: Frequency: hydrogen/potassium gastro esophageal children interaction.
Omeprazole OD ATPase enzyme reflux -Combination
system in the gastric disease(GERD), therapy with Monitor therapeutic
Route: parietal cell: including erosive clarithromycin effectiveness and adverse
PO characterize as a esophagitis and should not be used reaction at the beginning
gastric acid pump symptomatic in patients with of therapy and periodically
inhibitor, since it blocks GERD. Long term hepatic throughout the therapy.
the final step of acid treatment impairment.
production of pathologic hyper Assess GI system: bowel
secretory sounds 8 hr, abdomen for
condition: to pain and swelling, appetite
maintain healing of loss.
erosive esophagitis.
Short term Monitor hepatic enzymes.
treatment of active
benign gastric ulcer Assess knowledge/ teach
appropriate use of this
medication, interventions to
reduce side effects, and
other symptoms to report