Bukidnon State University COLLEGE OF NURSING City of Malaybalay A Case Study on

PLEURAL EFFUSION
In partial fulfilment of all the requirements in NCM 103 CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID ELECTROLYTE BALANCE, METABOLISM AND ENDOCRINE

by DIONEFLOR P. ARTANA LUCKY CHARM D. ROSOS LYRA DAIN O. LORCA MA. VANESSA L. RONOLO MARVIN C. TELIN

SY 2013 2014
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ACKNOWLEDGEMENTS

The students are very grateful to the many people who have contributed for the completion of this case study. First of all, we thank our dear parents for their never ending support all throughout the year as we pursue our aspiration to become professional and competent nurses in the future. Thank you so much for providing us our needs. Secondly, to our college, College of Nursing, Bukidnon State University for allowing students to experience your academic proficiency and to our clinical instructors, .for sharing their knowledge and expertise in the clinical field and in theory. Also, we thank the Bukidnon Provincial Medical Center (BPMC) clinical staff and administration for allowing nursing students to be exposed at the Emergency Room, Medical Ward and Surgical Ward for the first semester of SY 2013-2014. The clinical exposures we have had will make us competent and confident student nurses. We also would like to thank our patient, who with confidence allowed the students to study and present her case to the third year students of Bukidnon State University- College of Nursing and to all our very diverse patients in the Medical Ward, Surgical Ward, and Emergency Room, we thank you for the learning experience. Lastly, to our classmates, friends, duty mates, and mentors, thank you. Thank you for always encouraging us to move out from our comfort zones and for allowing us to challenge ourselves and for inspiring students to survive and excel in the many endeavours. May we always keep learning and may we never forget to help each other. May God bless us and guide us always! To God be all the glory!

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TABLE OF CONTENTS

ii iii iv I.

ACKNOWLEDGEMENT...3 TABLE OF CONTENTS.4 OBJECTIVES..5 INTRODUCTION...6 I.1 Patients Profile ...7 Demographic Data...7, 8 History of Past Illness......9 History of Present Illness...9, 10

I.2 Anatomy and Physiology/ Etiology of Disease ....11-15 I.2 Pathophysiology...16, 17 II. III. IV. V. VI. VII. THEORETICAL FRAMEWORK....18-27 ASSESSMENT.....28-32 NURSING CARE PLANS.......33-44 DISCHARGE PLAN....45-46 BIBLIOGRAPHY....47-48 APPENDIX....49 VII.1 Consent Form...49 VII.2 Researchers...50

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OBJECTIVES

GENERAL OBJECTIVE: At the end of two hours presenting our case study, students will be able to understand Pleural Effusion and its relationship to our patient.

SPECIFIC OBJECTIVE: At the end of two hours discussion, the student reporters will be able to 1. Present an overview of Pleural Effusion 2. Present and interpret the patients profile a. Demographic data b. State past and present health history of the patient c. Present the systems involved 3. Discuss the anatomy and physiology/etiology and pathophysiology of the patients condition 4. Present and interpret the Theoretical Frameworks 5. Present and interpret the Assessment Data gathered 6. Present a specific, measurable, attainable, realistic and time-bounded Nursing Care Plan for the client 7. Present the provided discharge plan for the patient and family

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I.

INTRODUCTION

The patient to be mentioned in this paper will be given a pseudo name Ms. X. Ms X was one of the patients admitted to the BPMC Female Medical Ward last June 15, 2013 due to complaints of shortness of breath and was diagnosed with Pleural Effusion. A Pleural Effusion is defined as an accumulation of fluid in the pleural space. Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleura, capillaries and lymphatics system. Any condition that interferes with either secretion or drainage of this fluid leads to pleural effusion. Clinical manifestations depend of the amount of fluid present and the severity of lung compression. If the effusion is small (ie 250 cc) its presence may be discovered only on a chest radiograph. For larger effusions, lung expansion may be restricted and the client may experience dyspnea primarily on exertion, and a dry, nonproductive cough caused by bronchial irritation or mediastinal shift. (Black, Hawk. 2008. Vol. 2 p1631) Effusions also occur when the rate of fluid formation exceeds the rate of fluid absorption. Pleural effusions are commonly classified as being either exudative or transudative. An exudative pleural effusion implies that there is a disease process that is affecting the pleura directly, causing the pleura to be damaged. A transudative pleural effusion results when the pleura itself is healthy and implies that a disease process is affecting hydrostatic and/or oncotic factors that either increase the formation of pleural fluid or decrease the absorption of pleural fluid. Deciding if the pleura is injured or intact helps in formulating a concise differential diagnosis for potential causes (Kollef et al., 2012, p.105). Factors that increase the chance of developing pleural effusion include: pneumonia, tuberculosis or other lung diseases, heart attack, heart failure, or infections such as pericarditis, recent cardiac surgery, pleurisy, tumors, cancers, such as lung, breast, surgery, especially involving the heart, lungs, abdomen and organ transplantation. Tests to diagnose pleural effusion include chest x-ray, ultrasound, CT scan, thoracentesis, pulmonary function tests and biopsy.
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DEMOGRAPHIC DATA

Name of Patient Age Sex Date of Birth Place of Birth Address Religion Nationality Civil Status Occupation Informant

: : : : : : : : : : :

Ms. X 57 Years Old Female 01-26-1956 Malaybalay City P-4 Kalasungay, Malaybalay City Bukidnon Baptist Filipino Married Street Vendor Mr X and Client Husband (Mr. X) June 15, 2013 4:11 PM Dr. Marie Alexis De Castro Temp.: 37oC RR: 30 cpm PR: 72 bpm BR: 100/80 mmHg

Relationship to Patient : Date of Admission Time of Admission Attending Physician Admitting Vital Signs : : : :

Food Allergy Drug Allergy

: :

No known food allergies No known drug allergies Elementary Level 3,000-4,000 Gardening, Selling cakes
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Educational Attainment : Monthly Income Source of Income : :

Chief Complaint Diet Admitting Diagnosis

: Shortness of Breath : On diet as tolerated with strict aspiration precaution : Right Pleural Effusion

Baseline Data (July 10, 2013) Height Weight Body Mass Index : 157 cm : : 55 Kg 22 (Within normal range)

Vital Signs (July 10, 2013) Blood Pressure Temperature Pulse Rate Respiratory Rate : 100/80 mmHg : 37 C : 80 beats per minute : 30 breaths per minute (Tachypnea)

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HISTORY OF PAST AND PRESENT ILLNESS

HISTORY OF PAST ILLNESS The patient experienced common illnesses during childhood such as fever, common colds, coughs and abdominal pain. Patient denies having been given vaccinations. HISTORY OF PRESENT ILLNESS The patient is a 57 years old married female presently residing at P-4 Kalasungay, Malaybalay City with her husband. Ms X experienced dizziness and shortness of breath last December 2012. On January 2013, which was her first BP measurement after many years, her blood pressure reading was 200/100 mmHg taken by a Barangay Health Worker and decided to have her check-up at Malaybalay Polymedic General Hospital. She was discharged after five days of admission. She was given prescription medications for hypertension by her physician but has difficulty complying due to financial difficulties. On February 13, 2013 Ms. X was admitted at Bethel Baptist Hospital and was diagnosed with Cardiovascular Disease (CVD). Then on May 13, 2013 patient was again admitted to BBH and was diagnosed with Hypertensive Cardiovascular Disease (HCVD) and Cerebrovascular Accident (CVA) which led to right residual weakness of her body. On June 6, 2013, she went to Bethel Baptist Hospital because she experienced shortness of breath and was admitted. Thoracentesis was done to the patient on the same day. On June 13, 2013, her physician suggested a Chest Tube Thoracostomy to be done at whichever hospital they prefer. A day after discharge from BBH, Ms. X experienced shortness of breath and was admitted at Bukidnon Provincial Medical Center (BPMC) on June 15, 2013 at 4:11PM and was for several diagnostic tests. X-ray was done on June 16, 2013 and revealed no significant interval change in the right hemithorax from the previous result. On June 17, 2013, chest ultrasound revealed a right loculated pleural fluid of not less than 1000 cc.
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On June 19, 2013, a final pathological report revealed a chronic inflammatory pattern negative for malignant cells. On June 20, 2013, thoracentesis was done and two days after, CTT was done. Chest CT scan, plain and contrast was done on July 22, 2013 and revealed the following: There is 23 x 8.8 x 13.8 cms (1396.60 cc) thick walled loculated pleural effusion which is slightly hyperdense in the right hemithorax There is volume loss of the right lung with no definite mass lesion seen and very minimal aerated lung at the upper lobe There is minimal reticular and haze densities at the upper lobe There is shift of mediastinal structure to left The heart is not enlarged but there is minimal pericardial effusion Aorta is normal in calibre with minimal calcification along the walls No enlarged lymph nodes seen There is minimal thoracic spondylosis There is chest tube in place in the right side with tip at the medial aspect, level of T8-9 The patient is still for sputum Acid-Fast Bacilli (AFB) 3x and medications were given to her. She was discharged last July 25, 2013.

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ANATOMY AND PHYSIOLOGY/ ETIOLOGY OF THE DISEASE

PLEURAL EFFUSION The pleural space is a potential space between the

visceral pleura, which covers the outer surface of the lung, and the parietal pleura, which lines the inside of the chest wall. In this space, there is a small amount of fluid present that functions to mechanically couple the lung to the chest wall and lubricate the interface of the visceral and parietal pleura. Pleural fluid normally results from the filtration of blood through high-pressure systemic blood vessels, and is drained from the pleural space through lymphatic openings in the parietal pleura that drain into parietal lymphatic vessels, in different disease states, fluid may originate from the interstitial spaces of the lungs, the intrathoracic lymphatics, the intrathoracic blood vessels, or the peritoneal cavity.

A pleural effusion is defined as an abnormal collection of fluid in the pleural space. Effusions occur when the rate of fluid formation exceeds the rate of fluid absorption. Pleural effusions are commonly classified as being either exudative or transudatice. An exudative pleural effusion implies that there is a disease process that is affecting the pleura directly, causing the pleura and/or its vasculature to be damaged. A transudative pleural effusion results when the pleura itself is healthy and implies that a disease process is affecting hydrostatic and/or oncotic factors that either increase the formation of pleural fluid or decrease the absorption of pleural fluid. Deciding if the pleura is injured or intact helps in formulating a concise differential diagnosis for potential causes (Kollef et al., 2012, p.105).
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SYSTEMS INVOLVED

RESPIRATORY SYSTEM

The pleural space is approximately 10-20 um wide and encompasses the area between the mesothelium of the parietal and visceral pleura (the two layers of the pleura). The pleural space actually contains a tiny amount of fluid (0.3 mL/kg body mass) with a low concentration of protein (~1 g/dL). The pressures of the pleural space are important determinants of the mechanical

properties of the lung and chest wall and, thus, of the total respiratory system. This is because the distending pressure of the lung and chest wall is critically dependent on the relevant pressures of the pleural space. Any distortion of the pressures of pleural space affects the distending pressure of the lung and chest wall and this the relevant volumes, which in turn influences the gas exchange properties of the lung via several mechanisms. It follows that pleural effusion, which alters both the liquid and surface pleural pressures affect the mechanical properties of the respiratory system as well as the gas exchange properties (Demosthenes Bouros, 2004, p.61)

The accumulation of pleural effusion has important effects on respiratory system function. It changes the elastic equilibrium volumes of the lung and chest wall, resulting in a restrictive ventilatory effect, chest wall expansion and reduced efficiency of the inspiratory muscles. The magnitude of these alterations depends on the pleural fluid volume and the underlying disease of the respiratory system (Mitrouska et al., 2004).

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On physical examination, signs that an effusion is present include dullness to percussion over the effusion, loss of fremitus, decreased breath sounds, and crackles immediately above the effusion. Presence of crackles on both lung fields upon auscultation is due to a friction created by the excess fluid. Hyporesonance percussion sound which is dull suggests a consolidation such as effusion. Dyspnea is noted as the effusion can affect the mechanics of the diaphragm, cause a restrictive ventilator defect, and/or cause compressive atelectasis leading to hypoxemia. Tactile fremitus is absent or attenuated because the fluid absorbs the vibrations emanating from the lung (Kollef et al., 2012, p.105).

CARDIOVASCULAR SYSTEM

The cardiovascular system has three basic functions: to maintain normal systemic arterial pressure, to maintain normal tissue blood flow, and to maintain normal systemic and capillary pressures. Elaborate control mechanisms are present throughout the body to maintain these functions within normal limits (Slatter, 2003, p.915).

In addition to deleterious effects on lung ventilation, perfusion, and mechanics, intrapleural air and/or fluid collections can significantly affect the cardiovascular system. Air and/or fluid in the pleural space not only occupy intrapleural volume, but also may increase the relative pressure inside the thorax and sometimes shift the position of the mediastinum. Cardiac output diminishes further if the pressure becomes great enough to shift the mediastinal position, distorting and obstructing vessels. Pressure alterations within the thorax from pleural air and/or fluid collections also can affect ECG tracings and invasive hemodynamic monitoring values and waveforms (Kinget al., 2008, p.359)

Significant tachypnea, dyspnea, tachycardia, hypoxemia, or changing mental status should raise concerns that pulmonary or cardiovascular compromise is not being adequately tolerated or is worsening (King et al.).

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Hypertensive cardiovascular disease also known as hypertensive heart disease occurs due to the complication of hypertension or high blood pressure. In this condition the workload of the heart is increased manifold and with time this causes the heart muscles to thicken. Eventually hypertensive heart disease can also lead to congestive heart failure. Some symptoms of hypertension and the eventual congestive heart failure include arrhythmias, shortness of breath, weakness and fatigue, and swelling in lower extremities. Hypertensive cardiovascular disease may also result in ischemic heart condition and in this case there might be chest pain, sweating and dizziness, nausea and shortness of breath. Hypertrophic cardiomyopathy could also be a result of cardiovascular disease (Ambekar, 2008).

MUSCULOSKELETAL SYSTEM

The skeletal system includes the bones of the skeleton and the cartilages, ligaments, and other connective tissue that stabilize or connect the bones. In addition to supporting the weight of the body, bones work together with muscles to maintain body position and to produce controlled, precise movements. Without the skeleton to pull against, contracting muscle fibers could not make us sit, stand, walk, or run (The Cleveland Clinic Foundation, 2009)

Two common symptoms of muscular disorders are pain and weakness in the affected skeletal muscles. The potential causes of muscle pain include the problems with the nervous system. Muscle pain may be experienced due to inflammation of sensory neurons or stimulation of pain pathways in the CNS.

INTEGUMENTARY SYSTEM

The integumentary system is the organ system that protects the body from various kinds of damage, such as loss of water or abrasion from outside. The system comprises
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the skin and its appendages. The integumentary system has a variety of functions; it may serve to waterproof, cushion, and protect the deeper tissues, excrete wastes, and regulate temperature, and is the attachment site for sensory receptors to detect pain, sensation, pressure, and temperature (Wikipedia, 2013)

Chest tube thoracostomy is done to drain fluid, blood, or air from the space around the lungs. Some diseases, such as tuberculosis, pneumonia and cancer, can cause an excess amount of fluid or blood to build up in the space around the lungs (called a pleural effusion). Also, some severe injuries of the chest wall can cause bleeding around the lungs. Sometimes, the lung can be accidentally punctured allowing air to gather outside the lung, causing its collapse (called a pneumothorax). Chest tube thoracostomy (commonly referred to as "putting in a chest tube") involves placing a hollow plastic tube between the ribs and into the chest to drain fluid or air from around the lungs. Thus a disruption of the skin happens. The tube is often hooked up to a suction machine to help with drainage. The tube remains in the chest until all or most of the air or fluid has drained out, usually a few days. Occasionally special medicines are given through a chest tube (American Thoracic Society, 2013)

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Predisposing Factors: Age: 57 Gender: F Ethnicity: Lumad (Higaonon) Familial

Precipitating Factors: Stress from noisy environment with poor sanitation, P3000-P4000 monthly family income, inability to maintain prescribed medications for HPN, children, nature of work: street vendor, diet: High in Na (Dried fish, ginamos, etc.), cardiovascular Disease (Feb 2013)

Increase peripheral vascular resistance

Hypertension (December 2012)

200/100 mmHg

Increased hydrostatic pressure in arterial end of capillary

Cerebrovascular accident with right residual weakness (May 2013)

Fluid movement into tissue

Presence of +2 bipedal edema Page | 16

Pleural Fluid Cytology: Final pathological report: Chronic Inflammatory Pattern Negative for Malignant Cells. Gross/Microscopic Description: Specimen consists of 1 liter blackish fluid for cytology Microscopy Description: Cell block shows lymphocytes and red cells Chest Ultrasound: Loculated fluid of not less than 1,000 is seen occupying the right hemithorax

WBC = 16.1/L Hb =11.4 g/dL Hct =34.4 vols% Platelets =329,000

Prevent forward flow of blood from left side of the heart Backward pressure Shortness of breathing Pulmonary edema tachypnea

Laboratory and Diagnostic Examinations

Pleural effusion

Impaired gas exchange

orthopnea dyspnea

Chest xray: Shown progression of the density in the right hemothorax with very aerated lung seen at the outer aspect of right upper lobe, left lung is clear

Crackles, dullness to upon percussion, tactile fremitus is attenuated

1. 2. 3. 4. 5. 6. 7. 8. 9.

CT Scan There is 23 x 8.8 x 13.8 cms (1396.60 cc) thick walled loculated pleural effusion which is slightly hyperdense in the right hemithorax There is volume loss of the right lung with no definite mass lesion seen and very minimal aerated lung at the upper lobe There is minimal reticular and haze densities at the upper lobe There is shift of mediastinal structure to left The heart is not enlarged but there is minimal pericardial effuse Aorta is normal in calibre with minimal calcification along the walls No enlarged lymph nodes seen There is minimal thoracic spondylosis There is chest tube in place in the right side with tip at the medial aspect, level of T8-9

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THEORETICAL FRAMEWORK

NURSING THEORIES Theorist 1. Florence Nightingale 2. Virginia Henderson 3. Dorothea Orem Theory Environmental Theory 14 Components Of Basic Nursing Care Self Care Deficit Theory

Florence Nightingales Environmental Theory, Virginia Hendersons 14 Components of Basic Nursing Care and Dorothea Orems Self Care Deficit Theory are the three theories the students have chosen as fundamental guide in providing care of patient X. As decided and observed by the students, these theories have great impact to the patients condition by many ways. First is thru means of manipulating the environment to support the patients healing and recovery. Second, by ensuring that the 14 basic needs (referring to Hendersons Theory) of a person be met by being the substitute for the patient, by being a helper to the patient and by being a partner to the patient with emphasis that by these actions, the patient/person will gain independence of himself as rapidly as possible. And lastly thru help from Dorothea Orems Theory, students will be able to define their roles in maintaining universal requisites of self-care of the patient.

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ENVIRONMENTAL THEORY by Florence Nightingale Florence Nightingale Lady with the Lamp defined nursing as the act of utilizing the patients environment to assist him in his recovery. She states that nurses must focus on changing the environment to place the patient in the best possible condition available. Nightingale have identified twelve environmental canons namely ventilation and warmth, light, cleanliness, health of house, noise, bed and bedding, personal cleanliness, variety, chattering hope and advices, taking food, petty management and observation of the sick. Upon following the nursing process and thought suggested by Nightingale, these are the results gathered and the needed action to be done NIGHTINGALES CANONS NURSING PROCESS AND THOUGHT (BPMC-Female Medical Ward Area) NURSING ACTION PLAN ACTUAL

Ventilation and Warmth

Check

the

patients Body temperature: Since the Female Medical Ward upon our assessment is filled with other 19 in-patients, this number of Room Warm Room Odour: Foul Room Ventilation: Accessible windows Temp: patients with their watchers/family care providers will add to the room congestion thus will affect room temperature, ventilation, and then finally affect the patients body temperature and type of air she is breathing.

body temperature, room 36.0 C temperature, ventilation and foul odours.

Light

Check

room

for Patient is placed in Patient

receives

adequate

light

adequate light. Sunlight bed #3 which is without her being exposed to direct 19 | P a g e

is beneficial to patient.

located at the right sunlight. side of the room. This side allows the patient to witness change of time

(day/night) via the transparent windows open at the porch.

Cleanliness

Keep room free from Since the Medical Student dust, dirt. dampness

nurse

can

focus

on

and Ward is a huge area maintaining or doing basic cleaning for cleaning. at the patients bedside.

Health of House

Remove stagnant

garbage, Patients watcher is Student nurse can remind watcher water, and well informed of and patient of proper waste

ensure clean water and the proper disposal disposal. Accessible windows with fresh air. of waste products screens can be opened to allow air and maintenance of inside the room. health of patients area. The medical ward Remind visitors and student nurses tends to be noisy to maintain a peaceful and quiet Noise Attempt to keep noise level in minimum due to presence of environment to allow patients to rest visitors. and sleep without any interruption. Student nurses are responsible in maintaining that patient is well Bed and Bedding Keep the bed dry, Sheets are available rested in any 20 | P a g e position

wrinkle free.

upon request.

(sitting/supine/etc) by doing bed making and regular linen changing.

Patient provide Personal Cleanliness Attempt to keep the patients skin dry and clean at all times.

must own in Assist patient in doing self-care.

paraphernalias maintaining skin integrity.

good

Variety

Attempt to accomplish Patient may also By encouraging family members to variety in the room and feel well by making engage with patient in stimulating with the client sure her bedside is activities. kept clean and well maintained.

Chattering hopes and advices

Avoid talking advice If without a fact.

patients

have Respect the patient as a person and avoid personal talk.

questions that need to be answered by a superior, then allow the superior to

answer to prevent misinterpretation and miscommunication. Taking Food Check patient. the diet of Food is prepared by Note on the amount of food and BPMC. fluid ingested by patient at every meal. Observation of the Sick Observe anything patient. and about record The nurses notes Continue the allow nurses observation in the

to patients environment and make

record and evaluate changes in the plan of care if the manipulation of needed. environment.

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The nursing diagnosis formulated by the students upon assessing the environment and its effect to the patient are as follows: Disturbed sleep pattern related to noise; lack of sleep privacy; interruptions for therapeutics, monitoring, lab tests; unpleasant odours

14 COMPONENTS OF BASIC NURSING CARE

by Virginia Henderson According to Virginia Henderson, a patient is an individual requiring help toward achieving independence. She states that The unique function of the nurse is to assist individual, sick or well, in the performance of those activities contributing to health or its recovery (or peaceful death) that she would perform unaided if he had the necessary strength, will, or knowledge and to do this in such a way to help him gain independence as rapidly as possible. (Balita, Octavio. 2008) Henderson conceptualized 14 Fundamental Needs of humans and herewith are the needs we have observed to our patient: 1. Breathing normally: patient has DOB due to presence of pleural effusion Patient must be given O2 as per doctors order and must be placed in a semi fowlers or sitting position. 2. Eating and drinking adequately 3. Eliminating body wastes Patient must be given laxatives as per doctors order. And must be encouraged to increase fiber intake. 4. Moving and maintaining a desirable position: Patient is unable to move due to recent stroke. Patient is assisted in changing positions and doing activities of daily living. 5. Sleeping and resting: Patient cannot sleep well due to environmental factors and physiologic factors such as difficulty in breathing.

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Provide strategies that can deviate patients thoughts from the environmental stressors surrounding her. 6. Selecting suitable clothes 7. Maintaining normal body temperature by adjusting clothing and modifying the environment 8. Keeping the body clean and well groomed to promote integument (skin): Patient is unable to move due to recent stroke. Patient is assisted in changing positions and doing activities of daily living 9. Avoiding dangers in the environment and avoiding injuring others: By making sure bedrails are up and teaching patient of situations that are risky for her to acquire injuries Use of bedrails, assistive device and health teaching 10. Communicating with others in expressing emotions, needs, fears or opinions: Patient uses native/binukid language and a little of vernacular thus she is more comfortable of sharing her thoughts to her husband. Allow the husband to the secondary/ follow-up speaker so that patient may understand the student nurse and vice versa. 11. Worshipping according to ones faith 12. Working in such a way that one feels a sense of accomplishment: Patient cannot feel sense of accomplishment due to impaired mobility. Encourage and praise patient of her little improvements to allow sense of accomplishment. 13. Playing or participating in various forms of recreation: Patient remains rested at bed but is well entertained and cared for by family members. One way of providing recreation is by conversing to the patient, this allows her to express her thoughts and emotions. 14. Learning, rediscovering or satisfying the curiosity that leads to normal development and health: Patient is not observed to be curious of health development but significant others are. 23 | P a g e

Explain to the patient the procedures, nursing intervention, medication and health teachings she must know for her to gain knowledge regarding her health thus she will be aware of her condition and may feel determined to improve herself.

Henderson also emphasized the need to view the patient and her family as one unit since in order for patient to achieve health. The patient must be able to meet her need for support system (emotional needs) as provided by the family. The nursing diagnoses formulated by the students upon assessing the patient are as follows: 1. Ineffective Breathing Pattern related to Decreased Lung Volume Capacity as evidenced by tachypnea, presence of crackles on both lung fields and dyspnea 2. Impaired Gas Exchange related to Alveolar Capillary Membrane Changes 3. Disturbed Body Image related to Insertion of Chest Thoracostomy Tube 4. Self-Care Deficit related to musculoskeletal impairment secondary to CVA 5. Knowledge Deficit related to unfamiliarity with information resources, cognitive limitation, information misinterpretation, lack of recall 6. Risk for Impaired Swallowing related to neuromuscular/perceptual impairment 7. Self-Care Deficit related to neuromuscular impairment, decreased strength and endurance, loss of muscle control/coordination

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SELF CARE DEFICIT THEORY by Dorothea Orem

Dorothea Elizabeth Orem emphasized that nursing is helping clients to establish or identify ways to perform self-care activities and that nursing actions are geared towards the independence of the client. If the patient is highly dependent, there is a need for the nurse to assist and address the needs of the client. (Balita, Octavio. 2008). In addition, Orem defined self-care as an activity that promotes a persons well-being. Concerning our patient, she is unable to provide self-care due to her present condition and her recent case of infarction (as diagnosed by her last physician from Bethel Baptist Hospital last June 2013) of which she cannot move her right peripherals. It is another nursing task to assist in providing self-care to the partially unable patient.

There are eight universal self-care requisites according to Orem and these are the following:

UNIVERSAL SELF CARE REQUISITES Maintenance of a sufficient intake of air

NURSING STUDENT ACTION Patient must be given O2 as per doctors order and must be placed in a semi fowlers or sitting position. Allow proper ventilation inside the room

Maintenance of sufficient intake of food

Allow patient to use left hand when eating, drinking. Praise patient whenever she does independent activities even if its the basic to make her feel good about herself and to prevent self-pity.

Teach patient on good nutrition Maintenance of sufficient intake of water Allow patient to use left hand when drinking, instruct and remind constantly to take in small amount of fluid to prevent aspiration 25 | P a g e

Provision of care associated with elimination

Offer bedpan and clean patient afterwards. Also allow patient to use left hand when necessary.

Maintenance of balance between activity and rest

Since patient has hemiplegia, her activity is limited. Offer stimulating conversations, activities that do not need too much physical effort.

In terms of exercise, she can perform passive ROM at left peripherals, deep breathing exercise Maintenance of balance between solitude and social interaction Maintain balance between solitude and social interaction. Converse with patient together with her husband about how she feels. Allow her to express herself. Pts husband reports that patient is feeling kagu-ol regarding her present condition and worries about her children through they are already mature adults.

Remind family to show emotional support by showing appreciation and value towards their mother. Prevention of hazards to human life, human functioning and human well-being Since patient is hemiplegic, PREVENTION of any complication, illness, injury is very important. Always provide safety measures to patient such as raising bed rails, providing physical assistance upon walking, turning to side, and sitting. Assist in self-care activities. Promotion of human functioning and development According to Erik Erikson, during ages 40 to 65 (Generativity vs Stagnation/ Middle adulthood Stage) adults need to create or nurture things that will outlast them, often by having children 26 | P a g e

or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world.

It is important to remind the family of the importance of making their mother feel the essence of being productive/accomplished

CONCLUSION: All the nursing theories cited are fundamental guides for student nursing upon providing care/interventions to patient X. These theories will help in identifying the patients problem, and alleviate or address the patients problem. Above all, these theories are aimed at promoting patients well-being.

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ASSESSMENT
DIGESTIVE/METABOLIC SYSTEM SUBJECTIVE TULO NA SIYA KA ADLAW WALA KALIBANG MAAM, AS VERBALIZED BY PATIENTS HUSBAND IKA TULO SIYA MOKAON PERO GAMAY RA IYANG GA KAN-ON , AS VERBALIZED BY PATIENTS HUSBAND GA INOM SIYA UG TUBIG (1 BASO) KADA HUMAN UG KAON UG GA GATAS OG KAPE SIYA SA HAPON , AS VERBALIZED BY PATIENTS HUSBAND OBJECTIVE APATHETIC DRY, WARM SKIN SUNKEN EYEBALLS MOIST TONGUE NO OF TEETH: 28 T:37C P: 80 BPM R: 30 CPM BP: 100/80 MESOMORPH LOSS OF APPETITE WEIGHT 55 KG BMI: 22

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RESPIRATORY SYSTEM SUBJECTIVE DILI KO KAGINHAWA OG TARONG SAUNA MAAM. PERO ADTONG GI BUTANGAN UG TUBO NI ARANGARANG AKONG GINHAWA AS VERBALIZED BY THE PATIENT BISAG MUHIGDA O MOLINGKOD DI MAN GUHAPON SIYA MAKA GINHAWA UG MAAYO, NIINGON MAN SIYA SA AKOA ADTONG NAA PAMI SA BALAY AS VERBALIZED BY THE PATIENTS HUSBAND OBJECTIVE FINE CRACLES AT RIGHT LUNG FIELD HYPORESONANCE AT RIGHT LUNG FIELD USE OF ACCESSORY MUSCLE DYPNEA RR-30CPM CTT ATTACHED TO RIGHT MIDAXILLARY RESGION DRAINING TO WATER SEALED BOTTLE DECREASED TACTILE FREMITUS DIAGNOSTIC TEST Multiple axial tomographic secretions of the chest with and without contrast were obtained revealing the following: There is 23 x 8.8 x 13.8 cms (1396.60 cc) thick walled loculated pleural effusion which is slightly hyperdense in the right hemithorax There is volume loss of the right lung with no definite mass lesion seen and very minimal aerated lung at the upper lobe There is minimal reticular and haze densities at the upper lobe There is shift of mediastinal structure to left The heart is not enlarged but there is minimal pericardial effuse Aorta is normal in calibre with minimal calcification along the walls No enlarged lymph nodes seen There is minimal thoracic spondylosis There is chest tube in place in the right side with tip at the medial aspect, level of T8-9

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CARDIOVASCULAR/ CIRCULATORY SYSTEM SUBJECTIVE NABAL-AN NGAHIGHBLOOD SIYA MAM NIADTONG PAG ADTO NAMO SA MALAYBALY POLYMEDIC GENERAL HOPITAL GI-ADMIT PUD SIYA SA BETHEL (DIAGNOSED WITH CVD, HCVD AND CVA WITH RIGHT RESIDUAL WEAKNESS) AY SAUNA MAHILIG NI SIYA UG KUBI-KUBI PERO KARUN DILI NAGYUD NIYA MAKAYA. KUN MAG CR SIYA, UBANAN GYUD SIYA, AS VERBALIZED BY PATIENTS HUSBAND AKO NAMAN ANG GA PLASTAR SAIYA MAAM. KUN MOHIGDA SIYA O MO LINGCOD BA KAHA, AKO SIYANG ALALAYAN, AS VERBALIZED BY PATIENTS HUSBAND OBJECTIVE TEMPERATURE OF 37 C BLOOD PRESSURE: 100/80 REGULAR APICAL PULSE WITH A RATE OF 84 BEATS PER MINUTE REGULAR, STRONG RADIAL PULSE WITH THE RATES OF R: 84 L: 84 WEAK DORSALIS PEDIS WEAK POSTERIOR TIBIA REGULAR HEART RHYTHM: 80 BEATS PER MINUTE PALE NAIL BEDS BIPEDAL +2 PITTING EDEMA INABILITY TO PERFORM BASIC ROM AT RIGHT PERIPHERALS DIAPHORESIS WEIGHT 55KG

INTEGUMENTARY SYSTEM SUBJECTIVE GI TAORAN SIYA UG TUBO DIRI MAAM, AS VERBALIZED BY PATIENTS HUSBAND KATONG PAG TAOD AND COLOR NGA AKONG NAMATIKDAN KAY PULA, AS VERBALIZED BY HUSBAND OBJECTIVE DRY, WARM SKIN POOR SKIN TURGOR BIPEDAL +2 PITTING EDEMA TEMPERATURE OF 37 C NORMAL HAIR DISTRIBUTION DIRTY, UNTRIMMED NAILS PALE NAIL BEDS

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ELIMINATION SUBJECTIVE TULO NA SIYA KA ADLAW WALA KALIBANG MAAM, AS VERBALIZED BY PATIENTS HUSBAND IKA TULO SIYA MOKAON PERO GAMAY RA IYANG GA KAN-ON , AS VERBALIZED BY PATIENTS HUSBAND GA INOM SIYA UG TUBIG (1 BASO) KADA HUMAN UG KAON UG GA GATAS OG KAPE SIYA SA HAPON , AS VERBALIZED BY PATIENTS HUSBAND GA TAGAAN SIYA UG TAMBAL (SUPPOSITORY) PARA MAKALIBANG SIYA , AS VERBALIZED BY PATIENTS HUSBAND SIGE SIYA UG PANINGOT KARUN , AS VERBALIZED BY PATIENTS HUSBAND OBJECTIVE WITH ASSISTANCE INTAKE AND OUTPUT DATE INTAKE OUTPUT July 10, 2013 315 cc 230 cc July 11, 2013 390 cc 320 cc July 12, 2013 630 cc 300 cc BIPEDAL +2 PITTING EDEMA DARK YELLOW, CLOUDY URINE TEMPERATURE OF 37 C

MUSCULOSKELETAL SYSTEM SUBJECTIVE GAKAPOYAN KO UG LIHOK DALI RA KO SINGTON AS VERBALIZED BY THE PATIENT OBJECTIVE AVERAGE WEAKNESS OBSERVED LIMITED RANGE OF MOTION AT RIGHT PERIPHERALS DIAPHORESIS PREVIOUS DIAGNOSIS FROM BBH S/P OR CEREBRAL VASCULAR ACCIDENT INFARCT WITH RIGHT SIDED RESIDUAL WEAKNESS

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COGNITIVE AND PERCEPTUAL/ NEUROLOGIC SUBJECTIVE NABAL-AN NGAHIGHBLOOD SIYA MAM NIADTONG PAG ADTO NAMO SA MALAYBALY POLYMEDIC GENERAL HOPITAL GI-ADMIT PUD SIYA SA BETHEL (DIAGNOSED WITH CVD, HCVD AND CVA WITH RIGHT RESIDUAL WEAKNESS) NOTE: PATIENT COMMUNICATES WITH US VIA HIS HUSBAND SINCE SHE IS COMFORTABLE IN SPEAKING BINUKID. PATIENT ALSO USES CUES SUCH AS NODDING UP AND DOWN OR LEFT AND RIGHT UPON ANSWERING OUR QUESTIONS OBJECTIVE RESPONSIVE (VIA USE OF CUES) DECREASED SENSATION AT RIGHT PERIPHERALS PUPILLARY SIZE: PERRLA OREINTED TO PERSON, PLACE, TIME/DATE AND PAIN T:37C P: 80 BPM R: 30 CPM BP: 100/80 POSITIVE LEFT PATELLA, BICEPS, TRICEPS, ACHILLES REFLEXES NEGATIVE RIGHT PATELLA, BICEPS, TRICEPS, ACHILLES REFLEXES AGE: 57

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IV. NURSING CARE PLANS

NCP #1 DATA NURSING DX OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATI ON SHORT TERM: This can decrease extracellular fluid retention To reduce tissue pressure and risk of skin breakdown Pulmonary fluid sh ifts potentiate respi ratory complications Limited cardiac res erves result in fatig ue/activity intolerance. In addition, lying down favors diuresis and reduction of After nursing intervention patient was able to verbalize understanding of individual dietary restrictions

SUBJECTIVE CUES: EXCESS FLUID VOLUME RELATED TO EXCESSIVE SODIUM INTAKE

SHORT TERM: After 30 minutes patient will be able to verbalize understanding of individual dietary restrictions

INDEPENDENT: Review dietary restrictions and safe substitutes for salt

Kasagara namo nga ga kan-on kay bulad ug ginamos, as verbalized by patients husband

Elevate edematous extremities, change position frequently Encourage coughing/deepbreathing exercises.

OBJECTIVE CUES: Bipedal edema +2 RR-30cpm Crackles at right lung upon auscultation dyspnea right pleural

LONG TERM: After 3 days of nursing intervention

Encourage bedrest. Schedule care to provide frequent rest periods.

LONG TERM: After giving nursing intervention 33 | P a g e

effusion as evidenced by an ultrasound pallor poor skin turgor

patient will be able to stabilize fluid volume as evidenced by vital signs within clients normal limits and reduced signs of edema

edema. Provide safety precautions as indicated, e.g., use of siderails, bed in low position, frequent observation, softrestr aints (if required) Fluid shifts may ca use cerebral edema or changes in mentation, especially in the geriatric population To facilitate movement of diaphragm, thus improving respiratory effort

Place in semi-Fowlers position, as appropriate

patient was able to stabilize fluid volume as evidenced by vital signs within client;s normal limits and reduced signs of edema

DEPENDENT: Consult dietitian, as needed

To address ongoing nutrition concerns or dietary needs Extracellular fluid shifts, sodium restriction affect serum sodium levels.

Monitor laboratory studies as indicated, e.g., electrolytes, BUN. ABGs

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NCP #2 DATA NURSING DX OBJECTIVES NURSING INTERVENTIONS INDEPENDENT: RATIONALE EVALUATION

SUBJECTIVE CUES: Galisod ko ug ginhawa maam, as verbalized by the patient INEFFECTIVE BREATHING PATTERN RELATED TO DECREASED LUNG VOLUME CAPACITY AS EVIDENCE BY TACHYPNEA AND PRESENCE OF CRACLES ON THE RIGHT SIDE OF THE LUNG FIELDS

SHORT TERM: After 30 minutes of nursing intervention, patient will reveal no abnormal breath sounds upon auscultation; patient will demonstrate adequate breathing pattern, with easy, unlabored respirations; Patient will demonstrate correct technique in pursed-lip breathing,

SHORT TERM:

Provide relaxing environment

To promote adequate rest periods and to limit fatigue To promote lung expansion

OBJECTIVE CUES: Tachypnea Presence of crackles at right lung field upon auscultation Use of accessory muscle RR-30cpm Orthopnea Diaphoresis Dypnea Restlessness Decreased Tactile fremitus Dull resonance

Elevate patient head

The patient shall have demonstrated appropriate coping behaviors and method to improve breathing pattern

Assist patient in the use of relaxation techniques Force Fluids

To maximize oxygen available for cellular uptake

LONG TERM : The patient shall have applied techniques that improved breathing pattern and be free from signs and symptom of 35 | P a g e

To liquefy secretions These activities allow patient participate in maintatinng health status and ventilation

Teach patient on pursed-lip breathing, abdominal breathing and

abdominal breathing and relaxation techniques.

relaxation techniques DEPENDENT: Give oxygen as prescribed

Supplemention of oxygen helps to improve breathing pattern and relieve respiratory distress To remove excess fluid from pleural space

respiratory AEB respiratory rate within normal range absence of cyanosis, effective breathing and minimal used of accessory muscles during breathing

Chest thoracostomy tube

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NCP #3

DATA

NURSING DX

OBJECTIVES SHORT TERM:

NURSING INTERVENTIONS INDEPENDENT Stress and model proper hand washing techniques to client and caregiver

RATIONALE

EVALUATION SHORT TERM:

SUBJECTIVE CUES: Risk for infection related to surgical procedure as evidenced by presence of right midaxillary chest thoracostomy tube

OBJECTIVE CUES: Presence of chest thoracostomy tube at the right midaxilliary area Open environment Over crowded area

After 30minutes of nursing intervention the patient will be able to identify behaviour and practice to prevent and reduce the risk for infection

Maintain aseptic technique with any procedures. Provide routine site care and wound care as appropriate

LONG TERM: After 3 days of giving nursing intervention the client will achieved timely wound healing free of signs Inspect dressing not characterized by drainage

Reduce cross contaminati on and bacterial colonizatio n Prevent entre of bacteria reducing risk nosocomial infection

The patient shall identify behaviour and practice in preventing infection

Early detection of developing infection

LONG TERM : The patent shall achieve wound

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of infection and inflammation purulent drainage and fever Encourage frequent position changes and being out of bed or early ambulation as tolerated

Monitor vital signs

DEPENDENT: Administer antibiotics as indicated

Ceftriaxone 1 mg/q8/IVTT

provides opportunity for timely intervention and prevention and more serious complicatio n Limit stasis of body fluids promotes optimal functional organ system and gastrointest inal tract To have base line data specially increase temperature Wide

healing and free from infection and inflammation

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spectrum antibiotics may be used prohylactic ally or antibiotic therapy may be geared toward specific organism

In inhibits the cell wall synthesis causing cell death

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NCP #4

DATA

NURSING DX

OBJECTIVES

NURSING INTERVENTIONS INDEPENDENT Anterior posterior auscultated and chest

RATIONALE

EVALUATION

SUBJECTIVE CUES: luya jud siya as verbalized by the significant others OBJECTIVE CUES: Slight weakness Crackles at the right lung field upon auscultation Tachypnea RR: 30 cpm Dyspnea Used if accessory muscle Pallor

Ineffective airway clearance related to weakness and poor cough effort.

SHORT TERM GOAL: At the end of 4 hours in giving nursing intervention patients lung sounds will be clear to auscultate; Patient will be free of dyspnea; Patient will demonstrate correct coughing and deep breathing techniques LONGTERM GOAL: At the end of 1 day of giving nursing intervention patient

To determine the decrease or absence of ventilation and the presence of sound barriers. To reduce the viscosity of secretions. To avoid worsening patients condition.

Maintain adequate hydration. Inform patients and families that smoking is an activity that is prohibited in the treatment room. Instruct patients about cough and deep breathing techniques. Encourage

To facilitate the release of secretion.

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will maintain a patent airway

physical activity If the patient is unable to perform ambulation, the location of the patient sleeping position changed every 2 hours. Inform patients before starting the procedure. Encourage to take a deep breath hold for two second, and cough two or three times in succession.

To improve the movement of secretions. To avoid pneumonia and pressure ulcers.

To reduce anxiety and increase self-control.

Controlled couching is accomplished by closure of the glottis and the explosive expulsion of air from the lungs by the work by the abdominal and chest muscle. Promotes better lung expansion and improved gas exchange. Early supplemental
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Elevate the head of the patient in semi high fowlers position.

DEPENDENT

Administer supplemental oxygen.

oxygen is essential since early mortality is associated with inadequate delivery of oxygenated blood to the brain and vital organs

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NCP #5

DATA

NURSING DX

OBJECTIVES

NURSING INTERVENTIONS Perform comfort measures to promote relaxation such as repositioning and relaxation techniques. Provide patient with information to help increase pain tolerance; for example reasons for pain and length of time it will last

RATIONALE

EVALUATION

SUBJECTIVE CUES: Ang sakit ra man gyud na iyang gibati kay dapit sa gibutangan ug tubo, dili kayo siya maglihok-lihok as verbalized by the significant others Patient verbalized pain scale of 6 out of 10. OBJECTIVE CUES: Facial grimace Guarded behaviour on the CTT site Tachypnea RR: 30 cpm Dyspnea

ACUTE PAIN RELATED TO PLACEMENT OF CHEST THORACOSTOMY TUBE

SHORT TERM:

After 3 hours of nursing intervention the patient will be able to report a decrease of pain.

These measures reduce muscle tension or spasm, and help patient focus on non-pain related subjects

SHORT TERM:

The patient shall have reported pain is relieved from a pain scale of 6/10 to 3/10

LONG TERM: After 2 days of nursing interventions the patient will be free from pain and demonstrate relaxational skills.

This educates patient and encourages compliance in trying alternative pain relief measures LONG TERM :

Manipulate the environment to promote periods of

This promotes health, well-being, and increased

The patient shall be free from pain as evidenced by demonstration of relaxation skills 43 | P a g e

Use of accessory muscle Pallor Loss of appetite

uninterrupted rest

energy level important to pain relief. Deep breathing exercises contribute to relief of pain

and diversional activities with the help of the SO.

Encourage and assist client to do deep breathing exercises Encourage verbalization and feelings of pain

Only the client can judge the level and degree of pain; pain management should be a team approach that includes the client

DEPENDENT: Administer medications, particularly analgesics, as prescribed (e.g Tramadol+PCM (P-dol) 1 tab TID PO) To relieve pain

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VII. DISCHARGE PLANS

Instruct patient to comply on the following medication regimen:

1. Moriamin Forte 1 cap twice a day for vitamins and minerals Medications: supplementation which is essential to the body. 2. Tramadol + Paracetamol to relieve pain discomfort. 3. Bisacodyl suppository per rectum to relieve constipation and stimulate bowel movement. 4. Acetylcystein (Mucomyst) 30mg to liquefy or dissolve mucus so that it maybe coughed up easily. 5. Multivitamins + Iron 1 tab at once daily to supplement vitamin and mineral deficiency and iron to aid in the formation of haemoglobin. Take medications on time.

Instruct patient to perform deep breathing exercise to help strengthen the lungs, build lung capacity and prevent further accumulation of fluid between the pleural cavities.

Exercise:

Advice patient to perform simple coughing exercise to allow chest wall contraction and may help prevent excess fluid from accumulating and help prevent condition such as pneumonia. To decrease pain when coughing, hold a pillow over the chest where the pain is located and take pain medications as directed.

Perform passive active exercise (e.g. bending, and moving) to help joints and muscle become stable. It keeps the joint areas flexible. Exercise also helps calf pump which promotes venous return and thus presents further formation of edema. Without these exercises, blood flow and flexibility of the joints can decrease. 45 | P a g e

 Treatment:

Position the patient to high fowlers position or elevate the head of patient to promote optimal lung expansion. Provide relaxing environment to promote adequate rest periods and to limit fatigue. Frequent position changes every two hours to prevent pressure ulcers. Maximize respiratory effort with good posture and effective use of accessory muscle to promote wellness. Stop smoking or avoid second hand smoke, because it can exacerbate the condition.

Outpatient (Check-up):

Instruct patient to return to the hospital 1 week after discharge or as set by the doctor for updates of the patients condition. Or when the following situations occur: Accidental expulsion of Chest tube thoracostomy or Inability to breathe

Instruct patient if fever, increasing trouble breathing or rapid breathing, coughing up blood, and worsening or continued chest pain occur, she must seek medical attention immediately.

Limit foods rich in sodium (e.g. dried fish, junk foods, etc.). Because it can exacerbate the condition and it retains fluid on the

Diet:

body adding more complication to the patient. Eat a healthy diet (e.g. fruits, vegetables, and protein like meat); good nutrition can help body fight illness and protein helps in oncotic pressure/absorption mechanism of fluid. Drink plenty of fluids at least 8 glasses per day or more within patients tolerance to keep the air passage moist and better able to get rid of germs and other irritants, and liquefy secretions.

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BIBLIOGRAPHY

BOOKS/EBOOKS Balita, Octaviano (2008). Theoretical Foundations of Nursing: The Philippine Perspective. Ultimate Learning Service

Black, J., Hawk, J. (2008). Medical Surgical Nursing: Clinical Management for Positive Outcomes, 8th Ed. Management of Clients with Digestive Disorders. Singapore: Elsevier Pte Ltd.
Bouros, D., (2004). Pleural Disease. Boca Raton, FL: CRC Press Khan, Daw (2011). Do the right thing:how to judge a good ward: ten standards for adult inpatientmental healthcare. London King, C., & Henretig F. (2008). Textbook of Pediatric Emergency Procedures. Baltimore, MD: Lippincott Williams & Wilkins Kollef, M., & Isakow, W. (2012). The Washington Manual of Critical Care. Baltimore, MD: Lippincott Williams & Wilkins Rinzler, C. A., (2011). Nutrition for Dummies (5th edition). Hoboken, NJ: Wiley Publishing, Inc. Slatter, D. (2003). Textbook of Small Animal Surgery. Philadelphia, PA: Elsevier Health Sciences.

INTERNET Ambekar, A. (2008). Hypertensive Cardiovascular Disease. Jellons. Retrieved from http://www.articleswave.com/articles/hypertensive-cardiovascular-disease.html American Thoracic Society. (2013). Chest Tube Thoracostomy. American Thoracic Society. Retrieved fromhttp://www.thoracic.org/clinical/critical-care/patient-information/icu-devicesand-procedures/chest-tube-thoracostomy.php 47 | P a g e

ArcMesa Educators. (2013). Neurological System. Nursing Link. Retrieved from http://nursinglink.monster.com/training/articles/240-physical-assessment---chapter-8neurological-system Enchanted Learning. (2010). Human Digestive System. Retrieved from http://www.enchantedlearning.com/subjects/anatomy/digestive/ Mitrouska I, Klimathianaki M, Siafakas NM. (2004). Effects of pleural effusion on respiratory function. National Center for Biotechnology Information. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15505703. Storm, J. (2011). Loss of Appetite It's No Good. The Nations Health. Retrieved from http://nation-health.blogspot.com/2011/05/reasons-of-loss-of-appetite.html The Cleveland Clinic Foundation. (2009). Normal Structure and Function of the Musculoskeletal System. Cleveland Clinic. Retrieved from http://my.clevelandclinic.org/anatomy/musculoskeletal_system/hic_normal_structure_and_functi on_of_the_musculoskeletal_system.aspx Waldstein, S. (2001). The Relation of Hypertension to Cognitive Function. Psychological Science. Retrieved from http://www.psychologicalscience.org/journals/cd/12_1/Waldstein.cfm Wikipedia (2013). Retrieved from http://en.wikipedia.org/wiki/Integumentary_system

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CONSENT FORM

Access to Health Information for Presentation and/or Publication

I, . , hereby consent to allow Dioneflor Artana, Lyra Dain Lorca, Maria Vanessa Ronolo, Lucky Charm Rosos, and Marvin Telin from Bukidnon State University College of Nursing to review my health information for the purpose of presenting my deidentified information at a research conference and/or to publish as a case report in a scientific journal. I understand that my name will not be associated in any way with the information presented or published. Any information that is obtained that can identify me will remain confidential and will be disclosed only with my permission or as required by law.

If I have any questions about the above, I can contact: Lyra Dain Lorca at 09357400***.
I have read the information above. I have been given the opportunity to discuss it. All of my questions have been answered to my satisfaction. This signature on this consent form means that I agree to allow access to my personal health information for the purposes of presentation and publication.

__________________________ Signature of Patient __________________________ Signature of Patients

Authorized Legal Representative

______________ Name (Printed) ______________ Name (Printed)

_____ / ______ / _____

Year Month

Day

_____ / ______ / _____

Year Month

Day

__________________________ Witness to Patients Signature

______________ Name (Printed)

_____ / ______ / _____

Year Month

Day

I will be given a signed copy of this consent form

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NCM 103 RLE GROUP 1

DIONEFLOR P. ARTANA BSN III, Student Nurse

LUCKY CHARM D. ROSOS BSN III, Student Nurse

MARVIN C. TELIN BSN III, Student Nurse

LYRA DAIN O. LORCA BSN III, Student Nurse

MA. VANESSA RONOLO BSN III, Student Nurse

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