“It’s okay to have nothing,

Than to have no air… at all” -Jjmdrn-

(A case study presented by the TEAM OR Volunteer NURSE)

BATCH MAY- AUGUST 2010

DIAMA, JENIFER JOY M.

CANDAZA, ROMELYN

SECRETARIO, RACEL

GOMEZ, KAMILLE

VILLA-OR, JAMIELA

GUZMAN, MERYL

SENENSE, MONICA

FUSELERO, HILDA

VELOS, JOSEPH

I. INTRODUCTION

One of the most distressing symptoms that anyone can experience is shortness of breath—

dyspnea. Patients describe themselves as 'not getting enough air. This triggers a series of

physiological and behavioral reactions that include increased heart rate, blood pressure and hormonal

secretions accompanied by a feeling of general panic. Shortness of breath is a common symptom of

many respiratory illnesses.

Just as the gut separates and absorbs food from the outside world into the body, the lungs

are a passage for the exchange of used air and fresh air. But there's a crucial difference between

food and oxygen—we can't store oxygen. We must meet a second-by-second demand for the life-

giving element or die within minutes. The body responds immediately to any interference with this

exchange.

What will be the cause? ------- It is Pneumonia. This is an inflammation or infection of

the lungs most commonly caused by a bacteria or virus. Pneumonia can also be caused by

inhaling vomit or other foreign substances. In all cases, the lungs' air sacs fill with pus, mucous,

and other liquids and cannot function properly. This means oxygen cannot reach the blood and

the cells of the body.

Most pneumonias are caused by bacterial infections. The most common infectious cause

of pneumonia is the bacteria called Streptococcus pneumoniae or Pneumococcus... Bacterial

pneumonia can attack anyone.

GENERAL OBJECTIVE

After the case presentation ended, the participant would be able to gain knowledge about

the linkage effects of diseases from the body, demonstrate adequate skills in analyzing the

nursing process and appreciate the importance of nurse’s role in providing appropriate

management.

SPECIFIC OBJECTIVE

Can present anatomy and physiology and tackle the pathophysiology that leads to

disease process...

Relate the significance of laboratory results of the client’s condition or the disease

process.

Identifies all operation being done to the patient, know the responsibilities and

safety precautions.

Identify classification, indication, mechanism of action, special precaution, side

effects, and nursing responsibilities in administration of drugs.

II. PATIENTS PROFILE

NAME: AB. Aranel

AGE: 39 years old

SEX: Female

RELIGION: Roman Catholic

DATE ADMITTED: May 29, 2010 around 11:15 A.M

ADMISSION DIAGNOSIS: Pleural Effusion Right secondary to Pneumonia

FINAL DIAGNOSIS: Empyema right thoracic

III. PATIENTS HISTORY

Chief complaint: Difficulty of Breathing

General Data: This is a case of a 39 year old female Filipino, presently residing in

Western Bicutan, Taguig. And who was admitted in Taguig City Hospital on May 29, 2010.

History of Present Illness:

5 days prior to admission, patient had positive signs and symptoms of

cough, yellowish phlegm, persistent fever and back pain. Knowing that these

signs and symptoms were just forms of little discomforts, she self medicated

with paracetamol. However, she noticed no changes and experienced

difficulty of breathing so she sought medical consultation.

Past Medical History

According to the patient she has immunization of BCG, DPT, OPV, HEPA B, and

MEASLES. She has a history of chicken pox when she was a grade school. This is her second

time of hospitalization. Her first hospitalization was last 2007 brought about abdominal pain/

UTI.

Family Medical History

There is no known familial disease in her paternal side but there is a history of

hypertension in her maternal side.

Personal and Social History

The patient is non smoker; however she stated that her husband and her older

brother who was residing together with them were chain smokers. She doesn’t drink alcoholic

beverages and does not use any forms of drugs. She is a retired office employee, and now

managing the sewing shop of her late mother.

IV. Review of Systems

System assessment General

(+) Weight Loss 20% for 2 months

HEENT (-) blurring of visions, (-) sorethroat

Gastroenterology(-) abdominal pain, (-) diarrhea, (-) constipation, (-) melena, (-) hematochezia

GUT (-) dysuria, (-) oliguria (-)anuriaEndocrinology (-) polyuria, polydipsia, polyphagiaMusculoskeletal (-) myalgiaHematology (-)easy brusabilityNeurology (-) neuropathy, (-)seizures

PHYSICAL ASSESSMENT/ EXAMINATION

Date Assessed: May 29, 2010

Time Assessed: 11: 50 Am (OR/DR complex area)

Vital Signs:

Blood Pressure: 110/60 Temperature: 38.1 C Pulse rate: 97 bpm Respiratory rate: 26 breaths/min

General appearance: The patient is awake, lying on bed, conscious and coherent with an IVF of PNSS

and side drip of D5W with incorporation of aminophylline on the right arm.

HEENT: Anicteric sclera, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no nasoaural discharge, no cervicolymphadenopathy,

Chest and

Lung

Symmetrical chest expansion, no lagging, no retractions, dull at percussion at Right base, decreased breath sounds at right base, decreased tactile and vocal fremitus at right base, fine crackles at right base.

Heart Adynamic pericardium, normal rate, regular rhythm, PMI at 6th ICS at MCL, normal

S1 and S2, (-) S3 and S4, no murmurs.

Abdomen Flat, soft, normo active bowel sounds, non-tender

Extremities Full pulses, no edema, extremities with full range of motion

V. ANATOMY AND

PHYSIOLOGY

The LUNGS are paired,

cone-shaped organs which take up

most of the space in our chests, along

with the heart. Their role is to take

oxygen into the body, which we need

for our cells to live and function

properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs,

a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by

'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart

takes up some of the space in the left side of our chest. The lungs can also be divided up into even

smaller portions, called 'bronchopulmonary segments'. These are pyramidal-shaped areas which are

also separated from each other by membranes. There are about 10 of them in each lung. Each

segment receives its own blood supply and air supply.

The PLEURA is the body cavity that surrounds the lungs. And this is divided into two, the

inner and outer. The pleural cavity, with its associated pleurae, aids optimal functioning of the

lungs during respiration. The pleural cavity also contains PLUERAL FLUID, which allows the

pleurae to slide effortlessly against each other during ventilation.

Physiology of pleural fluid

It is believed that the fluid that normally enters the pleural space originates in the capillaries in the parietal pleura. In humans, Amount of pleural fluid formed daily in a 50-kg individual = approximately 15 mL. The mean lymphatic flow from one pleural space = 0.40 mL/kg/hour

Pleural fluid accumulates when the rate of pleural fluid formation exceeds the rate of pleural fluid absorption.

Normally, there should be a small amount (0.01 mL/kg/hour) of fluid constantly enters the pleural space from the capillaries in the parietal pleura.

VI. PATHOPHYSIOLOGY

In the healthy state, the pleural cavity contains a small amount of fluid (10 ml in a 70 kg

man) that serves as a lubricant to facilitate the gliding of the visceral pleura over the parietal

pleural membrane (see Pleural Effusions: Pleural Fluid, Transudate and Exudate.Pleural Space).

This fluid is a transudate and contains mainly macrophages. Normally, fluid exits the pleural

cavity via the stomata on the parietal pleura, which empty into lymphatic channels.

Pleural effusions develop when there is increased fluid formation or reduced fluid

removal or both. Transudative effusions, most commonly due to cadiac failure or hepatic

cirrhosis, accumulate from imbalances in hydrostatic and oncotic pressures, such that excessive

pleural fluid formation saturates the drainage capacity of the pleural cavity.

Pleural inflammation, lymphatic disruptions, or malignancy underlie the development of

most exudative effusions. Exudates accumulate due to increased vascular permeability. In many

cases, decreased fluid re- sorption also contributes to the accumulation of the pleural fluid. This can

be a result of blockage of the lymphatic stomata in the parietal pleura (e.g., by meta- static

carcinomas) or obstruction of the downstream lymphatic flow (e.g., by regional lymphadenopathy).

Occasionally, fluid can enter the pleural cavity from extrapleural sites. Transdiaphragmatic

migration of ascitic fluid into the pleural cavity is well described. This occurs because the

intraperitoneal pressure is less negative than the intrapleural pressure, and dia- phragmatic pores

exist in many individuals that per- mit transdiaphragmatic movement of the ascitic fluid. Blood

from traumatic laceration of blood vessels, cerebrospinal fluid from a dural–pleural fistula, or urine

from a renal tract fistula can accumulate in the pleural cavity. Puncture of central veins by venous

catheters can lead to subsequent pleural accumulation of fluids administered intravenously (e.g.,

parental nutrition).

PATHOPHYSIOLOGY DIAGRAM

Virulent Microorganism

Streptococcus pneumoniae

Microorganism enters the nose (nasal passages)

Passes through the larynx, pharynx, trachea

Microorganism enters and affects both airway and lung parenchyma

Airway damage lung Invasion

Infiltration of bronchi flattening of epithelial cells

Infectious organism lodges macrophages and leukocytes

Stimulation of bronchioles necrosis of bronchi tissue

Mucus and phlegm production

Alveolar collapse narrowing of air passage

Increase pyrogen in the body DIFFICULTY OF BREATHING

COUGHING PRODUCTIVE/NONPRODUCTIVE

Fever

Necrosis of pulmonary tissue

Overwhelming sepsis

DEATH

VII. DIAGNOSTIC EXAMINATION

Chest x-ray result:

Impression: There are reticolu nodular opacities on both lung fields with upward traction

of right hilus. There are dilated thick walled bronchi noted on both lower lobes. Heart is not

enlarged. Aortic knob is sclerotic other visualized structures are unremarkable. Findings are

suggestive of Extensive PTB; Bilateral with cicatrical changes, Right upper lobe. Bacteriologic

correlation is suggested.

Type of exam Abnormal flag Result Reference range

HEMOGLOBIN Low 5.4 g/dl 13.0 -18.0

HEMATOCRIT Low 15.9 % 40.0 – 52.0

RBC Low 1.71 nl/ mm3 4.70 – 5.40

MCV 93 fl 80 – 100

Clinical Chemistry Result:

test results Normal range

Sodium 124.9 mmol/L 135.0-148mmol/L

Hematology Result:

MCH 32 pg 28 – 33

MCHC 34 % 32 -38

WBC High 21,900 mm3 4,800 – 10, 800

NEUTROPHILS High 19, 272 2,00 – 7, 500

LYMPHOCYTES 1,533 1, 500 – 4, 000

MONOCYTES High 1, 095 200 – 800

EOSINOPHILS 0 40 – 500

BASOPHILS 0 10 - 100

Urinalysis:

Color: Light Yellow

Transparency: Slightly Hazy

Reaction: (pH) 6.0

Protein: +1

Glucose: negative

Specific Gravity: 1.010

Pus cells: 3-4/HPF

Cont.

RBC: 2-3/ hpf

Crystals: a urates many

Mucus threads: few

Cast: fine granular cast: 1-2/hpf

VIII. MEDICAL MANAGEMENT

1. vital signs monitoring- to continually monitor clients health status

2. IVF therapy implemented to maintain the fluid and electrolyte balance of the body which

sustain bodily function on the optimum level

D5W – supplies body water for hydration.

PNSS – a way to replace water at correct electrolyte deficit. It provides

medium for IV drug administration.

3. O2 inhalation therapy – inhalation (1-2 Lpm)

4. Medications:

Paki include ung drugs na nilagay ko sa drug stud…

5. Chest x ray of posterior and anterior view of chest – for viewing of lungs and pleural fluid

accumulation.

SURGICAL INTERVENTION

1. The patient underwent chest thoracotomy tube (CTT) Right insertion”.

Chest thoracotomy tube - Exchange of oxygen and carbon dioxide in the lungs

depends on effective ventilation and adequate circulation of blood through both

lungs. And getting the secretions, such as , blood air or pus

2. General anesthesia - a state of total unconsciousness resulting from general anesthetic

drugs

IX. DRUG STUDY

Generic Name: Hydrocortisone Sodium succinate

Brand Name: Solu-Cortef

Classification: Corticosteroid, short acting

Dosage:100mg IV, q 6 hours

Indications:

Replacement therapy in adrenal cortical insufficiency

Hypercalcemia; associated with cancer

Short term inflammatory disorders

Contraindications:

Infections, especially tuberculosis, fungal infections, amoebiasis,

hepatitis B, liver disease, liver cirrhosis, active or latent peptic ulcer.

Adverse Reaction:

Vertigo, headache, hypotension, shock, thin, fragile skin, petechiae,

amenorrhea, muscle weakness.

Nursing Considerations:

1. Give daily before 9AM to mimic normal peak diurnal corticosteroid

levels and minimize HPA suppression.

2. Space multiple dose evenly throughout the day.

3. Use minimal dose for minimal duration to minimize adverse effects.

4. Use alternate day maintenance therapy with short acting corticosteroids whenever possible

Generic Name: Acetylcysteine

Brand Name:Fluimucil

Classification:Mucolytic Agent

Indications:

Mucolytic Adjuvant therapy for abnormal, viscid, or inspissated mucus

secretion in acute and chronic bronchopulmonary disease (pneumonia,asthma,TB).

Contraindications:

Contraindicated with hypersensitivity to acetylcysteine; use caution and discontinue if

bronchospasm occurs.

Adverse Reaction:

Nausea, rhinorrhea, bronchospasm especially in asthmatics,

stomatitis,and urticaria.

Nursing Considerations:

1. dilute with normal saline solution or sterile water for injection

2. Administer the ff drugs separately because they are incompatible

with acetylcysteine: tetracyclines, hydrogen peroxide, trypsin.

3. Use water to remove residual drug solution on the patient’s face

after administration by face mask.

4. Inform patient that nebulization may produce an initial disagreeable

odor, but will soon disappear.

Please add poito sa drug stud… aminophylline

CAN YOU ADD PARACETAMOL AMPULE… I FORGOT TO INCLUDE THIS THANKS.

AND PLEASE FORMAT THE DRUG STUDY LIKE THE TABLE na kasunud.

Ung cefuruxime yaan nyo lang antibiotic na nya yan haha

DRUG STUDY

GENERIC/

BRAND

DOSAGE/ROUTE

CLASSIFICATIO

N

ACTIONS INDICATION

S

CONTRAINDICATION

S

ADVERSE

EFFECTS

NURSING

CONSIDERATIONS

G = cefuroxime

sodium

B = ceftin

1.5 g T. I.V

> anti infective/

antibiotic

>second –

generation

cephalosporin

that inhibits

cell wall

synthesis,

promoting

osmotic

instability;

usually

bactericidal.

> pre

prophylaxis /

perioperative

prevention

> contraindicated in

patient hypersensitive

to drug or other

cephalosporin.

> use cautiously in

patient with

hypersensitivity to

penicillin because of

possibility of cross-

sensitivity with other

beta lactam

antibiotics..

> nausea, anorexia,

vomiting, diarrhea,

temperature

elevation, urticaria.

>obtain specimen

for culture and

sensitivity test

before giving first

dose. Ask patient or

relatives if there is

sensitivity in

penicillin or other

cephalosporin

drugs.

X. NURSING CARE PLAN

Problem: Difficulty of breathing

Subjective: Diagnosis Scientific Interference Goal of care Nursing Intervention Rationale Evaluation

“nahihirapansiyang huminga dahil madami siyang plema kaya sinugod namin siya sa ospital”asverbalized byrelative.

Objective:

*RR- 26

*Dyspnea

*(+)productivecough

*Use ofaccessorymuscle ( nasal flaring)

 

> Impaired gas exchange related to excessive or thick secretions as evidence by dyspnea on exertion

 

Increased mucus production is often caused by an underlying illness. If mucus is the most prevalent symptom, it isusually caused bysomething simple like allergies or the common cold. Other illnesses that result in excessive mucus production include pneumonia, flu and bronchitis

 

Short term

goal:

> after 3-4 hours of nursing intervention, patient will be able to breathe on room air without SOB

>RR will decrease from 26 cpm to normal rate of 16-20 cpm

 

Independent:

1.Encourage deep breathing

2.Teach patient the importance of deep breathing

> Position the patient:

   HOB elevated at 30-45 degrees

   Turn the patient every two hours

4.Auscultate breath sounds listening for sounds of crackles or wheezes

5.Expplore with patient potential etiologic factors that contribute to impaired gas exchange and provide appropriate health teaching

 

1. to open up lung bases to increase oxygen exchange in the blood

2. to increase patient’s compliance

3. to facilitate optimum breathing patterns

4. to evaluate the improvement of the patient’s condition

5. to be able to recognize etiologic factors and to avoid it to prevent the disease from occurring again

 

 

 

 

 

 

Goal half met.

After 4 hours ofnursingintervention,patient was able to breathe on room air without SOBandRR decreasedfrom 26/min to22/min and

Collaborative:

6.Administer mucolytics as indicated

7. Providedsupplementalfluids. (IVF: PNSS)

8.Monitor oxygen saturation levels

 

 

 

 6.Assist in mobilizing secretions7. Fluids arerequired toreplaceinsensible lossand aids inmobilization ofsecretions.8. To be able to evaluate the development of the patient’s condition