A Case Study Of Malignant Bilateral Pleural Effusion Secondary To Breast Cancer

By: Group 14

Chan, Jacky Casaclang, Hazel

De Leon, Eurika Egasan, Krystal Mae Flores, Ian Galang, Ana Gamaro, John Gorospe, Evelyn Gutierrez, Paula Micaela Javellonar, Warren

Introduction Nursing Health History Gordons Typology of 11 Functional Health Pattern

Physical Assessment
Anatomy & Physiology .Pathophysiology/Psychopathology Laboratory/Diagnostic Results Drug Study List of Prioritized Problems

Nursing Care Plan/Care Map/Peg Nursing Care Plan

Evidence Based Nursing On going Appraisal Health Teaching Plan Discharge Plan

I.

Introduction Case Abstract

The Department of Health says breast cancer is now the most common cancer in the Philippines, accounting for 16% of the 50,000 cases of the dreaded disease in the country. Breast cancer is also the leading cause of cancer among women, accounting for 28% of the total cases of cancer.

Cancer is the third leading cause of death in the country with mortality rates of up to 50,000 deaths among Filipinos and growing by 5% every year as per population growth. Having breast cancer as the most common type of cancer calls for intensified advocacy for the prevention and early detection as we need to double efforts to save our women for this early disease.

If breast cancer is not treated, it could lead to a complication called Malignant Pleural Effusion secondary to the said disease. It is a cancer condition in which cancer causes an abnormal accumulation of fluid in the pleural space. It is estimated that malignant pleural effusion affects 150,000 people per year in the Philippines. Most patients with pleural effusion come to the doctor complaining of shortness/difficulty of breathing, which is caused by fluid accumulating in the chest and compressing the lung. Once a malignant pleural effusion is diagnosed, the prognosis is very poor.

Three (3) years prior to admission, the patient was diagnosed to have Intraductal Carcinoma on her left breast, stage IV with involvement of T N M. She had undergone Modified Radical Mastectomy at Philippine General Hospital last (October 2009). One month after the MRM she had chemotherapy from September 2009 up to January 2010 and the second batch of chemotherapy was last September 2011 up to February 2012. Four days prior to admission, the patient manifested hoarseness of voice. Few hours prior to admission, she was having difficulty of breathing especially when performing activity of daily living. Therefore, she consulted the doctor in Jose R. Reyes Memorial Medical Center.

II. Nursing Health History

A. Biographic data
Patients Initial: B. M. Educational Attainment: Second Year College Gender: Female Age: 48 Date of Birth: February 16, 1964 Place of Birth: Catanduanez

Occupation: House wife

Date of No. of days in Admission: August hospital: 6 days & 23, 2012 still admitted

Order of Admission: Ambulatory

Source of Information: B. M.

B. Chief Complaint(s)

Hirap akong huminga isang linggo na as verbalized by the patient.

C. History of Present Illness Three (3) years prior to admission the patient was diagnosed to have Intraductal Carcinoma on her left breast, stage IV with involvement of T N M. She had undergone Modified Radical Mastectomy at Philippine General Hospital last (October 2009). One month after the MRM she had chemotherapy from September 2009 up to January 2010 and the second batch of chemotherapy was last September 2011 up to February 2012. Four days prior to admission, the patient manifested hoarseness of voice. Few hours prior to admission, she was having difficulty of breathing especially when performing activity of daily living. Therefore, she consulted the doctor in Jose R. Reyes Makati Medical Center.

D. History of Past Illnesses

Childhood Illness(es) Childhood/adult immunization(s) Accidents & Injuries Chicken pox, asthma

Complete

Not applicable

Previous hospitalization/surgery Medication Prior to confinement

Ceasarean Section Delivery (1997), IDCA MRM Stage IV (2009)

Vitamin C, B-Complex, Multivitamins

E. Family History General Family Information:

Name

Relation

Age

Gender Educatio Occupati Diseases nal on /disorder Attainm s ent Male High school graduate Grade 4 Market Vendor None

B.B

Husband

36

J.B

Son

Male

Student

None

B.B. 36 yrs. old

M.B. 48 yrs. old

Legend:

Husband

Wife
J.B. 9 yrs old

Son

F. Developmental History
Theory Ericksons Psychosocial Age 48 Development task Generativity vs. stagnation Client Description The client is productive because she is the one who prepares food for the family and the one to do the household chores in daily living. The client can rationalize clearly and uses proper reasoning when ask questions. Interpretation In this stage the client has achieve the productivity in and concern for others

Piagets Cognitive

48

Formal operation

Kohlbergs Moral

48

Post conventional

Fowlers Spiritual

48

Paradoxical-reflexive

In this stage the client had already develop proper rational thinking and reasoning The client has control in In this stage the client her own decision but she lives autonomously depends on her husbands and defines moral decision to maintain values and principles equality. that are distinct from personal identification The client has strong faith In this stage the client and she never loses hope to achievement in relief her illness. awareness of the truth from a variety of viewpoints is maintained

G. Environmental History The family lives in a 24 sq. metered space in a street in bulacan. Their house is made from cement and metal. Inside their house, they have 3 windows,3 electric fans, 1 T.V. and 1 refrigerator. They only have 1 bedroom. Outside their house, the area is saturated, the area is peaceful but 2 yrs. Ago they often encounter riots in their area. But it was controlled by the barangay. Their house has good ventilation, 1 window has a measure of approximately 55 inches. The other 2 is around 21 inches. When it comes to waste disposal. They have their own trash bin and it is collected every day. In toilet, they only use a pale of water to flush out wastes. Pests can be seen in the house especially roaches, and they use pesticides to kill them.

H. OB/Gyne History

Menarche Age: 10 years old

Amount: 2-3 soaked pads/day

Characteristic: Bright red,

Duration: 2-3 days per month

Associated Symptom: None

Obstetric History

A L

Type of Delivery: Caesarean Section

Complications: None

Exposure to Tetratogenic Agents: None

III. Gordons Typology of 11 Functional Health Pattern a.Health Perception/Health Management Pattern b.Nutritional/Metabolic Pattern c.Elimination Pattern d.Activity-Exercise Pattern e.Sleep-Rest Pattern f.Cognitive-Perceptual Pattern g.Self-perception/Self-concept Pattern h.Role-relationship Pattern i.Sexuality-reproductive Pattern j.Coping-stress Tolerance Pattern k.Value-belief Pattern

System Reviews A. Health Perception Health Management Prior to confinement, my client believed herself to be a weak person. Client rated her health as 5 out of 10, 1 being poor and 10 being healthy. Client mentioned that whenever she is sick she would take Paracetamol in hopes that her temperature would go back to the normal range. Whenever client is suffering from cough and colds, she would take Robutussin. Client takes a shower daily and brushes her teeth twice a daily. She trims her nails every week or whenever she feels that they are long. Client claims that she wears slippers around the house. J.B. stated that she does not have any vices such as drinking and smoking. Client also mentioned that she tries to keep her surroundings cleans as possible and is tolerable.

Currently, my client still believes she is weak. Nahirapan ako mag huminga at mag salita, naghihirapan din ako mag punta sa C.R. magisa as verbalized by the client. During her stay at JRRMMC, client is given care management. Client underwent a series of blood test. Abnormalities were referred to the physician. Client is taking medications as ordered by the physician (Look at Drug Study). Due to his illness, client is not able to perform his daily hygiene without the help of a relative. After every meal client is ordered to use Bactidol Mouthwash, to prevent further complications. Client sometimes complains about a headache. Client is seen asleep most of the time.

Analysis: Strong predictors of access to quality health care includes having health insurance, a higher income level, and a regular primary care provider or other source of ongoing health care. Use of clinical preventice services can serve as indicators of access to quality health care services. (Healthy People 2012: Understanding and Improving Health 2nd Edition, page 44)

Interpretation: It is advisable that the patient should have at least an annual physical examination to prevent development of disease and maintain a healthy status. Dry skin, hair loss, change of color of hair is normal for the patients age. The client is using eyeglasses because h according to his wife.

Nutritional Metabolic Pattern

BREAKFAST DAY 1 Pandesal Water DAY 2 Pandesal Water DAY 3 Pandesal Water

LUNCH

Giniling
Sayote 1 cup of rice Water

Nilaga Soup
Boiled vegetables 1 cup of rice Water Tinolang Manok 1 cup of rice Water

Beefsteak
Sayote 1 cup of rice Water Fried Fish 1 cup of rice Water

DINNER

Fried Fish 1 cup of rice Water

Prior to confinement, my client has been eating all the food she desires. Her favorite dish is Liempo with rice, but would still eat anything good. Basta masarap kainin ko as verbalized by the client. Usually clients food preparation for her family is grilled food.My client lives with her husband, who provides money for food. The only time J.B. gets to eat with her family is during breakfast and dinner. Client drinks about 8 to 10 glasses of water a daily. According to my client, he does not any discomforts whether it would be chewing or swallowing what he consumed. My client is currently on DAT diet. She is allowed to eat anything that pleases her without restrictions.

Analysis: Skin changes are part of normal aging. As skin ages, it generally becomes thinner, dry, wrinkling, and poor skin turgor. Circulation to the skin is reduced, and healing is slower. The nails may become thicker and brittle, and hair may lose pigment and turn gray. Pruritus commonly occurs in older adults and is caused mainly by dry, scaling skin. Skin tags, which are loose flaps of skin, occur mainly around the neck, eyelids, and axillae. (Fundamentals of Nursing, Human Health and Function 5th Edition, chapter 40; page 1006) Adults take nutritional supplements for a variety of reasons that may include obtaining nutrients deficient in the diet, to provide extra protection for disease prevention or to treat or manage a specific medical condition. (U.S. Department of Agriculture; Dietary Guidelines for Americans 2010; 2010)

Interpretation: Having skin changes like skin being dry, wrinkling, and poor skin turgor is normal for his age. Nails that are thick and hair changes are also normal. Theres also loose flaps of skin on the upper part of the arm. Since the client is stuporous, it is expected that he will be fed through NGT.

Elimination Pattern Prior to confinement, about the clients elimination pattern. My client verbalized, Isang beses ako dudumi araw araw pero minsan wala. She described her stool to be a brownish color with a foul smell. Client had no problems defecating but it is not on a daily basis, my client urinates 5 to 6 times depending on how much fluid she consumes. She described her urine as yellow and cloudy with no foul smell. Client did not have any problems urinating. During menstruation, client consumes two to three pads a day for five days.

During her stay at JRRMMC, client finds the hospital to be a difficult place to defecate but does defecate when needed. Clients stool is said to be brownish in color with foul smell. Client urinates frequently but has a hard time going to the C.R. without assistance.

Analysis: The total amount of urine voided during 24-hour period usually ranges between 1200-1500 ml. Most people void six to eight times a day (Sampselle, 2003a). The color of urine ranges from a light yellow, to a darker yellow, to a dark-yellow brown, called amber. The frequency of defecation can normally range from one or two bowel movements per day to one bowel movement every 2 to 3 days. (Fundamentals of Nursing, Human Health and Function 5th Edition, chapter 42, pages10791080; chapter 43, page1117)

Interpretation: The clients urinary elimination does not show any alteration in terms of frequency, color and pain.

Activity and Exercise According to my client, my client sleeps at 12mn and wakes up around 4am in the morning, takes a shower, then prepares food for her family. After her husband leaves with their son around 6am , she takes a nap At 10am she cleans the house and prepares lunch for herself. After she eats lunch, she takes another nap, if the client does not have anything to do she goes to the market to help her husband. Around 6pm when her husband and son comes home, she starts preparing for dinner. After dinner, she and her husband usually talk about their day. On Sundays, she stays at the house and takes care of her child while her husband attends mass.

In JRRMMC, client is seen asleep on the bed most of the time. Client is awake when she has visitors. When she needs to use the restroom client walks with assistance.

Analysis: Special problems in self-care arise in older adults. As adults approach middle age (40 to 60 years), muscle tone, and bone density and mass decrease. Joints lose elasticity and flexibility. Fear of falling causes some older adults to restrict activity voluntarily. (Fundamentals of Nursing, Human Health and Function 5th Edition, chapter 34, page 730; chapter 35, page 781)

Interpretation: The clients daily activities are not that helpful to the body. She is not fond of exercice.. Which is a risk for developing illnessess, it is expected that the client wont be able to establish self-care techniques right now because of her condition.

Sleep/Rest According to my client, my client usually sleeps around 12 mn after she puts her son to sleep. When my client has difficulty in sleeping she remains on the bed and contemplates. Client lives in a 1 bedroom house with her husband and son and sleeps next to them. Before sleeping, my client brushes her teeth, finishes whatever task that is needed to be done, and then talks to her husband. She claims that talking to her husband relaxes her at times. My client is seen asleep most of the time due to limited movement. In the morning, her niece stays with her until J.B.s husband takes over around 6pm.

Analysis: Adults vary widely in the number of hours of sleep that they require and in their preferred portion of the 24-hour period for sleeping. By middle age, the frequency of nocturnal awakening tends to increase. As people age, the amount of stage 4 sleep decreases significantly. (Fundamentals of Nursing, Human Health and Function 5th Edition, chapter 44, page 1161)

Interpretation: Patient tends to sleep throughout the day is normal since the client cannot stand on her own. Before, the client takes naps in the afternoon, and this is normal. But continuous sleeping at night without nocturnal awakening is not normal.

Cognitive Perceptual
Client is currently a housewife. Her highest educational attainment is being a college undergraduate. She was not able to finish her last two years of college in her province due to financial problems. She has no difficulties on writing, hearing, and following directions. Clients visual acuity is weak and needs corrective lens to read. When spoken to, client was able to answer the questions that were asked without any difficulties. Client was able to follow directions when given instructions on taking the medication given. When observed client showed signs of squinting and when given a material to read, it takes time for her to read out loud.

Analysis: As adults feel progressively more competent, they become less rigid and more flexible. (Fundamentals of Nursing, Human Health and Function 5th Edition, chapter 47, page 1240) Adults cognitive and intellectual abilities change very little. Cognitive processes include reaction time, memory, perception, learning, problem solving and creativity. (Kozier and Erbs Fundamentals of Nursing, Vol. 1 page 399)

Interpretation: Before, the client does not have any difficulty in speech, hearing, writing and memory. But during hospitalization, the client is conscious. The only problem be is that she has a hoarse voice due to her condition.

Self Perception Prior to confinement, my client sees herself physically weak but still has faith in God. She mentioned that there are more people out there with greater complications. My client has no known enemies and gets along with everyone around her. When my client is angry or sad, she speaks to her husband because she claims that it relaxes her.

During confinement, my client believes that she will get better because her family is there to support her no matter what. When taking her VS, client is approachable but has difficulty speaking due to hoarseness.

Role Relationship M.B is a housewife who lives with her husband and son. Her role, as a wife and mother is to clean the house, take care of her son, and tend to the familys needs.

Currently, my client is being taken care of her niece in the morning and her husband at night.

Analysis: Roles play an extremely important part in healthy family functioning. Most researchers agree that the establishment of clear roles within family is directly connected to a familys ability to deal with day-to-day life, unforeseen crises, and the normal changes that occur in families over time. (http://pubs.ext.vt.edu) Family is the basic unit of society. Cultural values can determine communication within family group, the norm for family size, and the roles of specific family members. Decisionmaking within the family includes different alternatives to family problems. (Kozier and Erbs Fundamentals of Nursing, Vol.1 page 319)

Interpretation: Before, the client was able to sustain a good relationship with his family and wife but during the hospitalization, the client cant meet his role as a father to his children and as a husband to his wife. The need for peer group support while confined in the hospital is normal.

Sexuality Reproductive Before my client was diagnosed with malignant carcinoma on the left breast, she her and her husband were sexually active. They were able to conceive a son. Even after she had a son.. she was still active in sexual intercourse

Now that she is in the hospital, having intercourse is not possible.

Analysis: Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment. (Reference: Fundamental of Nursing, 8th Edition, p.352)

Interpretation: Prior to hospitalization, the patient has a happy relationship with his partner. But during hospitalization, the client express her feelings and love towards his children and her husband that much because of hes condition.

Coping/Stress Tolerance When my client is stressed, my client talks to her husband. He finds their advice to be valuable at times. When my client cannot cope with her stress, she prays. The last time my client encountered stress, as she recalled, was when she found out she had a malignant tumor on her left breast. Currently, my client is a bit stressed because she has a possible tumor on her right breast. She is supported by her family, so she always prays and tries to stay positive most of the time.

Analysis: The various demands of adulthood impose daily stress. Adults draw on coping skills developed throughout life and learn new ones. Previous exposure to stressful situations may help people cope with similar situations more constructively than did in younger years. (Fundamentals of Nursing, Human Health and Function 5th Edition, chapter 51, page 1346)

Interpretation: Patients way of handling stress is normal and that is verbalizing her feelings to her friends and husband and praying.

Values/Beliefs My client is a devoted Roman Catholic but does not attend mass every Sunday with her husband. She believes that her family is the only thing that makes her think positive. Regarding her health, my client finds herself physically weak. Although my client was not able to attend mass every Sunday, she still has faith in God. In her stay in the hospital, she often prays and tries to stay positive.

Analysis: The expression of spirituality, often through a specific religious group, usually follows an established order of practices. These practices may range from simple meditation and relaxation to more formal worship such as church services or rituals at shrines. (Fundamentals of Nursing, Human Health and Function 5th Edition, chapter 53, page 1393)

Interpretation: It is normal and good for the client to go to church every Sunday.

The patient appears alert and coherent. The patient is cooperative in our nursing assessment and she was able to answer most of our questions. She is very attentive and listens carefully to the questions and discussion of the group when performing. Patient has difficulty in speaking. She understands fully what was happening during the interview.

IV. Physical Assessment General Survey

Body Built:
Endomorph

Grooming/Hygiene:
Patient is appropriately dressed, clean and neat

Posture & Gait:

Patient cannot walk without assistance, unable to support herself

Body Odor and Breath Odor:

No Body odor, No Breath odor

Signs of Distress: Orientation: Time____ Person_____ Place_____ Level of Consciousness:

Obvious Signs of Illness(es): DOB, Contraptions, Enlargement of Right Breast Affect: Mood: GCS: 15 Cannot be assessed

Conscious and Coherent

Organization of thoughts: cannot be assessed

Quantity & Quality of Speech:

Anthropometric Measurement

Temperature: Pulse Rate: 37.1 90

Respiratory Rate: 22

Blood Pressure: 120/90

Vital Signs .

Height: 53

Weight: 170lbs

IBW/BMI: 30.1 (obese)

V. Anatomy and physiology

VI. Pathophysiology

VII. Laboratory Results

SPECIMEN: PLEURAL FLUID

Laboratory and Date (August 23, 2012) Color Normal Pale yellow Result BC: Orange Turbid; AC: Yellow, clear with red sediments Analysis and Interpretation Turbid pleural fluid can occur from either increased cellular content or increased lipid content. These 2 entities can be differentiated if the pleural fluid is centrifuged and the supernatant examined. If the turbidity remains after centrifugation, it is in all probability due to increase lipid content, and the fluid should be sent for lipid analysis. Less than 100/mm Indicates transudate.

WBC Count

4 u/ L

Monocyte
Lymphocyte

2%
80%

Normal.
Pleural lymphocyte values of 5070% of the nucleated cells suggest malignancy. Pleural fluid lymphocytosis, with lymphocyte values greater than 85% of the total nucleated cells, suggests TB, lymphoma, sarcoidosis, chronic rheumatoid pleurisy, yellow nail syndrome, or chylothorax.

Neutrophil RBC Count

18% 19.92 mm^3

Normal. >100,000 RBC/ in malignancy, trauma, parapneumonic effusions, and pulmonary embolism

Gramstain

Negative

Few puss cells found.

Puss may indicate empyema

Specimen: Blood

Laboratory and Date (August 23, 2012) HEMOGLOBIN

Normal Values 120-180

Result 141.0 g/L

Analysis and Interpretation The cardiopulmonary system maintain good oxygen carrying capacity There is the amount of the total blood volume that is made up of RBCs. There is adequate amount of transport and exchange of oxygen

HEMATOCRIT

0.40-0.54

0.43

RBC COUNT

4.6-6.2

4.62 x10^12/L

MCV

80-96

94 fl

There is the adequate amount of the average amount of weight of hemoglobin within RBC.
There is the adequate amount of the average amount of weight of hemoglobin within RBC. Normal The WBC is within normal range.

MCH

27-31

31 g/L

MCHC WBC COUNT

33-36 5-10

33 g/dL 7.1 x10^9/L

Differential count Neutrophils

50-70

54.9 %

Lymphocytes

25-35

32.8 %

Normal. There is an adequate amount of neutrophil that digest microorganisms. Normal. There is an adequate amount of lymphocytes that plays a large role in defending the body against disease. There is an increase amount of basophil may indicate lymphoma, endocrine caused estrogen increase or viral infection An increased percentage of monocytes may be due to inflammation disease or viral infection. There is adequate amount of phagocyte that produces the anti-inflammatory protein histamine.

Basophils

0.4-1.0

4.4 %

Monocytes

4.0-6.0

6.6 %

Eosinophils

1-3.0

1.3 %

VIII. Drug Study

DRUG Pre-operation DATE ORDERED: August 23, 2012 GENERIC NAME: cefuroxime BRAND NAME:

INDICATION

ACTION

SIDE EFFECT/ADVERSE REACTION

NURSING CONSIDERATION

PATIENT TEACHING

Cefuroxime was ordered by the physician as a pre-op prophylaxis prior to insertion of CTT.

Cefuroxime inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death

CLASSIFICATION: Cephalosporin DOSAGE: 1.5g initial dose 750mg q8

Pain, induration, phlebitis after IV administration, rash, diarrhea, eosinophilia, casts in urine, thrombocytosis and leucopenia. Elevation of AST, ALT and BUN and creatinine. GI disturbances, nausea, vomiting, headache, dizziness, edema, oliguria

Perform skin test before initiation of dose. Assess patients previous sensitivity reaction to penicillin or cephalosporins. Assess patient for signs and symptoms of infection before and during treatment. Assess renal function before and during therapy. Assess for allergic reaction and anaphylactic reaction. Assess for possible superinfection

Inform patient that she will be receiving the medications as prescribed length of time ordered even if she feels better. Teach patient to report sore throat, bruising bleeding and joint pain, this may indicate blood dyscrasia (rare). Advise patient to report bloody, mucoid diarrhea which may indicate pseudomembr anous colitis.

DRUG

INDICATION

ACTION

SIDE EFFECT/ADVERSE REACTION

NURSING CONSIDERATION

PATIENT TEACHING

DATE ORDERED: August 23, 2012 GENERIC NAME: ranitidine BRAND NAME:

Ranitidine was ordered to inhibit gastric acid secretion so as not to induce GI discomfort during intake of antibiotics.

Ranitidine inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretion.

CLASSIFICATION: Antacid DOSING: 50 mg IV, q12

Cardiac arrhythmias, bradycardia. Headache, fatigue, dizziness, hallucination, depression, insomnia. Rash, nausea, vomiting, abdominal discomfort, diarrhea, constipation, hypersensitivity reaction -

Perform skin testing before initiation of dose. Assess potential interactions with the other pharmacological agents patient may be taking. Evaluate results of laboratory tests, therapeutic effectiveness and adverse reactions Teach patient the purpose of drug and possible side effects and adverse symptoms to report.

Instruct patient to avoid alcohol. Follow the diet as physician recommends. May cause drowsiness, dizziness or fatigue Report chest pain or irregular heartbeat; skin rash; weakness, yellow skin and eyes; change in color of urine and stool.

DRUG

INDICATION

ACTION

SIDE EFFECT/ADVERSE REACTION

NURSING CONSIDERATION

PATIENT TEACHING

DATE ORDERED: August 24, 2012

Post op med
GENERIC NAME: Tramadol BRAND NAME:

Tramadol is indicated for the patients post operation pain

Tramadol is a centrally acting analgesic not chemically related to opioids but binds to mu-opiod receptors and inhibits reuptake of norepinephrine and serotonin.

CLASSIFICATION : Analgesic (opioid) DOSING:

Vasodilation, dizziness, headache, stimulation, anxiety, confusion, coordination disturbances, euphoria, nervousness, sleep disorder, seizures, sweating, rash, dry mouth, diarrhea, constipation, vomiting, dyspepsia, abdominal pain, flatulence. Decreased hemoglobin, hypertonia.

50mg amp, q8

Assess patients pain before therapy and regularly thereafter to monitor drug effectiveness(gi ve before pain become extreme) Assess hypersensitivity reaction Monitor Intake and Output Assess changes in bowel pattern

Advice patient to avoid alcohol Advice patient to avoid OTC medications without medical advice. Warn patient to be careful when standing and changing position to prevent orthostatic hypotension

DRUG

INDICATION

ACTION

SIDE EFFECT/ADVERSE REACTION

NURSING CONSIDERATION

PATIENT TEACHING

DATE ORDERED: August 25, 2012 GENERIC NAME: Paracetamol BRAND NAME:

Paracetamol is indicated for relief of patients fever caused by suspected infection.

CLASSIFICATION : Analgesic/antipyretic DOSAGE: 300mg, IV, q4

Paracetamol decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilatation.

simple fevers, headaches, joint pain and other small aches and pains Hematologic: hemolytic anemia,neutropenia, leucopenia, pancytopenia. Hepatic: Jaundice Metabolic: Hypoglycemia Skin: rash, urticaria

Assess patients fever/pain: type of pain, location, intensity, duration, temperature, and diaphoresis. Assess allergic reactions. Assess hepatotoxicity; dark urine, clay-colored stools, yellowing skin and sclera, itching, abdominal pain. Give with food or milk to decrease gastric symptoms

Advise patient to avoid taking more than one product containing paracetamol, as this may cause toxicity. Advise patient to avoid alcohol; acute poisoning with liver damage may result. Teach patient to recognize signs of chronic overdose.

DRUG Post-operation

INDICATION

ACTION

SIDE EFFECT/ADVERSE REACTION

NURSING CONSIDERATION

PATIENT TEACHING

DATE ORDERED:
August 26, 2012 GENERIC NAME: cefuroxime BRAND NAME:

CLASSIFICATION: cephalosporin DOSAGE: 500mg, 1 tab, TID

Cefuroxime was ordered by the physician as a treatment of infection after initiation of CTT. 400 cc of pus w/ fluid was drained after induction of CTT. This pleural fluid was analyzed 2 days before operation and has results of positive pus cell and increased WBC (lymphocyte) count content which suggests that the patient has an infection.

Cefuroxime inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death

Pain, induration, phlebitis after IV administration, rash, diarrhea, eosinophilia, casts in urine, thrombocytosis and leucopenia. Elevation of AST, ALT and BUN and creatinine. GI disturbances, nausea, vomiting, headache, dizziness, edema, oliguria

Assess patients previous sensitivity reaction to penicillin or cephalosporins. Assess patient for signs and symptoms of infection before and during treatment. Assess renal function before and during therapy. Assess for allergic reaction and anaphylactic reaction. Assess for possible superinfection

Inform patient that she will be receiving the medications as prescribed length of time ordered even if she feels better. Teach patient to report sore throat, bruising bleeding and joint pain, this may indicate blood dyscrasia (rare). Advise patient to report bloody, mucoid diarrhea which may indicate pseudomembra nous colitis.

DRUG

INDICATION

ACTION

SIDE EFFECT/ADVERSE REACTION

NURSING CONSIDERATION

PATIENT TEACHING

DATE ORDERED: August 26, 2012 GENERIC NAME:

celecoxib
BRAND NAME:

Celecoxib is indicated to Celecoxib inhibits relieve patients postprostaglandin synthesis operational pain. by selectively inhibiting cyclo-oxygenase-2 (COX-2). Relieves pain and inflammation.

Anaphylactic reaction, renal toxicity. Hallucination, constipation, diverticulitis, dysphagia, dry mouth, melena, hemorrhoids, vomiting, hypertension, anorexia, anxiety, increased appetite, depression, peripheral edema

CLASSIFICATION: Nonsteroidal antiinflammatory drugs (NSAIDs) DOSAGE: 200mg, 1 cap, BID -

Assess for appropriateness of therapy for pain. Check the patients Rang of motion. Monitor blood count during therapy; watch for decreasing platelets. Watch out for signs of blood dyscrasias. Administer with food or milk to decrease gastric symptoms. Do not crush, dissolve, or chew capsules Do not increase dose May adversely affect liver

Teach patient that the drug has to be continued for prescribed time to be effective. It may take several days before c onsistent pain relief is felt. Teach patient to take with full glass of water for enhanced absorption. Inform patient the drug must not be crushed, dissolved or chewed. Instruct patient to report bleeding, bruising, black tarry stool, cramping, fatigue and malaise. Report nausea, fatigue, lethargy, itching, jaundice experienced.

DRUG

INDICATION

ACTION

SIDE NURSING EFFECT/ADVERS CONSIDERATIO E REACTION N

PATIENT TEACHING

DATE ORDERED:

Multivitamins drug is indicated for August 26, 2012 nutritional supplement of GENERIC patient and NAME: immune system multivitamins booster. BRAND NAME:

Supplies Excessive use may vitamins and lead to toxicity. mineral demand of body to attain optimal functioning of system.

Give with foods for better absorption. Assess for any signs of toxicity.

CLASSIFICATI ON: Vitamins and minerals DOSAGE: 1 tab, OD

Instruct patient to aid this medicine with healthy diet as prescribed. Teach patient not to exceed prescribed dosage.

DRUG

INDICATION

ACTION

SIDE EFFECT/ADVERSE REACTION

NURSING CONSIDERATION

PATIENT TEACHING

DATE ORDERED: August 26, 2012 GENERIC NAME: Ascorbic acid BRAND NAME:

Ascorbic acid aids in enhancement of patients natural immune function.

Needed for wound healing, collagen synthesis, carbohydrate metabolism, protein, lipid synthesis, prevention of further infection.

Gastro-intestinal discomfort, urinary stone

CLASSIFICATION :

May be taken with meals. Assess patients nutritional status inclusion of foods high in Vitamin C. Monitor input and output ratio. Not to exceed prescribed dose

Vitamins and minerals

DOSAGE: 500mg, 1tab, TID

Teach patient necessary foods to be included in diet that are rich in Vitamin C. Teach patient not to exceed RDA recommende d dose and prescribed dose, urinary stones may occur.

IX. PEG Nursing Care Plan

XI. Evidence-based Nursing (for NCM & RLE 103 & onwards)
Present Practice Present Practice: To Strip or Not to Strip? Physiological Effects of Chest Tube Manipulation In practice, stripping usually refers to compressing the chest tube with the thumb or forefinger and, with the other hand, using a pulling motion down the remainder of tubing away from the chest wall; milking involves manipulations such as squeezing, twisting, or kneading to create bursts of suction to move clots. But study shows that Stripping chest tubes may significantly increase negative intrathoracic pressures that could cause harm. (AJCC, p.609) Evidenced-Based Nursing EBN: Go with the flow of CHEST TUBE THERAPY To maintain tube patency, avoid dependent loops in the drainage tube. Avoid aggressive chest tube manipulation, including stripping or milking; studies have shown that these maneuvers increase negative pressure in the tube (as high as -400 cm H2O) and do little to maintain chest tube patency. If necessary, however, you may try gentle techniques, such as squeezing hand over hand along the tubing and releasing the tubing between squeezes. (Nursing2006, p.40) Recommendation to Present practice If careful assessment suggests that some manipulation of the tube is necessary, contemporary expert opinion strongly recommends gentle manual squeezing and releasing of small segments of chest tubing between the fingers (milking) instead of stripping.( AJCC, p.611) Recommendations: We therefore recommend for future nurses, staff nurses and future researchers that the use gentle milking instead of stripping significantly lessens complications to the patient undergoing chest tube therapy.

Reference: www.ajcconline.org AJCC, November 2007, volume 16, No. 6 www.nursing2006.com Nursing2006, Volume 36, number 3

XII. On-going Appraissal

XII. Discharge Plan

Medication

Present to the significant others and patient the take home medications that will be prescribe by the physician. Emphasize to them the therapeutic effects and suspected side effects, as well as the daily dose and proper route of the medication. This will minimize anxiety and will encourage compliance of the drug. Inform the family to seek medical help immediately if signs and symptoms of the adverse effect of drug occur.
Teach patient arm and shoulder exercise to restore movement, prevent painful stiffening of the shoulder, and improve muscle power. Tell the family that they should take part on the treatment of the patient to strengthen the support system of the client. Inform the patient and his family not to self medicate especially when unusual situations occur. Advice patient to avoid trauma on chest.

Exercise Treatment

Health Teaching

Outpatient follow-up care

Diet Spiritual

Emphasize the importance of keeping follow-up appointments and participating in other health screenings. Point out the importance of adherence to medications and strict avoidance of carcinogenic substance. Discuss with the patient the different carcinogenic foods that may cause recurrence of cancer. Suggest to eat organic foods. Encourage the family to teach patient to pray to God always, ask for guidance, and pray for healing and restoration of health. Provide assistance and emotional support to patient and family in dealing with its long term implications.