Client s Name: SeverinoAmbatAmbat Age: 66 y/o Diagnosis: Pleural Effusion 2o Lung CA Stage 4, Status Post CTT

NURSING BACKGROUND DIAGNOSIS KNOWLEDGE Subjectives A1: Impaired Gas  Pleural effusion:  Hirapakogumala Exchange r/t increase systemic w excessive thick hydrostatic o secretions 2 disease pressure (push  Walaakongsakitn process force), decrease anararamdamann oncotic pressure A2: Impaired Nutrition gayon (pull force), Less than Body increase capillary Objectives requirements r/t lining (edema), and  Receivedpt in dysphagia and impaired side lying decreased appetite 2o lymphatic system position, A3: Activity  Lung conscious, CA: r/t coherent, and Intolerance Abnormal growth compromised oxygen communicative of cells found in with IVF #2 PNSS transport system 2o more than one 1L x 10gtts/min, pleural effusion lobe or may have received @ 950 metastasized to cc, hooked @ other organs RMCV, infusing well  CTT: insertion of tube into the  With O2via N.C @ pleural space to 5 LPM drain fluid, air, or blood.  With TPN 2000 mL x 24o CUES  With pulse oximetry: 02 sat = 96% PR = 114 bpm

LONG TERM P1: Within hospitalization, pt will maintain patent airway to facilitate maintenance of O2 to all body cells P2: Within hospitalization, pt will manifest good appetite through adequate intake of nutritious food and hydration. P3: Within 1 weeks, pt will be able to ambulate with assistance.

PLAN OF INTERVENTIONS P1:Within the To initiate NPI shift, pt will be able to verbalize easiness in To assess and breathing as record vital signs evidence by Q4 comfort To monitor and P2: Within the record I&O shift, pt will be able to intake small frequent To maintain feeding for easy cleanliness at digestion and bedside absorption of nutrients To encourage increase OFI P3: Within the shift, pt will progress activity from lying Reposition position to sitting frequently, placing position and in sitting and supine frequent turn side to side positions to side. To maintain O2 therapy @ 5 LPM SHORT TERM

EVALUATION SCHEME To establish E1: Reassessment rapport of ptsbreathing the For continuous through patient monitoring verbalization of the pt RATIONALE To observe any E2: abnormal input or Reassessment output of the body of pts intake and output To promote Reassess sanitation in the E3: activity tolerance area through Serve as observation and expectorant and to verbalization of pt prevent dehydration Maximizes expansion drainage secretions lung and of

To correct and prevent worsening of hypoxemia, improve survival and quality of life

 With CTT water seal bottle received @ 300 cc level  (+) cracles and expiratory wheezing ausculated @ L lower lung fied  (+) general malaise (+) dyspnea, use of accessory muscles, air hunger (+) exertional fatigue (+) pursed lip breating with prolonged expiratory phase (-) cough Skin warm to touch Inability to perform ADL (-) appetite  Hx of CA, chain smoker, and alcohol abuse  Radiographic Report: Minimal pleural based density and reticulohazed densities in L lung field; mild blunting

Promote bed rest Cessation of and provide care activity and prevent more serious respiratory compromise Provide calm and Promotes relation, quite environment conserving energy and reducing oxygen demand Provide small Helps reduce frequent feeding fatigue during mealtime, increases total caloric intake, and increases appetite Avoid gas producing foods and carbonated beverages Encourage to eat high calorie, nutrient-rich diet with adequate fluid intake Encourage energysaving techniques such as rest periods before and after meals, during activities, or sitting for care Produces abdominal distention and can increase dyspnea Metabolic tissue and needs are increased as to eliminate waste products Aids in reducing fatigue and dyspnea and conserves energy for cellular regeneration and respiratory function

To provide health Promotes maximal teaching of how to ventilation and perform proper oxygenation and pursed lip reduces or

in R lateral costophrenic sulcus Hematology: Hmg = 113 g/L (normal: 160-180 g/L) Body Fluid: Pleural fluid, red, cloudy, LDH = 1149 g/L  with initial vital signs of: RR = 17 cpm T= 36.2OC BP = 75/50 mmHg

breatingthrough prevents demonstration atelectasis (inhale through the nose and exhale slowly with partially closed lips) To provide health To prevent teachings about transmission infection infection precautions such as hand washing, covering of mouth when coughing, and placing sputum in covered container the of