UNIVERSITY OF THE CORDILLERAS

College of Nursing
Governor Pack Road, Baguio City, Philippines 2600 (+6374)
442-3316, 442-2564, 442-8219, 442-8256 E-mail:
webmaster@bcf.edu.ph Website: www.bcf.edu.ph

A CASE OF DENGUE FEVER WITH WARNING

SIGNS: BONTOC'S TOPICAL STRUGGLE

A Case Presented to the

College of Nursing

In Partial Fulfillment of the requirements in the Course

( eg: Nursing Care Management 107)

Submitted By:

AMOSLO, Kimberly T.
BANDAO, Marc Joseph
BOSANG, Rose- ann
CHAN, Olivia
DE ASIS, Sheila R.
DULNUAN, Jhane A.
DUMAG, Elaijah
GOYALA, Janella Hannes B.
ORPILLA, Alyssa Megan
WAG-E, Dawnmurph Dharlene P.

(Date: DAY-MONTH-YEAR )

Noted and Approved for Presentation:

Name of Case Presentation Adviser or Panel/s

Signature of Adviser/s / Date

CASE PRESENTATION FORMAT

ABSTRACT

(250 – 300 words only not including title and author information)

TITLE: A Case of Dengue Fever with Warning signs: Bontoc's Topical Struggle

AUTHOR INFORMATION: Flashes Left under the Title. Names should be arranged alphabetically based on
FAMILY name, but FIRST name should be written first followed by FAMILY name (ex., Grace Espino, and
Daniel John G. Soque)

BACKGROUND: Briefly describe the background for the case. Introduce the issue that the case addresses.
Explain why the case is noteworthy and what it adds to current knowledge. This section helps answer the
question “Why should we care?” You may want to end the introduction with a sentence that states explicitly
why the case is being reported.

CASE DESCRIPTION: This section should be longest and most detailed part of the abstract. Relevant
information may include demographics, client’s main symptoms, or other reasons for seeking care, clinical
findings, clinical assessment, treatment plan, and health outcomes. Given the space limitations, include only
the information to the reason for presenting the case.

CONCLUSION: This section should state the main “take-home” lesson(s) from the case. If reporting
outcomes, remember that case reports do not typically demonstrate cause and effect. Be careful not to overstate
conclusion but instead describe the strengths and limitations of the case. You may want to add a sentence or
two about the implications of the case for practice for future research.

１
 TABLE OF CONTENTS

I. Introduction..........................................................................................................................................３
II. Statement of Objectives.......................................................................................................................３
A. General Objectives...............................................................................................................................３
B. Specific Objectives...............................................................................................................................３
III. Patient’s Profile....................................................................................................................................３
IV. Chief Complaint...................................................................................................................................３
V. Present History of Illness.....................................................................................................................３
VI. Past History of Illness..........................................................................................................................４
VII. Family Health History.........................................................................................................................４
VIII. Developmental History........................................................................................................................４
IX. Social and Environmental History......................................................................................................４
X. Lifestyle and Health Practices............................................................................................................５
XI. Health Assessment................................................................................................................................５
A. General Survey.....................................................................................................................................５
B. Head to Toe Assessment......................................................................................................................６
C. 13 Areas of Assessment........................................................................................................................７
XII. Diagnostics..............................................................................................................................................9
XIII. Comprehensive Pathophysiology........................................................................................................12
XIV. Treatment/Management......................................................................................................................13
A. Drugs.................................................................................................................................................13
B. IV Fluids...........................................................................................................................................13
C. Surgery.............................................................................................................................................13
XV. Nursing Care Plans..............................................................................................................................16
A. Prioritization of Problems..................................................................................................................16
a.1. List of Problems...........................................................................................................................16
a.2. Basis for Prioritization................................................................................................................16
B. Nursing Care Plans............................................................................................................................17
NCP 1........................................................................................................................................................17
NCP 2............................................................................................................Error! Bookmark not defined.
NCP 3............................................................................................................Error! Bookmark not defined.
NCP 4............................................................................................................Error! Bookmark not defined.
NCP 5............................................................................................................Error! Bookmark not defined.
C. Discharged Plan...................................................................................................................................18
XVI. Learning Insights.................................................................................................................................18
XVII. List of References.................................................................................................................................19
XVIII. Appendices...........................................................................................................................................20
Appendix A: Approval/ Request Letter.....................................................................................................21
Appendix B: Interview Guides...................................................................................................................22
Appendix C: Others.....................................................................................................................................23

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 (Spacing from here would be 1.15)
III. Introduction
Definition and discussion of SPECIFIED CASE and description and enumeration of common
signs and symptoms. (preferably from textbook)
INCLUDE also relevant STATISTICS (international, national and local statistics) about the
CASE. (could be internet source)

II. Statement of Objectives

III.General Objectives

This case analysis aims to increase the understanding and knowledge of student
nurses on how to care for patients with Dengue fever with warning signs effectively and
efficiently.
B. Specific Objectives

Specifically, this case analysis aims to :

1. define (SPECIFY CASE) and its effects to the body as a whole;
2. illustrate the pathophysiology of (SPECIFY CASE) and in relation to the signs and
symptoms specifically observed in the patient;
3. describe and identify the common signs and symptoms of (SPECIFY CASE);
4. discuss the medical and surgical interventions for the management of (SPECIFY
CASE);
5. formulate appropriate nursing care plans suited for the patient based on the
assessment findings;
6. identify care measures to be given to the patient and family to promote
continuity of care and independence after discharge.

III. Patient’s Profile

This portion provides general information about the patient.

!!! ALERT !!! Anonymity and Confidentiality should at all times be observed.
All data presented should not be linked with the identity of the patient .
Name : Patient X (coding, we use X)
Age/Sex: : 40/ Female DELETE or use CODING
Civil Status : DELETE
Religion : Roman Catholic
Ethnic Background : Tagalog
Occupation : Student Nurse

Admitting Diagnosis : Spontaneous Pneumothorax

Final/Principal Diagnosis : Spontaneous Pneumothorax
Date and Time Admitted : April 05, 2018 at 3:00 am

IV. Chief Complaint

This presents the main complaint/s of the patient; the primary reason consultation was sought
and hence, admitted.
Dyspnea and Sharp Chest Pains

V. Present History of Illness

Narrative form. This is a brief account of when the patient’s condition started, how it developed, up
to the time of admission. Initial signs and symptoms are described in line with duration, domain/localization,
progression, character and how it has affected the physiological function of the patient. Any interventions
made by the patient to address the
illness are to be described (e.g. home remedies, medications, consultations) and whether these were
effective or not. Elaboration of the chief complaint.

３
 The patient’s condition started 3 days PTA, when the patient, while simply doing his homework, felt
a sudden sharp chest pain. Pain rate was with the severity of 8/10. It was not radiating to other parts of the
body but was accompanied by difficulty of breathing, weakness, shortness of breath, and sudden hacking
cough.
A few minutes after the said incident, the patient verbalized that all of the symptoms mentioned
slightly improved and was tolerable and only rest was promoted. No medications were taken nor were
consultations done during the incident. 2 days PTA, he was not feeling anything and verbalized that he was
alright until
One day PTA, the patient has the same manifestation but now the difficulty of breathing was so severe
that the patient decided to seek consult and subsequently admitted in this institution.

VI. Past History of Illness

Narrative form. This is a brief account of when the patient’s previous illnesses, includes childhood
illness, childhood immunizations, allergies, accidents and injuries hospital admissions and other medical
treatments
The patient had no history of accidents and or trauma, only minor illnesses, such as cough, colds and
fever and was remedied with over the counter medications such as Bioflu and water therapy with rest. The
patient however, was admitted last January 2009 at Sublime Medical Hospital due to the same problem and it
was the first time he was diagnosed to have spontaneous pneumothorax. He received medical interventions
such as
medications for pain and for inflammation and was discharged home after 5 days of hospitalization.
The patient has unrecalled immunization status and with no history of prolonged case of use of medications
such as aspirin or NSAIDs. He also verbalized that he did not have known allergies for foods or medications.

VII. Family Health History

Narrative form. This portion describes the presence of any hereditary
disorders/familial-tendency illnesses experienced by the patient or any member of the patient’s family (eg
DM, HPN, Cancer, Obesity ect.). Includes ages of siblings, parents and grandparents and their current
state of health or the cause of death. You can also
segregate Paternal and Maternal side

The patient claims to have familial history of Hypertension, Coronary Artery Disease
and Cancer on his mother’s family. Health problems such as Asthma, kidney diseases,
diabetes, or mental illness were verbalized to be absent. No present illness is currently experienced by any
member of the family.

VIII. Developmental History

Narrative form. This portion describes significant patterns of the patient’s behavior in line with his
current stage of development. (Can use other developmental theories like Erikson, Piaget, Sullivan and
others)

The patient is the last son out of the other 5 siblings, which are composed of 4 males and a female. He
is a 19 year old teenager with the task of developing his Identity according to Erik Erikson’s Developmental
theory. He has verbalized no problems with self-
image and concept and reveals the desire to achieve his goals in his studies especially in
maintaining his place in the dean’s list and hopefully graduating with honors or having a place in the Local
Nursing Licensure examination. He also noted no difficulty in interacting with people despite his silent nature.
He tends to observe most of the time but also recognized a great number of friends with whom he shared his
childhood with. He also
loves music. His passion is seen in his ability to play the guitar with ease and is now learning
how to play the piano.

IX. Social and Environmental History

Narrative form. As expressed in the sample below. Social history include relationship of the patient
with family members, to the society, any membership (like senior citizen, women’s club and others) and
work place or school, ethnic affiliation, educational history,

４
occupational history and economic status. Environmental history includes their house and the environment
(water source, ventilation, garbage disposal, transportation, any health threats like fertilizers and chemical
exposure), any threats from school or work.
The patient is non-smoker and non-alcoholic beverage drinker. No verbalized vices were identified.
However, he is constantly exposed to noxious fumes from outside air pollution and from second hand smokers.
He lives in a rented apartment together with his three other cousins near the main highway where jeepneys
frequently pass. He commutes daily using the public utility jeepneys for his transport to school.
The patient belongs to a family with two licensed nurses, hence, the value of maintaining a healthy
lifestyle is promoted. The patient with his family visits the local hospital from health problems unresolved by
home remedies and rest. The patient after experiencing the same sudden pain immediately went to the hospital
to confirm the initial findings he had when he was admitted in Sublime City. As a family that belongs to the
middle class, access to health care facilities and interventions is not much of a problem.
The house where they stay is made up of semi-permanent and permanent materials such as wood and
cement. Privacy is maintained with the 4 separate rooms present.
Water used daily is being supplied by the city water district while the source of drinking water is the
water refilling stations nearby.
Patient also verbalized that he did not have any direct contact to harmful chemicals nor has prepared
any chemotherapeutic drugs. As a student nurse however, he is able to care for various patients with having
different respiratory health problems such as tuberculosis, pneumonia and cough. The community exposure
they had as a part of the Clinical RLE allows them to travel to different areas where he experiences changes in
the weather and differences in altitude.

X. Lifestyle and Health Practices

Narrative form. As expressed in the sample below. Include also usual patterns or routine of daily
life (including personal habits, diet, sleep/rest patterns, activities of daily living and recreations/hobbies).
Any health practices whether traditional or medical.

As a student nurse, he is aware of the potential health threats associated with lifestyle related vices
like cancer for smoking and liver cirrhosis for alcoholic beverage drinking. He ensures that he receives
adequate nutrients by allowing himself to eat three complete meals in a day with snacks included specially
during his duty times. Food is prepared at home together with his cousins or is bought in fast-food chains. He
prefers pasta dishes and pizza. Fluid and electrolyte intake is a total of 2 – 3 liters a day coming from fruit
juices, carbonated beverages, water and milk. For maintenance he takes Vitamin C for supplement.

XI. Health Assessment

A. General Survey
This portion presents assessments performed as seen in the example below. The time that you FIRST
handled your patient. Include ht., wt., BMI, body built, posture and gait, hygiene and grooming, body and
breath odor, signs of distress, obvious signs, attitude, affect and mood, speech and thought process.

The patient was received awake, lying on bed with a moderate high back rest elevation. Patient with
ongoing IVF’s of D5LRS I L x 30 gtts per minute and a Tramadol drip (tramal) 300 mg in D5W 250 cc x 24
hours infusing well on the left arm and with oxygen inhalation at 2-3 LPM/ via the nasal cannula. He is
connected to three way bottle system chest drainage with the first bottle having 300cc bloody discharge.
Suction control is applied and there is bubbling noted in the third bottle.
Patient appears weak, needs assistance when assuming activities of daily living like toileting and
feeding or in changing positions. He wears a neat gown, hygiene is fair. Patient is conversant speech is well
formulated, oriented to the self and others around him, able to determine the time and date and is aware that he
stays in a private room for 3 days now.
Patient is an ectomorph. He verbalized that he is 5’6” tall and weighs 51 kilograms.

５
 B. Head to Toe Assessment (EXCEPT FOR PSYCHE PTS- USE MSE)

This portion presents assessments performed as seen in the example below. You can do FOCUS
assessment especially on the affected area (eg. CHF  focus on Cardiac Assessment) and focus on
abnormal findings.
1. Head Normocephalic, hair well distributed, oiliness and flaking
noted no areas of pain or tenderness during palpation.
2. Eyes Able to distinguish colors, with astigmatism, verbalized
difficulty to identify objects 6 feet away, wears corrective
lenses, sclera is anicteric, pupils are equally round,
reactive to light and accommodation, EOM is intact, able
to follow penlight with gaze, no detectable oscillations,
mucous membranes are moist and light pink.
3. Ears Able to understand and hear spoken language correctly,
with minimal cerumen build – up in the ear canal, sliver
and intact tympanic membrane.
4. Nose and sinuses Nose is patent, septum is located midline, no flaring
noted, able to distinguish the scent of alcohol and
perfume, and no episodes of epistaxis during the shift,
and sinuses are not tender on palpation.
5. Mouth Complete set of adult teeth, pearly white in color, and no
mal aligned tooth, had braces for 1 year and a half year.
No dental caries noted. Oral mucosa is moist and pinkish,
no lesions noted, tonsils are not inflamed, Grade 1
bilaterally present, uvula is located midline.
6. Neck ROM intact, able to change direction of head slowly but
with without complaints of pain, carotid pulse are
bilaterally symmetrical, full and strong pulses, 2+, jugular
vein is not distended, superficial cervical lymph nodes are
palpable but non tender. Thyroid is located midline, no
enlargement noted, trachea is located midline.
7. Chest Shape of the chest is elliptical, asymmetrical chest wall
expansion noted, with respiratory excursion best
appreciated on the left side of the thorax, decreased
tactile fremitus in the right lung area, decreased breath
sounds in the right, no crackles, no wheeze, no stridor,
production of hollow drum like sounds in percussion of the
right side and resonant sound appreciated on the left.
Patient with an Axillary thoracotomy, dressing intact and
dry, chest tube draining to a bloody discharge 300 cc in
amount. With limited movement on the right shoulder.
Patient verbalized, “mahina daw ung lungs ko,
spontaneous rupture of the bleb, kaya may
pneumothorax ako” “Masakit tlaga ung sugat, parang
8/10 din, pati ata sa loob masakit talaga, ditto lang
naman sya sa may incision, parang may tumutusok kaya
binigyan nila ako ng analgesic, ngayon, ayos ng konte
pero may pain pa din at 6 na cguro ung scale nya out of
10”. Patient is observed to guard area and grimaces
when a painful stimulus is felt. Diaphoresis noted, hands
are cool to touch. Maintains the supine position with
head of bed elevated to a moderate high back rest.
8. Cardiac Adynamic pericardium; normal rate, regular rhythm, PMI
at 50 ICS LMCL, no murmur noted, no visible pulsations in
the precordium, palpable apical pulse.

６
 9. Breast/Chest Skin color is similar with the rest of the body, nipple is dark
colored, no discharges.
10. Abdomen Flat, with normoactive bowels sounds heard in all the
quadrants, soft, no direct tenderness or rebound
tenderness upon palpation, tympanic, no organomegaly.
11. Genitals Patient verbalized that he had been inserted with a
catheter when he was in the OR. No complaints of
dysuria or urinary retention or incontinence post
operatively.
12. Musculoskeletal Muscle strength at the right side is 4/5 while the rest of
extremities are 5/5.
No visible tremors noted no complaints of pain.
13. Integumentary Skin…

C. 13 Areas of Assessment

This portion presents assessments performed as seen in the example below. Follow format on how to do your
13 areas of assessment. GORDON’S FUNCTIONAL HEALTH PATTERNS
1. Psychosocial and Psychological Status

2. Mental and Emotional Status

3. Environmental Status

4. Sensory Status
a. Visual Status

b. Auditory

c. Olfactory Status

d. Gustatory Status

e. Tactile Status

5. Motor Status

6. Thermoregulatory Status

Date Time Temperature

7am 36.3 °C
April 05, 2022 10am 36.4 °C
2pm 36.6 °C
7am 36.0 °C
April 06, 2022 10am 36.4 °C
2pm 36.0 °C
7am 36.0 °C
April 07, 2022 10am 36.5 °C
2pm 36.2 °C
Analysis:

７
7. Respiratory Status

Date Time RR SPO2

7am 21 cpm 93 %
January 05, 2022 10am 23 cpm 95 %
2pm 24 cpm 98 %
7am 22 cpm 92 %
January06, 2022 10am 20 cpm 93 %
2pm 19 cpm 95 %
7am 20 cpm 96 %
January 07, 2022 10am 18 cpm 95 %
2pm 17 cpm 97 %
Analysis:

8. Circulatory Status

Date Time CR Capillary

January 05, 2022 7am 98 bpm
10am 94 bpm 2-3 seconds
2pm 95 bpm
January 06, 2022 7am 89 bpm
10am 88 bpm 2-3 seconds
2pm 90 bpm
7am 97 bpm
January 07, 2022 10am 97 bpm 1-2 seconds
2pm 95 bpm
Analysis:

9. Nutritional Status

10. Elimination Status

11. Sleep, Rest and Comfort Status

12. Fluids and Electrolytes Status

13. Integumentary Status

During episodes of airway obstruction, the patient’s capillary refill is 2-3 seconds.
However, when managed, he appears to be pinkish in color and with good skin turgor.

８
XII. Diagnostics
This shows all diagnostic procedures performed with the client. LANDSCAPE and Tabular form. Content of the table must follow the format below.
For Chest X-ray, Ultrasound and Pathology
Diagnostic
Description of the Procedure
Procedure
Chest X-ray Chest radiography is the first
investigation performed to
Jan 3, 2022 assess pneumothorax because
it is simple, inexpensive, rapid,
and noninvasive; however, it is
much less sensitive than chest
CT in detecting a small
pneumothorax, blebs, and
bullae.
Significance/Purpose of the
Procedure
It is used to determine the severity
of the patient’s pneumothorax
and to determine the progress of
his medical and surgical
management.
Date of
Findings & Implications
Procedure
April 20, 2009 Follow-up study of the chest taken on the same day,
SIP CIT insertion reveals a relative partial reduction in
the size of the previously noted right-sided
pneumothorax. There is however no significant
change in the extent and appearance of the
massive atelectasis of the right lung field. A right
sided CTT is now seen.
April 22, 2009 Follow-up study of the chest since 6/20/2009 S/p
Axillary thoracotomy shows complete resolution of
the pneumothorax on the right with complete re-
expansion of the right lung. A right sided CTT is still
seen in SITU. No other internal change of note.
April 26, 2009 Follow-up study of the chest since 6/22/09 reveals the
presence of confluent hazy densities at the right
paracardiac areas, presenting a pneumonic process
with consolidation. There is now a homogenous
opacity with meniscus level seen at the right lower
hemithorax obscuring the right hemi diaphragm and
costrophenic angle representing fluid.
April 26, 2009 Follow-up chest study since 6-26-2009 reveals minimal
clearing of the confluent hazy densities at the right
paracardiac area. There is however, decrease in the
volume of the previously noted fluid in the right
9
 HEMITHORAX. A right sided CTT is still seen in SITU.

No other internal change of note.

Ultrasound Abcdeflkjdlj alkdjf Adfjlskdjf jldkjflasd April 29, 2009 aljkdhfklashdfa

Pathology Kdljfoijuelasldfjm Dgsdgasdufods April 24, 2009 Csalksdjfoi dlfjs;dfsa;fjds

For Blood Chemistry, Serum electrolytes, Urinalysis, Fecalysis and other lab test with quantitative results. SAMPLE not related with previous CASE.

Diagnostic procedure Description of procedure Significance/ Purpose of the Significant findings Nursing Implications
and date done procedure

Complete Blood Count A CBC may be ordered when a To determine general health Leucocyte (WBC) A low white blood cell count
Jan 3, 2022 person has any number of signs status, screen, diagnose, or Normal Range: indicates that the patient has an
and symptoms that may be related monitor any one of a variety of 5-10 x10^ 9/L infection.
to disorders that affect blood cells. diseases and conditions that Result:
When an individual has an affect blood cells, such as 0.58- Low
infection, inflammation, bruising, or anemia, infection, inflammation,
bleeding, a doctor may order a bleeding disorder or cancer.
CBC to help diagnose the cause
and/or determine its severity.
Neutrophils Within the normal range.
Normal Range:
0.50-0.70
Result:
0.31-Normal
Lymphocytes Indicates an acute bacterial
Normal Range: infection.
0.20-0.40
Result:
0.58- High

10
 Basophils No result
Normal Range:
0.00-0.01
Result:
Not included on the test
Monocytes Within the normal range.
Normal Range:
0.00-0.07
Result:
0.03- Normal
Platelet count Indicates Thrombocytopenia.
Normal Range:
150,000-450,000
Result: 310,000 –low

Urinalysis A urinalysis…
Jan 3, 2022

Facalysis A fecalysis…
Jan 3, 2022

11
XIII. Comprehensive Pathophysiology
This is a diagrammatic presentation of the course of the disease with emphasis of information relevant to nursing
care. Predisposing factors (Modifiable), Precipitating factors (Non-modifiable), course of illness or condition,
relevant diagnostic findings, signs & symptoms, management and appropriate nursing diagnoses presented must
be in line with actual events that occurred with the patient.
PREDISPOSING FACTORS PRECIPITATING FACTORS

nd Height (tall person), Male, 19 years old

Exposure to 2 hand Smoking & Pollution

Chemicals (Tar) Gradient of Pleural pressure increases from

lung base to apex
Blocks airway passages and degrade
elastic fibers of the lungs

Influx of neutrophils and macrophages Alveoli of lung apex receives

is induced the greater distension pressure

Imbalanced enzymes (protease & anti-protease)

and antioxidant system

________________Bullae/Blebs Formation______________________

Inflammation-induced obstructions of the airway Shearing forces

Increased alveolar pressure

Leakage to the lung interstitium, hilum and pneumomediastinum Rupture of blebs

Increased mediastinal pressure

Rupture of the mediastinal parietal pleura

_______________Pneumothorax____________________

Disequilibrium in the intrapulmonary and intrapleural pressure

Activation of the receptors that monitor Tidal volume affected Changes in the thoracic pressure
lung volume
Distortion of movement of air
Sympathetic stimulation in and out of the lungs

Tachypnea Air flows out of the alveoli

into the Pleural space

Lung collapse during recoil

Dyspnea Sudden, sharp, stabbing pain

Admission to the Hospital

---INEFFECTIVE BREATHING PATTERN---
Partial collapse of the affected lung

Impairment of gas conduction Air trapping in the collapsed lung Ruptured bleb and lung collapse
in the lower respiratory airways activate inflammatory response

Decreased tactile fremitus Hyper resonance on percussion Lung asymmetry

---------------------IMPAIRED GAS EXCHANGE-------------------

Transudation of fluid and blood from surrounding Axillary Thoracotomy

blood vessels of the injured lung and Bleb Excision

-------PAIN RELATED TO TISSUE TRAUMA-------

Pleural Effusion

Transudate accumulation in the pleural space

Further restriction of lung expansion Collapse of alveoli Disequilibrium in pulmonary and pleural pressures

Increased respiratory difficulty Bleeding Surgical Incision and Insertion of CTT

Stasis of pulmonary sections Decreased Hct and Hgb Tissue trauma and injury

Growth of microorganisms Decreased oxygen carrying Pain on the incision site

capacity of the lungs
---RISK FOR INFECTION--- ---IMPAIRED MOBILITY---
---ACTIVITY INTOLERANCE---

SOURCE:

12
XIV. Treatment/Management
This shows all treatments, including medical procedures, performed with the client. LANDSCAPE and tabular form. Content of the table must follow the format below. But for more COMPREHENSIVE
Nursing Implication, categorize your NURSING IMPLICATION as to Before, During and After giving the medication and each has Dx, Tx and EDx for DRUG STUDY.

A. Drugs
(Follow new Format for Drug Study)

DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECTS NURSING RESPONSIBILITIES

CONTRAINDICATION
GENERIC NAME (Based on Based on the case of the Based on the case of the Adverse effects manifested BEFORE
the doctor’s order) patient. patient. by your patient DURING
BRAND NAME (Based on the AFTER
doctor’s order)
CLASSIFICATION
DOSAGE
FREQUENCY
ROUTE Source
DATE

B. IV Fluids

Name Classification Component/s Use & Effects Nursing Responsibilities

1. PNSS

C. Surgery
(if any)

13
 Procedure Description & Indication Nursing Care/Responsibilities
Thoracotomy The process of making of a surgical incision into the  The nurse should….
January 17, 2022 chest wall which allowed for the study of the  The patient should be advised to…
condition of the lungs and removal of part of a lung.  others???
The client had undergone an Axillary thoracotomy.
This method is used by a majority of thoracic surgeons
for all pulmonary resections. Its major indication is now
for pneumothorax surgery, allowing easily apical
resection and pleurectomy with excellent long-term
results
Pleurodesis A procedure aimed at making adhesions between  The nurse should remind the patient to keep the wound from the chest
January 17, 2022 the visceral and parietal pleura, obliterating the tube clean and dry until it heals.
potential pleural space indicated for conditions such  The patient should watch for signs of wound infection such as redness,
as pneumothoraxPleurodesis is achieved by putting swelling, and/or drainage, and be alert to symptoms indicating that the
one of any number of chemicals (sclerosing agents or effusion recurred.
sclerosants) into the pleural space. The sclerosant  others???
irritates the pleurae which results in inflammation
(pleuritis) and causes the pleurae to stick together.
The patient is given a narcotic pain reliever and
lidocaine, a local pain killer, is added to the
sclerosant. A variety of different chemicals are used
as sclerosing agents. There is no one sclerosant that is
more effective or safer than the others.
Chest Tube Drainage Procedure made to place a flexible, hollows drainage The chest tube typically remains secure and in place until imaging studies such as
January 17, 2022 tube into the chest in order to remove an abnormal X rays show that air or fluid has been removed from the pleural cavity.
collection of air or fluid from the pleural space.  Nurses must also note for such complications like:
The client was attached to a three way bottle system  bleeding from an injured intercostal artery (running from the aorta)
 accidental injury to the heart, arteries, or lung resulting from the chest
with the first bottle as the drainage, the second as the
14
water seal and the third bottle connected to a suction
control
tube insertion
 a local or generalized infection from the procedure
 persistent or unexplained air leaks in the tube
 the tube can be dislodged or inserted incorrectly
 insertion of chest tube can cause open or tension pneumothorax
15
 XV. Nursing Care Plans

A. Prioritization of Problems

a.1. List of Problems (Write as many as you can)

This portion lists the health problems according to priority (No. 1 having the highest priority).

Health Problems are stated as Nursing Diagnoses using the Basic 3-Part Statement : PES
Format
- Problem Statement + Etiology + Signs and Symptoms
-
- Ex: Self-Esteem Disturbance related to rejection by husband as manifested by hypersensitivity to criticism,
stating "I don't know if I can manage by myself", and rejecting positive feedback
- Variations to the PES format in order to make the problem statement more descriptive
(e.g. adding "Secondary to") is acceptable as long as the part following
“secondary to” is a disease process
(Ex: High-Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary
to Diabetes)

Problems should comprise AT LEAST 3 Actual Problems and 2 Potential Problem ranked in order of
priority.

a.2. Basis for Prioritization (5 problems only)

This portion presents the basis of how the health problems were prioritized. Prioritization should also
be discussed.

NURSING DIAGNOSES JUSTIFICATION

1. PES Format as stated in
your list of problem
2. PES Format as stated in
your list of problem
3. PES Format as stated in
your list of problem
4. PES Format as stated in
your list of problem
5. PES Format as stated in
your list of problem
Why is it number 1 out of your 5 problem, you can
use nursing theories or concepts.
Why is it number 2 out of your 5 problem, you can
use nursing theories or concepts. Relate it with
number 1 or 3.
Why is it number 3 out of your 5 problem, you can
use nursing theories or concepts. Relate it with
number 2 or 4.
Why is it number 4 out of your 5 problem, you can
use nursing theories or concepts. Relate it with
number 3 or 4.
Why is it number 5 out of your 5 problem, you can
use nursing theories or concepts. Relate it with
previous problems.

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 B. Nursing Care Plans
The Care Plans for the Nursing Diagnoses shall be presented here.
The format discussed during the Orientation shall be followed. (Follow new Format for NCP)

NCP 1: PES Format as stated in your list of problem

Assessment Explanation of the
Problem
Objective data Strictly in NARRATIVE
Subjective data FORM
(Please do not DEFINE)
How did the patient
Nursing develop/acquire the
Diagnosis problem/disease?
Problem +Etiology
Objective
FOCUS on the MAIN PROBLEM
STO: can be achieved within the
shift (max of 8 hours)
LTO: can be achieved within the
(maximum of 24-72 hours)
Nursing Interventions Rationale Evaluation
PLEASE SPECIFY Explanation of the nursing Goal Met
Dx (scanned, reviewed, assessed, monitored, intervention/s.
auscultated, determined, etc.) Goal Partially Met
Tx (independent and dependent nursing
functions) Goat Unmet
Edx (health teachings) (please include recommendations)

Problem +
etiology + defining
characteristics
Source: Modified adaptation of Kozier’s NCP Format
Fundamentals of Nursing Practice by Kozier

Note: for potential problem/s:

a. instead of “evaluation,” please use expected outcome
b. for the nursing interventions, please use future tense.

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 C. Discharge Plan
Health Teaching
Diet/Nutrition 1. Aaaa
2. Bbbb
3. cccc
Activity 1. aaaa
2. bbb
3. cccc
4. DDD

Medication 1. Aaaa
2. Bbbb

Others 1. Aaaa
2. Bbbb

(Diet, Therapeutic regimens, Take home meds and Nursing education for the client)

XVI. Learning Insights

(Individual and arranged alphabetical order. Includes what you have learned from the case of your
patient, from assessment, diagnosis, planning, implementation or nursing care and evaluation.
PARAGRAPH FORM, express your writing skills.)
A. MAGWILANG, Judith Odanee G.

C. SOQUE, Daniel John G.

I believe that…
D. DD
Honestly, I am not part of the directly monitoring the patient but I was able to learn
a lot from our case by sharing my insights regarding…
E. EE
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
F. FF
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
G. GG
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
H. HH
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
I. II
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
J. JJ
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…

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 XVII. List of References
This portion cites all books, journals and other references that were used as shown in the example
below. Use APA Format and as much as possible use updated book source.

American Lung Association. (2000). Asthma statistics. [On-line.] Available:

http://lungusa.org/data.

Babu K.S., Salvi S.S. (2000). Aspirin and asthma. Chest 118, 1470– 1476.

Chan-Yeung M., Malo J. (1995). Occupational asthma. New England Journal of Medicine 333, 107–
112.

Chestnut M.S., Prendergast T.J. (2002). Lung. In Tierney L.M., McPhee S.J., Papadakis M.A. (Eds.),
Current medical diagnosis and treatment (41st ed., pp. 350–355). New York: Lange Medical
Books/McGraw-Hill.

Cotran R.S., Kumar V., Collins T. (1999). Robbins pathologic basis of disease (6th ed., p. 713). :
W.B. Saunders.

Dubuske D.M. (1994). Asthma: Diagnosis and management of nocturnal symptoms.

Comprehensive Therapy 20, 628–639.

Gilliland F.D., Berhane K., McConnell R., et al. (2000). Maternal smoking during pregnancy,
environmental tobacco smoke exposureand childhood lung function. Thorax 55, 271–276.

Light R.W. (1995). Diseases of the pleura, mediastinum, chest wall, and diaphragm. In George R.B.,
Light R.W.,

McFadden E.R., Gilbert I.A. (1994). Exercise-induced asthma. NewEngland Journal of Medicine 330,
1362–1366.

Romero S. (2000). Nontraumatic chylothorax. Current Opinion in Pulmonary Medicine 6, 287–291.

Sahn S.A., Heffner J.E. (2000). Spontaneous pneumothorax. New England Journal of Medicine 342,
868–874.

Sly M. (2000). Allergic disorders. In Behrman R.E., Kliegman R.M., Jenson H.B. (Eds.), Nelson
textbook of pediatrics (16th ed., pp. 664–685). Philadelphia: W.B. Saunders.

Tan K.S., McFarlane L.C., Lipworth B.J. (1997). Loss of normal cyclical B2 adrenoreceptor
regulation and increased premenstrual responsiveness to adenosine monophosphate in stable
female asthmatic patients.Thorax 52, 608–611.

Young S., LeSouef P.N., Geelhoed G.C., et al. (1991). The influence ofa family history of asthma and
parental smoking on airway responsiveness in early infancy. New England Journal of
Medicine 324,1168–1173.

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XVIII. Appendices

20
 Appendix A
Approval/Request Letter

21
 Appendix B
Interview Guides

22
 Appendix C
Others (just specify)

23