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DESCRIPTION OF HEALTH CONDITION
Lung Cancer is the leading cause of cancer death among men. It commonly occur in individuals more than 50 years of age who have a long history of cigarette smoking. Non small cell lung cancer (NSCLC) accounts for 80% of the primary lung cancers.
Adenocarcinoma has been associated with lung scarring and chronic interstitial fibrosis; is not related to cigarette smoking, often has no manifestations until -widespread metastasis is present.
DESCRIPTION OF HEALTH CONDITION
Lung Cancer is the leading cause of cancer death among men. It commonly occur in individuals more than 50 years of age who have a long history of cigarette smoking. Non small cell lung cancer (NSCLC) accounts for 80% of the primary lung cancers.
Adenocarcinoma has been associated with lung scarring and chronic interstitial fibrosis; is not related to cigarette smoking, often has no manifestations until -widespread metastasis is present.
Source: Medical Surgical Nursing: Assessment and Management of Clinical Problems volume 1 by Lewis p.578-585
STATISTICAL DATA
Lung cancer is currently responsible for 29% of cancer deaths in the United States. Even though more women are diagnosed with breast cancer and more men with prostate cancers, lung cancer remains the leading cause of cancer deaths for both men and women.
Source: http://lung cancer.about.com/od/whatislungcancer/a/lungcancerstats.htm
Here in the Philippines, lung cancer kills 80% of those diagnosed (8,518 or 14.2% mortality among 10,643 or 17.4% incidence) of all those diagnosed with the disease compared to 35% mortality among breast cancer. Every year, there are about 20,000 smoking related deaths in the country.
Source: http:/www.tribuneonline..org/metro/20101212met5.html
STATISTICAL DATA
Lung cancer is currently responsible for 29% of cancer deaths in the United States. Even though more women are diagnosed with breast cancer and more men with prostate cancers, lung cancer remains the leading cause of cancer deaths for both men and women.
Source: http://lung cancer.about.com/od/whatislungcancer/a/lungcancerstats.htm
Here in the Philippines, lung cancer kills 80% of those diagnosed (8,518 or 14.2% mortality among 10,643 or 17.4% incidence) of all those diagnosed with the disease compared to 35% mortality among breast cancer. Every year, there are about 20,000 smoking related deaths in the country.
Source: http:/www.tribuneonline..org/metro/20101212met5.html
OBJECTIVES
To define what lung cancer, its pathophysiology is and enumerate the signs and symptoms including its risk factors.
To understand options in the different type of medical treatment necessary
To learn new clinical skills, as well as sharpen our current clinical skills those are required in the management of a terminally ill patient having lung cancer.
To formulate and apply nursing care plan using the nursing process.
To provide nursing care applicable to a terminally ill lung cancer patient.
To help nursing students to avoid and quit smoking and be a model for others a part of the health care team.
OBJECTIVES
To define what lung cancer, its pathophysiology is and enumerate the signs and symptoms including its risk factors.
To understand options in the different type of medical treatment necessary
To learn new clinical skills, as well as sharpen our current clinical skills those are required in the management of a terminally ill patient having lung cancer.
To formulate and apply nursing care plan using the nursing process.
To provide nursing care applicable to a terminally ill lung cancer patient.
To help nursing students to avoid and quit smoking and be a model for others a part of the health care team.
SCOPE AND LIMITATION
SCOPE
This study covers and focuses on:
A brief discussion of lung cancer and its pathophysiology
Drug study that has been prescribed to and taken by the patient during
hospitalization at PPL-Bay, and we included medications that has been prescribed
by his previous consultation from other health care providers.
Nursing Care Plan that covers action that would help the patient in his terminal
condition.
LIMITATION
This study only covers the period of confinement of our patient that has been
hospitalized during our clinical exposure last February 13, 20011 during our 6-2
shift.
All the laboratory exams of the patients that we had gathered were limited to the
laboratory results the patient presented to us during his confinement at PPL-Bay
during our shift.
This study was only limited to Lung cancer, this is our main focus.
SCOPE AND LIMITATION
SCOPE
This study covers and focuses on:
A brief discussion of lung cancer and its pathophysiology
Drug study that has been prescribed to and taken by the patient during
hospitalization at PPL-Bay, and we included medications that has been prescribed
by his previous consultation from other health care providers.
Nursing Care Plan that covers action that would help the patient in his terminal
condition.
LIMITATION
This study only covers the period of confinement of our patient that has been
hospitalized during our clinical exposure last February 13, 20011 during our 6-2
shift.
All the laboratory exams of the patients that we had gathered were limited to the
laboratory results the patient presented to us during his confinement at PPL-Bay
during our shift.
This study was only limited to Lung cancer, this is our main focus.
BACKGROUND OF THE STUDY
We decided to choose to present this case due to the
complexity of the case, and our eagerness to learn and
explore new knowledge regarding lung cancer. Our group
found this case, uncommon and rare in any other cases that
we handled. And we do believe that this can be of great help
in understanding and performing appropriate nursing
interventions to the patient. It is of great advantage that the
patient also gains knowledge about this condition. Also, we
choose this case because we want to provide nursing care to
a terminally ill client and also, for those people who smoke to
let them know the consequences of smoking.
BACKGROUND OF THE STUDY
We decided to choose to present this case due to the
complexity of the case, and our eagerness to learn and
explore new knowledge regarding lung cancer. Our group
found this case, uncommon and rare in any other cases that
we handled. And we do believe that this can be of great help
in understanding and performing appropriate nursing
interventions to the patient. It is of great advantage that the
patient also gains knowledge about this condition. Also, we
choose this case because we want to provide nursing care to
a terminally ill client and also, for those people who smoke to
let them know the consequences of smoking.
SIGNIFICANCE OF THE STUDY
The study is done for the benefits of the following:
a. STUDENT NURSE
To impart to them the knowledge and understanding about lung cancer and to have the appropriate and relevant nursing care that can be use for this kind of condition.
b. CLIENT AND RELATIVES
To have the necessary information and help them understand the condition and its complications and how they can support and care for the person having the disease.
c. READER
For them to acquire and gain more knowledge about lung cancer, about its signs and symptoms, cause, treatment regimen and necessary type of management that can be use and necessary information on how to prevent themselves in getting it.
SIGNIFICANCE OF THE STUDY
The study is done for the benefits of the following:
a. STUDENT NURSE
To impart to them the knowledge and understanding about lung cancer and to have the appropriate and relevant nursing care that can be use for this kind of condition.
b. CLIENT AND RELATIVES
To have the necessary information and help them understand the condition and its complications and how they can support and care for the person having the disease.
c. READER
For them to acquire and gain more knowledge about lung cancer, about its signs and symptoms, cause, treatment regimen and necessary type of management that can be use and necessary information on how to prevent themselves in getting it.
Name: Mr. XXX
Address: Brgy. Dila Bay, Laguna
Age: 66 years old
Date of Birth: May 28, 1944
Place of birth: Calauan, Laguna
Religion: Roman Catholic
Nationality: Filipino
Date of Admission: February 13, 2011
Time: 08:45 am
Admitting Diagnosis: Lung Cancer, Stage IV
Case Number: 25112
Admitting Physician: Dr. Giovanni Lagoc, MD
Name: Mr. XXX
Address: Brgy. Dila Bay, Laguna
Age: 66 years old
Date of Birth: May 28, 1944
Place of birth: Calauan, Laguna
Religion: Roman Catholic
Nationality: Filipino
Date of Admission: February 13, 2011
Time: 08:45 am
Admitting Diagnosis: Lung Cancer, Stage IV
Case Number: 25112
Admitting Physician: Dr. Giovanni Lagoc, MD
A. PRESENT HEALTH HISTORY
2 yrs. prior to admission, the client quitted smoking and there he experience
withdrawal syndrome.
8 months prior to admission around May 2010, he felt difficulty in sleeping, night
sweat, chest pain, difficulty in breathing and productive cough.
7 months prior to admission around June 2010, he was advised to have chest X-ray
and after that he has been treated with RIPES for 6 months then after 6 months they
complaint of feeling bad and the treatment given afforded no relief.
2 months prior to admission around December 2010, he complaint of difficulty
swallowing and sleeping accompanied by severe cough by then they consulted a
physician and after several test he was then diagnosed to have a Lung cancer, stage
4.
1 month prior to admission around January 2011, he complaint of difficulty
urinating and defecating, hoarseness, numbness in the left upper extremities.
1 day prior to admission at February 20, 2011, he was admitted due to productive
cough, difficulty of breathing, chest pain, weakness, hoarseness, pain in the right
neck and numbness in the left upper extremities.
A. PRESENT HEALTH HISTORY
2 yrs. prior to admission, the client quitted smoking and there he experience
withdrawal syndrome.
8 months prior to admission around May 2010, he felt difficulty in sleeping, night
sweat, chest pain, difficulty in breathing and productive cough.
7 months prior to admission around June 2010, he was advised to have chest X-ray
and after that he has been treated with RIPES for 6 months then after 6 months they
complaint of feeling bad and the treatment given afforded no relief.
2 months prior to admission around December 2010, he complaint of difficulty
swallowing and sleeping accompanied by severe cough by then they consulted a
physician and after several test he was then diagnosed to have a Lung cancer, stage
4.
1 month prior to admission around January 2011, he complaint of difficulty
urinating and defecating, hoarseness, numbness in the left upper extremities.
1 day prior to admission at February 20, 2011, he was admitted due to productive
cough, difficulty of breathing, chest pain, weakness, hoarseness, pain in the right
neck and numbness in the left upper extremities.
B. PAST HEALTH HISTORY
He hadn’t experience any disease when he was a child
even when he turned into teenage life. But when he is at his
adulthood stage of life he was exposed to measles by then he
doesn’t have any serious complications until he reaches the
age of 65 where he experience having severe cough that soon
became his present condition, having lung cancer. One factor
is that when he started smoking when he was in grade 6, 1
stick per day and continued till he used to smoke 1 pack per
day. When he reaches the age of 63 he quitted smoking.
B. PAST HEALTH HISTORY
He hadn’t experience any disease when he was a child
even when he turned into teenage life. But when he is at his
adulthood stage of life he was exposed to measles by then he
doesn’t have any serious complications until he reaches the
age of 65 where he experience having severe cough that soon
became his present condition, having lung cancer. One factor
is that when he started smoking when he was in grade 6, 1
stick per day and continued till he used to smoke 1 pack per
day. When he reaches the age of 63 he quitted smoking.
C. FAMILY HEALTH HISTORY
According to the patient, no one of the member of
their family had cancer. His father died due to diabetes
mellitus and her mother had asthma. Her wife told us that
their family is in good health, and that this is the first time
that someone had cancer in their family.
C. FAMILY HEALTH HISTORY
According to the patient, no one of the member of
their family had cancer. His father died due to diabetes
mellitus and her mother had asthma. Her wife told us that
their family is in good health, and that this is the first time
that someone had cancer in their family.
EXPERIENCE VERBALIZATION INTERPRETATION
Erik Erikson’s Psychosocial Stages of Development: Integrity versus Despair
“Tanggap ko na kung anu mang ipagkaloob ng maykapal, kunin man nya ako, handa na ako.”, as verbalized by the patient.
INTEGRITY;As individuals approach the end of life, they tend to take stock of the years that have gone before. Our client feels a sense of satisfaction with his accomplishments in life.
D. DEVELOPMENTAL HISTORY
Sigmund Freud’s
Psychosexual Stages of
Development:
“Grade 6 ako unang nanigarilyo,
isang stick kada isang araw
hanggang sa maging isang kaha
na isang araw.”, as verbalized by
the patient.
ORAL STAGE;Freud believed that all human beings pass through a series of psychosexual stages; each stage dominated by the development of sensitivity in a particular erogenous or pleasure giving spot in the body. Furthermore, each stage poses for individual a unique conflict that they must resolve before they go to the next higher stage. If individuals are unsuccessful in resolving the conflict, the resulting frustration becomes chronic and remains a central feature of their psychological make-up.
Jean Piaget’s Cognitive
Stages of Development
“Pareho kami nang asawa kong
gumagawa ng desisyon tungkol
sa mga problema man na
nararanasan naming sa buhay.”,
as verbalized by the patient.
FORMAL OPERATIONAL
PERIOD;
Individuals are capable of
systematic deductive reasoning
that permits them to consider
many possible solutions to a
problem and pick the best action
to take.
Sources: Shaffer. David R. Developmental Psychology Theory Research and Application. California: Brooke Cole Publishing Company, 1985
E. SOCIO ECONOMIC
A person who was diagnosed having a lung cancer must
undergo certain procedures that cost much to maintain living and
prevent further complications. Given the privilege from raising his
children, patient XXX was being supported financially by her
daughter working abroad as a nurse. He receives ₱5000.00
monthly for the examinations and tests he must undergo. His
hospitalization and other needs such as medications, foods, and
etc. are being provided by his other relatives. Since he and his
wife don’t have work, they are seeking for help to sustained their
daily needs from their children and other relatives.
E. SOCIO ECONOMIC
A person who was diagnosed having a lung cancer must
undergo certain procedures that cost much to maintain living and
prevent further complications. Given the privilege from raising his
children, patient XXX was being supported financially by her
daughter working abroad as a nurse. He receives ₱5000.00
monthly for the examinations and tests he must undergo. His
hospitalization and other needs such as medications, foods, and
etc. are being provided by his other relatives. Since he and his
wife don’t have work, they are seeking for help to sustained their
daily needs from their children and other relatives.
F. PYCHOLOGICAL STATUS
BEFORE THE ILLNESS
Patient XXX is fond of smoking and considers a
cigarette as a part of his daily life. He thought that he can’t live without a
cigarette in his life and feels that his strength comes from his vice.
Even being prohibited by his daughter which is a
Nurse and his relatives, Patient XXX can’t stop himself from smoking.
WHEN DIAGNOSED / DURING ILLNESS
When patient XXX felt difficulty sleeping, swallowing
and having productive cough, her family consulted a Doctor for him. When
being advised by the doctor to quit smoking, he thought that he can
successfully cease his smoking habit to relieve his feeling of ill. His first
time trying not to smoke made him realize that it is hard to turn his back in
his daily habit and he stated, “Tanggap ko na kung ano mang ipagkaloob
sa akin ng panginoon” as verbalized by the patient.
F. PYCHOLOGICAL STATUS
BEFORE THE ILLNESS
Patient XXX is fond of smoking and considers a
cigarette as a part of his daily life. He thought that he can’t live without a
cigarette in his life and feels that his strength comes from his vice.
Even being prohibited by his daughter which is a
Nurse and his relatives, Patient XXX can’t stop himself from smoking.
WHEN DIAGNOSED / DURING ILLNESS
When patient XXX felt difficulty sleeping, swallowing
and having productive cough, her family consulted a Doctor for him. When
being advised by the doctor to quit smoking, he thought that he can
successfully cease his smoking habit to relieve his feeling of ill. His first
time trying not to smoke made him realize that it is hard to turn his back in
his daily habit and he stated, “Tanggap ko na kung ano mang ipagkaloob
sa akin ng panginoon” as verbalized by the patient.
G. SOCIO – CULTURAL
One of patient XXX’s child was a Registered Nurse
and it serves as a main factor that influenced his health belief – to
seek medical treatment. They first consulted a doctor when he felt
illness and preferred to Medical Management when it comes to his
health. However, they also believed in “faith healers”, as some of
Filipino’s tradition.
H. SPIRITUAL
As Christians, patient XXX and his family was able
to deal with God in their daily lives. When he was diagnosed having a
Lung Cancer, the family entrust patient XXX’s life on God’s hand and
prepared themselves to accept whatever will happen to patient XXX.
G. SOCIO – CULTURAL
One of patient XXX’s child was a Registered Nurse
and it serves as a main factor that influenced his health belief – to
seek medical treatment. They first consulted a doctor when he felt
illness and preferred to Medical Management when it comes to his
health. However, they also believed in “faith healers”, as some of
Filipino’s tradition.
H. SPIRITUAL
As Christians, patient XXX and his family was able
to deal with God in their daily lives. When he was diagnosed having a
Lung Cancer, the family entrust patient XXX’s life on God’s hand and
prepared themselves to accept whatever will happen to patient XXX.
I. NUTRITIONAL
BEFORE HOSPITALIZATION DURING HOSPITALIZATION
Breakfast 2-3 cups of rice 1 med. size fried fish 1 cup coffee 1-2 glasses of water
Breakfast 2-3 tbsp. soup ½ glass of water
Lunch 2-3 cups of rice 1 ½ servings of vegetable 1 med. size pork 2-3 glasses of water
Lunch 3-4 tbsp. soup ½ glass of water
Snack 4-5 pcs. Bread 1 glass of water
Dinner 2-3 cups rice 1 serving of vegetable 2-3 glasses of water
Dinner 2-3 tbsp. soup ½ glass of water
He ate meals in a moderate manner- the
usual meal for a sedentary man
When he was diagnosed, the doctor
ordered a soft diet for him to take.
After few days, he was ordered to have
a diet as tolerated.
His usual oral fluid intake was about 6-7
glasses of water per day, with exception
to coffee and beverages.
At the hospital, Patient XX’s fluid and
electrolytes was maintained through
intravenous fluids and supported by
oral fluid intake.
Before the illness, patient XXX weighs at
about 65 kilograms.
Previously, patient XXX weighs about
40 kilograms, due to his unusual eating
habits and having difficulty swallowing.
J. ELIMINATION
BEFORE HOSPITALIZATIONDURING HOSPITALIZATION
The patient defecates for at least 1-2
times a day.
January 2011 the patient defecates twice
or thrice a week.
Sometimes the patient defecate once a
day and sometimes none.
February 2011, the patient has difficulty in
voiding, he defecates twice or thrice a
week.
The patient urinates approximately 4-6
times a day with no other problems in
voiding.
During his hospitalization, the patient has
difficulty in urinating. He uses adult
diaper, he consume 2 diapers per day.
J. ELIMINATION
K. EXERCISE
BEFORE HOSPITALIZATION DURING HOSPITALIZATION
The patient was able to ambulate around
their house and going to the store
without any assistance in his side.
The patient was able ambulate with
assistance in his side.
The patient experience fatigue and
weakness due to decrease in oxygen level
in the body.
L. HYGIENE
BEFORE HOSPITALIZATION DURING HOSPITALIZATION He takes a bath 1-2 times a day with
Luke warm water.
His relative provides sponge bath to
him.
He washes his hand before and after
eating.
He neglects to wash his hand before
and after eating.
He brushes his teeth every after meal. He brushes his teeth irregularly.
He can change and wear clothes or
dress if ever he wants.
His wife changes his cloth or any
available relatives.
He can trim nails by his self. His relative is the one who trim his
nails.
M. SLEEP
BEFORE HOSPITALIZATION DURING HOSPITALIZATION
He usually sleeps around ten o’clock in
the evening and awake at five o’clock in
the morning or earlier.
He had a difficulty in sleeping due to the
attacks of his condition including
coughing.
He has a productive cough with clear
white sticky mucous secretions.
The patient sleep five hours or less due
to ambiance of hospital.
AREA METHODS FINDINGS INTERPRETATION
IntegumentSkin
Inspection
- brown- even in overall skin color- presence of paleness of the skin
-normal, older person’s skin becomes pale due to decreased melanin production and decreased dermal vascularity.
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007- Chapter 11 p. 166
Palpation
- poor skin turgor- dry, warm
-older person’s skin loses its turgor because of a decrease in elasticity and collagen fibers. Also, their skin may feel dryer because sebum production decrease with age.
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007- Chapter 11 p. 171
Hair
Inspection
- black to gray color- well distributed in the scalp and in the overall skin
-normal, gray or white hair is also result as a person ages because decrease in or a lack of melanin production.
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition © 2007- Chapter 5 Integumentary System p.112
NailsInspection
- pale nail beds - may indicate hypoxia
- lubbing of fingers - results from inflammatory changes in the bones of the fingers from prolonged oxygen deficiency.* The Respiratory System Chapter 12 p. 283
Head
Skull & Face
Inspection
- symmetrical skull and is appropriate in size
- symmetrical facial features
- no lumps or bumps on the scalp
- normal
Eyes & Vision
Inspection
- sclera is white
- conjunctiva clear & pinkish in color
- no blurring of vision
- pupils equally round, reactive to light and accommodation (PERRLA)
- normal
- eyes did not converge
- indicates a weakness in one or more extraocular muscles or dysfunction of the cranial nerve that innervates the particular muscle.
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007- Chapter 13 p. 225
Ears & Hearing
Inspection
- symmetrical ears and equal in size
- no build up of cerumen/ear wax
- can hear whispered words at a distance of 1 ft. in both ears
- normal
Palpation
- no pain reported upon palpation and no presence of swelling
both ear auricles non tender
- normal
Nose & Sinuses
Inspection
- nose is symmetrical in shape and same in color with face
- patient can breathe with one nostril and the other is occluded
- no presence of discharge
- normal
Palpation
- no presence of bumps and tenderness
no pain reported- normal
- non tender sinuses Mouth
& Oropharynx
Inspection
- no presence of lesions
- pink, moist oral mucosa
- no dentures
- normal
- cough reflex is weaker - because of weakened respiratory muscles and decreased ciliary movement.
- yellowish teeth with some tooth decays, and missing tooth
- persons who smoke may have yellow or brownish teeth
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007 - Chapter 15 p. 281
Neck
Neck muscles
Inspection
- symmetrical but weak in strength
- symmetrical movement of neck muscles
- normal
Lymph nodes of the neck
Palpation
lymph nodes are non palpable - normal
TracheaInspection
trachea is in midline position - normal
Auscultation
- coarse crackle heard in the tracheal site during early inspiration to early expiration
-
Thyroid gland
Palpation
butterfly in shape, in midline position, non palpable lobes, not enlarged, and rises as patient swallows
- normal
Thorax & LungsChest shape & size
Inspection
- symmetrical chest shape & size
- no barrel chest
- normal
- use of accessory muscles, (scalene and sternocleidomastoid) muscles while breathing
- the use of accessory muscles facilitates inspiration of O2
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007 - Chapter 16 p. 310
- there are retractions of the intercostals spaces
- indicates an increased inspiratory effort. This may be the result of an obstruction of the respiratory tract.
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007 - Chapter 16 p. 318
Palpation
- upon deep breathing anterior thoracic expansion: approx. 5 cm. ; posterior thoracic expansion: approx. 6 cm.
- symmetrical expansion
- because of loss of the accessory musculature in older persons thoracic expansion may be decreased although it should still be symmetrical
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007 - Chapter 16 p. 313
- increased fremitus in the upper region of the lungs
- usually the result of consolidation or bronchial obstruction
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007 - Chapter 16 p. 312
Percussion
- dullness present - dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space as in tumor.
Breath sounds
Auscultation
- coarse crackles heard in the 2nd L and R intercostals space during early inspiration to early expiration
- inhaled air comes into contact with secreations in the large bronchi
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007 - Chapter 16 p. 317
- wheezing heard in the 6th L and R intercostals space during expiration
- as air passes through constricted passages (caused by swelling, secretions, or tumor) a high-pitched, musical sound is produced
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007 - Chapter 16 p. 317
Cardiovascular & Peripheral Vascular System
Heart (Sounds) Auscultation
- S1 corresponds with each carotid pulsation. S2 immediately follows after S1
- no extra heart sounds and murmurs
-
Central vessels (carotid arteries & jugular vein)
Palpation
- equal in pulse rate, rhythm of carotid arteries, and amplitude of 2+
- normal
- no bruits upon auscultation of the carotid arteries
- jugular vein not distended
Peripheral Vascular system (peripheral pulses, veins, and perfusion)
Inspection
- uniform in color, presence of pallor
-Normal
- capillary refill of nail beds is 3 secs.
there is slow capillary nailbed refill with respiratory or cardiovascular diseases that cause hypoxia* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition - Chapter 11 p. 175
- peripheral pulses (radial, brachial, and femoral) are equal in pulse rate and rhythm- pink coloration returns to palms in 4 secs. if ulnar artery is patent and 3secs. if radial artery is patent.
-Normal
- bulging veins - normal findings in an elderly person
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition - Chapter 30 p. 856
Breast & Axillae
Breast size, symmetry & contour/shape
Inspection
- breasts are relatively equal
- normal
Palpation
- no presence of hardness in any area
Nipples size, shape, position, color, discharge & lesions
Inspection
- nipples at same level on chest, and of same dark brown color, no presence of lesions
- normal
Axillary, subclavicular & supraclavicular lymph nodes Palpation
- enlarged, hard, non-mobile left supraclavicular lymph node, approximately 2 cm. in diameter; no pain reported
- the left supraclavicular lymph node drains the thorax, abdomen via thoracic duct. Common causes of enlargement include lymphoma, thoracic cancer, bacterial or fungal infection.* Metastases in Supraclavicular Lymph Nodes in Lung Cancer: Assessment with Palpation, US, and CT. Radiology 2004;232: 75-80.
Abdomen:
Abdominal contour, symmetry
Inspection
- sunken abdomen is observed
- a scaphoid (sunken) abdomen may be seen with severe wiehgt loss
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007 - Chapter 20 p. 441
- symmetrical, no presence of scars, lesions
- normal
- slight pulsation of abdominal aorta in the epigastric region
- abdominal respiratory movement is seen
- normal
Palpation
- no palpable mass, no pain reported
- no tenderness and is soft
- lower edge of liver is palpable and is firm & even; other organs non palpable
Bowel sounds
Auscultation
- normal bowel sounds: 5 times/min, heard in all four quadrants
-Normal
Vascular sounds
Inspection
- no bruits over abdominal aorta & femoral arteries
- no friction rubs over area of liver & spleen
- normal
- tympany is heard over abdomen
- dullness over the liver and spleen
Musculoskeletal System:
Muscle
Inspection
- decreased muscle mass, tone, and strength
- rate of muscle strength is 4 – active motion against some resistance
- several changes occur in aging skeletal muscle that reduce muscle mass. There is loss of muscle fiber & fast-twitch muscle fibers as aging occurs. The number of motor neurons also decrease
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition © 2007- Chapter 7 Muscular System p.194
Bones
Inspection
- no deformities & fractures - normal
- exaggerated thoracic curve - an exaggerated thoracic curve (kyphosis) is common with aging
Joints
Inspection
- non tender joints - normal - bilaterally equal decreased ROM except R arm
- the ligament & tendon surrounding a joint shorten & become less flexible with age, resulting in a decrease in ROM of the joints.
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition © 2007- Chapter 6 Skeletal System p.151
- Non tender joints -normal
Neurologic:
Mental statusInspection
- good grooming, dresses appropriately to weather
- speech is of appropriate age and flows easily
- maintains eye contact, can smile & frown appropriately
-normal
Level of consciousness Inspection
- awake, alert, and oriented to time, place, person, and responds to stimuli – Glascow coma Scale: score of 15
Cranial nerves
CN I
Inspection
- decreased sense of smell
- elderly people experience only a slight loss in the ability to detect odors.
CN II - can read a printed writing at 14 inches without difficulty
-normal
CN III, IV, & VI
- eyes did not converge - indicates a weakness in one or more extraocular muscles or dysfunction of the cranial nerve that innervates the particular muscle.
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition © 2007- Chapter 13 p. 225
CN V- temporal and masseter
muscles contract bilaterally
- correctly identified sharp and dull stimuli of an object
- normal
CN VII - can smile, frown, show yeeth, puff out his cheeks, raise eyebrows. These are all symmetrical in movement.
- can hear whispered words at a distance of 1 ft. in both ears
- normal
CN IX & X - uvula and soft palate rises bilaterally and symmetrical upon saying “ah”
- gag reflex is present
- normal
CN XI - there is symmetric but weak contraction of the trapezius muscles upon shrugging of shoulders against resistance
-most of the loss of strength in an elderly is due to the loss of muscle fibers and the loss of fast-twitch muscle fibers.
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition © 2007- Chapter 7 Muscular System p.194
CN XII - tongue movement is symmetrical and smooth and strength is bilateral
- normal
Reflexes Deep
tendon reflex
Inspection
Biceps reflex - both elbows flexed and contraction of biceps muscle is felt
- normal
Triceps reflex
- both elbows extended, triceps muscles contracts
Triceps reflex
Patellar reflex (knee-jerk reflex)
- knee extends, quadriceps contracts Patellar reflex (knee-jerk reflex)
Achilles reflex
- both foot has plantar flexion Achilles reflex
Motor functions Inspection
- no tremors seen
- normal
- gait is slow and has bent-forward appearance
- information on the position, tension, and length of tendons and muscles also decreases, resulting in additional reduction in the senses of movement, posture, and position, as well as reduced control and coordination of movement
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition © 2007- Chapter 8 Nervous System p.237
- the surface area of the neuromuscular junction decreases and, as a result, action potentials in neurons stimulate action potential production in muscle cells more slowly and fewer action potentials are produced in the muscle fibers.
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition © 2007- Chapter 8 Muscular System p.194
- having difficulties of rapid alternating movements
- there is a general decline in the number of motor neurons. Muscle fibers innervated by the lost motor neurons are lost.
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition © 2007- Chapter 8 Nervous System p.237
Sensory functions
Inspection
- decreased light touch sensation
- correctly identifies direction of movement of fingers & toes with eyes is closed
- as a result of decreases in the number of skin receptors, elderly people are less conscious of something touching or pressing on the skin.
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition © 2007- Chapter 8 Nervous System p.237
Genitals/Inguinal:
Inspection
- pubic hair is thin.
- normal findings in an elderly person
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition - Chapter 30 p. 860-861
Palpation
- penis and testes size decreased
- no swelling and no masses
Rectum/Anus:
Inspection
- anus is darker than the surrounding skin
- normal findings in an elderly person
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition - Chapter 30 p. 861
Others:
Senses
Inspection
- numbness in his neck, left shoulder and arm,
- there is compression of the left subclavian artery & brachial plexus
Mechanism of BreathingMechanism of Breathing
PREDISPOSING FACTORS-GenderAge: 65 y/o
PREDISPOSING FACTORS-GenderAge: 65 y/o
PRECIPITATING FACTORS-Smoking History: 53 pack-yrs. of smoking
PRECIPITATING FACTORS-Smoking History: 53 pack-yrs. of smoking
Passage of Cigarette Smoke to lower respiratory systemPassage of Cigarette Smoke to lower respiratory system
NicotineNicotine TarsTars Carbon MonoxideCarbon Monoxide
Goblet CellsGoblet Cells
Mucocilliary Clearance System ImpairementMucocilliary Clearance System Impairement
Ineffective Cough Reflex
Ineffective Cough Reflex
Impaired Alveolar Macrophages
Impaired Alveolar Macrophages
Ability to Phagocytize inhaled Foreign Particles
Ability to Phagocytize inhaled Foreign Particles
Chronic irritation and exposure of epithelial tissue to smokingChronic irritation and exposure of epithelial tissue to smoking
↑ Vulnerability of epithelial tissue to irritants and carcinogens↑ Vulnerability of epithelial tissue to irritants and carcinogens
Interruption of Normal cellsInterruption of Normal cells
Activation of normal cancer cellActivation of normal cancer cell
Primary growth of tumor in the epithelial tissuePrimary growth of tumor in the epithelial tissue
- Desquamation of cells-Hypersecretion of mucus-Hyperplasia of the basal cells-Metaplasia of normalRespiratory epithelium
- Desquamation of cells-Hypersecretion of mucus-Hyperplasia of the basal cells-Metaplasia of normalRespiratory epithelium
Exposure / inhalation of infected aerosol through dropletExposure / inhalation of infected aerosol through droplet
Inhaled nuclei lodge in alveoliInhaled nuclei lodge in alveoli
Binding of bacterial cell wall to macrophageBinding of bacterial cell wall to macrophage
Spread of bacilli via lymphatic system to upper lobes of the lungs
Spread of bacilli via lymphatic system to upper lobes of the lungs
Tubercle bacilli replicates slowly due to sensitivity to heatTubercle bacilli replicates slowly due to sensitivity to heat
Failure of the immune system to recognize cancer cell as foreign body
Failure of the immune system to recognize cancer cell as foreign body
Patient stopped for smoking 2 years ago (2008)Patient stopped for smoking 2 years ago (2008)
Progression and proliferation of cancer cellsProgression and proliferation of cancer cells
Progression of tubercle bacilliProgression of tubercle bacilli
Increased tumor sizeIncreased tumor sizeFormation of granulomaFormation of granuloma
Obstruction of the bronchus due to tumor
Obstruction of the bronchus due to tumor
Cancer cell detached from primary tumor
Cancer cell detached from primary tumor
Tumor enlarges through blood vessels
Tumor enlarges through blood vessels
Migrate via lymph nodes or blood circulation
Migrate via lymph nodes or blood circulation
Cancer cells established at secondary sites
Cancer cells established at secondary sites
FNAB Dec. 23, 2010Non small cells lung
cancerPositive for
Adenocarcinoma
FNAB Dec. 23, 2010Non small cells lung
cancerPositive for
Adenocarcinoma
Drainage of necrotic material into the tracheobronchial treeDrainage of necrotic material into the tracheobronchial tree
Scar formationScar formation
Full blown immunity of bacilliFull blown immunity of bacilli
Active infection of Bacilli-hemoptysis-productive cough-chest pain and tightness-night sweating(May 2010)
Active infection of Bacilli-hemoptysis-productive cough-chest pain and tightness-night sweating(May 2010)
May 22, 2010X-ray shows Koch’s infection
at right upper lobe
May 22, 2010X-ray shows Koch’s infection
at right upper lobe
January 2011-hoarseness-dysphagia-Non- productive cough-anorexia-weight loss
January 2011-hoarseness-dysphagia-Non- productive cough-anorexia-weight loss
February13, 2011 -hoarseness-dysphagia-Non- productive cough-numbness of the Left neck, shoulder & arm-dyspnea-wheezes on 6th intercostal space-crackles on trachea & 2nd intercostals space-palpable lymph node on left neck
February13, 2011 -hoarseness-dysphagia-Non- productive cough-numbness of the Left neck, shoulder & arm-dyspnea-wheezes on 6th intercostal space-crackles on trachea & 2nd intercostals space-palpable lymph node on left neck
May 2010Started anti-tubercular drugs
for six months (May-Nov. 2010)
May 2010Started anti-tubercular drugs
for six months (May-Nov. 2010)
Recurring of symptoms after 6 months of treatment
Recurring of symptoms after 6 months of treatment
Dec. 13, 2010•Pulmonary mass lingular segment, with mediastinal and Left Hilar lymphadenopathy, biopsy is suggested•PTB of undetermined activity, Right upper lobe
Dec. 13, 2010•Pulmonary mass lingular segment, with mediastinal and Left Hilar lymphadenopathy, biopsy is suggested•PTB of undetermined activity, Right upper lobe
Dec. 23, 2010Unchanged right upper lobe
PTB and left hilar mass
Dec. 23, 2010Unchanged right upper lobe
PTB and left hilar mass
May 12, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Minimal Kock’s infection, Right upper lobe.•Interstitial pneumonitis Right hemithorax.•Consolidation pneumonia Lingular zone.•Please correlated clinically.
May 12, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Minimal Kock’s infection, Right upper lobe.•Interstitial pneumonitis Right hemithorax.•Consolidation pneumonia Lingular zone.•Please correlated clinically.
November 2, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Follow up study since May 12, 2010 shows progression of the confluent opacities in the Left perihilar area and Left lower lobe. Note of slight interval clearing of the Right upper lobe infiltrated. No other interval changes seen.
November 2, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Follow up study since May 12, 2010 shows progression of the confluent opacities in the Left perihilar area and Left lower lobe. Note of slight interval clearing of the Right upper lobe infiltrated. No other interval changes seen.
December 5, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Consider moderate PTB disease, Right, activity undetermined clinical is suggested•Intercurrent pneumonia, Left
December 5, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Consider moderate PTB disease, Right, activity undetermined clinical is suggested•Intercurrent pneumonia, Left
December 13, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Pulmonary mass lingular segment, with mediastinal and Left Hilar lymphadenopathy, biopsy is suggested•PTB of undetermined activity, Right upper lobe•Atherosclerotic aorta
December 13, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Pulmonary mass lingular segment, with mediastinal and Left Hilar lymphadenopathy, biopsy is suggested•PTB of undetermined activity, Right upper lobe•Atherosclerotic aorta
December 23, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Resolving Pneumonia, Left Hilum.•Unchanged right upper lobe PTB and left Hilar mass.•Mild cardiomegallo.•Atherosclerotic thoracic aorta.•Degenerative osseous changes.
December 23, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Resolving Pneumonia, Left Hilum.•Unchanged right upper lobe PTB and left Hilar mass.•Mild cardiomegallo.•Atherosclerotic thoracic aorta.•Degenerative osseous changes.
December 23, 2010
FNABIMPRESSION:
•Positive for malignant cells.•Non small cell compatible with adenocarcinoma.
December 23, 2010
FNABIMPRESSION:
•Positive for malignant cells.•Non small cell compatible with adenocarcinoma.
DATE TIME DOCTOR’S ORDER INTERPRETATION2/ 13/11 8:45 am admit To monitor the
condition of the patient and for implementation of proper treatment.
secure consent It protects the client’s right to self-determination.
To inform the client on what treatment or procedure he/she might be involved.
TPR q shift & record
to know if there’s any alteration on vital signs
DAT if not dyspneic
to avoid aspiration
DATE TIME DOCTOR’S ORDER INTERPRETATION IVF D5 NM 1L x 12
hours
for replacement of fluid and electrolyte loss
O2 at 1-2 4m via nasal cannula
Decreases shortness of breath. Nasal Cannula delivers a relatively low concentration of oxygen which is 24% to 45% at flow rates of 2 to 6 liters per minute.
moderate high back rest
it promotes total expansion of the lung
DATE TIME DOCTOR’S ORDER INTERPRETATION
Nebulizaton with salbutamol + ipratropium q 8 1 amp.
salbutamol relieves nasal congestion and reversible bronchospasm by relaxing the smooth muscles of the bronchioles.
ipratropium relieve any reversible airways blockage associated with problems such as repeated infections affecting the airways.
refer For further studies of the disease and for more improved medical management.
Meds:
Dexamethasone 250 g IV q8
Dexamethasone reduces the swelling, itching, and redness that can occur in these types of conditions. This medication is a mild corticosteroid.
Assessment Diagnosis Planning Interventions Rationale Evaluation
S> “Naninikip and dibdib ko” as verbalized by the patientO> with non productive cough With mucous secretions: • scant in amount•Clear , thick whitish sputum>use sternocleidomastoid muscles and scaline muscles while breathing>with clubbing of fingers in both hands.> RR= 12bpm
Impaired gas exchange related to altered oxygen supply as evidenced by clubbing of fingers
GOAL:Adequate gas exchange DESIRED OUTCOMESAfter the nursing interventions, the patient will be able to :a.Demonstrate improved ventilation and adequate oxygenation.b.Participate in treatment regimen with in level of ability or situation
INDEPENDENT>Note respiratory rate, depth and ease of respiration.
>Observe for the use of accessory muscle, pursed lip breathing, changes in skin or mucous membrane color.
>Maintain patent airway
>Reposition frequently, placing patient in sitting positions and supine to side positions.
>Respiration may be increase as a result of pain or as an initial compensatory mechanism to accommodate for loss of lung tissue. Increased work of breathing and cyanosis may indicate increasing oxygen consumption and energy expenditures and reduced respiratory reserve
>Airway obstruction impedes ventilation, impairing gas exchange.
>maximize lung expansion and drainage of secretions.
After series of nursing intervention the patient was able to demonstrate improve ventilation and adequate oxygenation.
Assessment Diagnosis Planning Interventions
Rationale Evaluation
>encourage or assist with deep breathing exercises and pursedlift breathing as appropriate
DEPENDENT
>Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high humidity face mask as indicated. Oxygen saturation: 1-2 L/min
>promote maximal ventilation and oxygenation and reduces or prevent atelectasis
>Maximizes available oxygen, especially while ventilation is reduced because of pain.
Assessment
Diagnosis
Planning Interventions Rationale Evaluation
S>”Nahihirapan akong huminga” as verbalized by the patient O > with non productive cough>with mucous secretionsoScant in amount and
oClear, thick, whitish sputum
>with crackles breath sounds heard on the second intercoastal spaces>with wheezing on the sixth intercoastal space heard upon expiration
Ineffective airway clearance related to constriction of the airway as evidenced by decreased respiratory rate:12bpm and deep shallow breathing.
GOAL:Effective airway clearanceDesired Outcome:After nursing intervention patient will be able to:a.Demonstrate patent airway b.Expectorate secretionsc.Clear breath soundsd.Decrease use of accessory muscles for breathinge.Demonstrate behavior to improve or maintain clear airways
Independent: >Auscultate chest for character of breath sounds and presence of secretions >Observe amount and character of sputum secretions.Investigate changes as indicated>encourage oral intake if not contraindicated and within cardiac tolerance.Dependent:>Administer bronchodilators, expectorants and/ or analgesics as indicated
>noisy respiration, ronchi, and wheezes are indicative of retained secretions and/or airway obstruction>presence of thick and tenacious bloody or purulent sputum suggest development of secondary problems>adequate hydration aids in keeping secretions loose or enhance expectorations
>relieves bronchospasms to improve airflow. Expectorants increases mucous production and liquefy and reduce viscosity of secretions, facilitating removal. Alleviation or chest discomfort promotes cooperation and breathing exercises and enhances effectiveness of respiratory therapies.
After series of nursing interventions, patient will demonstrate patent airway, will have expectorated secretions and decrease use of accessory muscles while breathing.
Assessment Diagnosis Planning Interventions
Rationale Evaluation
S>” Hindi na ako makagawa ng datirating kong ginagawa ditto sa bahay” as verbalized by the patient.O>decreased physical activity > easy fatigability>body malaise>RR; 12bpm>decrease depth of breathing >poor muscle tone
Activity intolerance related to imbalance between oxygen Supply and demand as evidence by decreased physical activity & easy fatigability
Goal: Enhance activity tolerance Desired Outcome: After nursing interventions, patient will be able to: a.Participate in techniques to enhance activity toleranceb.Eliminate and reduce factors that contribute activity tolerancec.Demonstrate a decrease in physiological signs of intolerance
Independent:>evaluate client’s response to activities.
>Note reports of dysnea, increased weakness or fatigue, and changes in vital signs during and after activities. >Encourage use of stress management and diversional activities as appropriate.
>Assist and encourage to assume comfortable position for rest and sleep.
>Establishes client’s capabilities or needs and facilitates choice of intervention >Symptoms may be result of/or contribute to intolerance of activity >Reduces stress and excess stimulation, promoting rest
>Patient may be comfortable with head of bed elevated, sleeping in chair or leaning forward on overbed table with pillows support.
After nursing intervention patient will be able to:Participate in techniques to enhance activity toleranceEliminate and reduce factors that contribute activity intoleranceDemonstrate a decrease in psychological signs or intolerance.
Assessment Diagnosis Planning Interventions
Rationale Evaluation
>Encourage adequate fluid intake >Assist with self care needs when indicated and ambulation Dependent:>Provide supplemental oxygen as indicated at 1-2L/min.
>Prevents dehydration (which increases fatigue) >weakness may make ADLs difficult to complete or place patient at risks for injury during activities. >Presence of hypoxemia reduces oxygen available for cellular uptake and contributes to fatigue.
DRUG NAME ACTION INDICATIONCONTRAINDI-
CATIONADVERSE REACTION
NURSING RESPONSIBILI
TIES
Date Ordered:
Feb.13 2011
Generic Name:
Nebulizaton
with
SALBUTAMOL
+ ipratropium q
8 1 amp.
Brand Name:
Activent
Dosage and
Frequency:
1Neb. 1amp
every 8 hours.
Classification:
Symphatomim
etics
>Stimulates Beta2 receptors of bronchioles by increasing the levels of cAMP which relaxes smooth muscles to produce bronchodilation.
> Relief and prevention of bronchospasm in patients with reversible obstructive airway disease or COPD
>Inhalation and treatment of acute attack of bronchospasm
>Hypersensitivity to a salbutamol, also to atrophine and its derivatives. >Cardiac arrhythmia associated w/ tachycardia caused by digitalis intoxication.
>Fine skeletal muscle tremor, leg cramps, palpitations, tachycardia, hypertension, headache, nausea, vomiting, dizziness, hyperactivity, insomnia,
>Assess cardio-respiratory function: B/P, heart rate and rhythm and breath sounds>Monitor for evidence of allergic reactions and paradoxical bronchospasm
DRUG NAME ACTION INDICATIONCONTRAINDI-
CATIONADVERSE REACTION
NURSING RESPONSIBI-
LITIES
Date Ordered:
Feb.13 2011
Generic Name:
Tramadol
Brand Name:
Dolotral
Dosage and
Frequency:
Classification:
Analgesics,
Muscle
Relaxants and
Uricosurics
Corticosteriods
.
>Centrally acting analgesic not chemically related to opioids but binds to mu-opioid receptors and inhibits reuptake of norepinephrine and serotonin.
>Tramadol is used for moderate to severe pain.
>Hypersensitivity>Acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic agents.
>Vasodilation:Dizziness/vertigo, headache, somnolence, stimulation, anxiety, confusion, coordination disturbance, sleep disorders, seizures.>Pruritus, sweating, rash.>Visual disturbances, dry mouth.>Nausea, diarrhea, constipation, vomiting, dyspepsia, abdominal pain, anorexia, flatulence.
>Assess patient’s pain (location, type, character) before therapy and regularly thereafter to monitor drug effectiveness. >Assess for hypersensitivity reactions:pruritus, rash and urticaria.>Monitor for possible drug induced adverse reactions: CNS: stimulation, dizziness, vertigo, headache, somnolence, anxiety, confusion, coordination disturbance, malaise, euphoria, nervousness, sleep disorder, seizures.
DRUG NAME ACTION INDICATION CONTRAINDICATION
ADVERSE REACTION
NURSING RESPONSIBI-
LITIES
Date Ordered:
Feb.13 2011
Generic Name:
Dexamethason
e 250 g IV q8
Brand Name:
Decilone
Dosage and
Frequency:
Classification:
Hormones and
related drugs.
>Synthetic glucocorticoid w/ marked anti-inflammatory effect because of its ability to inhibit prostaglandin synthesis, inhibit migration of macrophages, leukocytes and fibroblasts at sites of inflammation, phagocytosis and lysosomal enzyme release. It can also cause the reversal of increased capillary permeability.
>Respiratory diseases
>systemic fungal infection: IM injection use in idiophatic thrombocytopenic purpura:
>Thromboembolism or fat embolism; thromboplebitis; necrotizing angiitis; cardiac arrhythmias or ECG changes.>vertigo> headache>Impared wound healing>visual acuity>thoat irritation
> Obtain pt. history of underlying condition before therapy.>Assess for possible drug induced adverse reaction.>Monitor renal status and function.>Assess mental status: Affect, mood, behavioral changes.>Assess pt’s and family’s knowledge on drug therapy.
DRUG NAME ACTION INDICATION CONTRAINDICATION
ADVERSE REACTION
NURSING RESPONSIBI-
LITIES
Date Ordered:
Feb. 13, 2011
Generic Name:
Nebulizaton
with
salbutamol +
IPRATROPIUM
q 8 1 amp.
Brand Name:
Atrovent
Classification:
Anticholinergic
s
Chemically related to atropine, it antagonizes the effect of acetylcholine. It causes a local and site specific bronchodilatation by preventing the increase in intracellular cyclic guanosine mono-phosphate which produced by the interaction of acetylcholine w/ the muscarinic receptors of the bronchial smooth muscles.
Acute exacerbations of chronic obstructive pulmonary disease (COPD). Used in conjunction w/ beta-adrenergic stimulant for acute asthmatic attacks.
Hyper sensitivity to soya lecithin or related food products. Atropine or any anticholinergic derivates.
Dryness of mouth, throat irritation or cough.
>Assess patient’s condition before and after drug therapy. Monitor peak expiratory flow.>Monitor for evidence of allergic reactions, paradoxic bronchopspasm.>Assess pt’ and family’s knowledge on drug therapy.>Inform pt. that drug is not effective for treatment of acute bronchopspasm>Teach pt. the proper way of drug administration.
ACTION RATIONALE
>Assessed respiratory rate and depth >useful in evaluating the degree of respiratory distress and /or chronicity of the disease process .
>Auscultated chest , noting presence or characteristic of breath sounds, presence of secretions.
>to identify etiology or precipitating factors
>Observed characteristics of cough >cough can be persistent but ineffected, especially if client is elderly, acutely ill, or debilitated.
>Performed physical and or psychological assessment
>to determine the extent of the limitation of the current condition.
ACTION RATIONALE
>Encouraged adequate rest periods between activities
>to limit fatigue
>Established a minimum weight goal and daily nutritional requirements
>provides comparative baseline for effectiveness of therapy
>Give frequent oral care, remove expectorated secretions promptly, provide specific container for disposal of secretions and tissue
>noxious tastes, smell and sights are prime deterrents to appetite and can produce nausea and vomiting with increase respiratory difficulty
This case study has provided us with important information about the patient’s lung cancer disease condition and its nursing care interventions prior to the treatments and medical procedures done with the patient. In order to help managing or controlling present condition, the group would like to recommend the following:
This case study has provided us with important information about the patient’s lung cancer disease condition and its nursing care interventions prior to the treatments and medical procedures done with the patient. In order to help managing or controlling present condition, the group would like to recommend the following:
To the Patient:Despite of his age and the severity of his condition, the patient cooperation and willingness to prevent further complications related to his lung condition.
•The patient must be able to verbalize any problems and needs that he is experiencing about his present condition and his perceptions about this event happens in his manner of living .
•His capability on how he complies with therapeutic regimen that involve in his managing complications on his condition.
•He must be open minded in the process of therapeutic regimen given to him to relieve negative reaction occurring during the course of an illness and accepting the fact about his situation.
To the Patient:Despite of his age and the severity of his condition, the patient cooperation and willingness to prevent further complications related to his lung condition.
•The patient must be able to verbalize any problems and needs that he is experiencing about his present condition and his perceptions about this event happens in his manner of living .
•His capability on how he complies with therapeutic regimen that involve in his managing complications on his condition.
•He must be open minded in the process of therapeutic regimen given to him to relieve negative reaction occurring during the course of an illness and accepting the fact about his situation.
To the Patient’s family:The patient’s family is the one that can provide a great
significant role in patient’s status with regard to conditions.•Family should available themselves to the patient to provide support and show their concern to him. Help his to build strength and stabilized good outcome about the patient’s status.
•Family also inspires patient to obtain stability as he experienced painful, traumatic and extremely disturbing procedures. Also, it is important to them to know the information about the patient’s condition so that they can act appropriately according to the situation.
• Listening, touching, expressing sympathy, attending to the patients' wishes, comforting, encouraging and being present with them are important in accordance with the patient need of emotional incapability.
To the Patient’s family:The patient’s family is the one that can provide a great
significant role in patient’s status with regard to conditions.•Family should available themselves to the patient to provide support and show their concern to him. Help his to build strength and stabilized good outcome about the patient’s status.
•Family also inspires patient to obtain stability as he experienced painful, traumatic and extremely disturbing procedures. Also, it is important to them to know the information about the patient’s condition so that they can act appropriately according to the situation.
• Listening, touching, expressing sympathy, attending to the patients' wishes, comforting, encouraging and being present with them are important in accordance with the patient need of emotional incapability.
To our fellow Students:
However, it is important that may have a complete nursing care in the long run of confinement of your patient, to begin with assessment, admission, and until the patient recovered that includes discharge or may go order and follow-up consultations for further studies in every actual goal and for proper nursing interventions in each occurring problems connected on his condition and this can also provide us to become more aware of our health.
To our fellow Students:
However, it is important that may have a complete nursing care in the long run of confinement of your patient, to begin with assessment, admission, and until the patient recovered that includes discharge or may go order and follow-up consultations for further studies in every actual goal and for proper nursing interventions in each occurring problems connected on his condition and this can also provide us to become more aware of our health.
“ COURAGE gives you the urge to fight and PREPARATION gives you the chance to win.”
GROUP 1… so happy together!!!!
GROUP 1… so happy together!!!!