DE LA SALLE HEALTH SCIENCES INSTITUTE

COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY

LEVEL III
NURSING CARE PLAN

1. Client’s Name 13. Usual Source :

2. Gender (Sex) of Medical
3. Age Care
4. Birth date
5. Birthplace A.D.T
6. Civil Status : Female
: 46 y.o
7. Race and : March 14, 1964
Nationality : (-)
: Married
8. Religion : Filipino
9. Address :
10. Telephone Christian
Number : Silang, Cavite
11. Educational : (-)
Background :
12. Occupation College Graduate
:
Physician
: Hospital

I. CHIEF COMPLAINT / OTHER COMPLAINTS:

“Continuous dry cough”

II. NURSING HISTORY

Patient A.D.T was admitted to the OR room last May 21, 2010 to
undergo an operation of Thymectomy. She is a 46 year old, female,
married, Filipino, physician. The operation was due to her CT scan results
that showed mass on her pericardial cavity. Since she is a doctor by
profession, thus the operation was pursued as planned.
According to the patient’s chart as the most reliable source of
information, patient had been having complaints of dry cough and sleep
disturbances 3 mos. ago but never sought consultation. She did not find it
remarkable. Then 2 mos. after the first complaints occurred, she then had
series of persistent productive cough of yellowish phleghm and increase to
the intensity and frequency of the cough. She then also felt pain on the left
side of her chest. 1 mos. after having previous complaints did patient seek
consultation. She had then a chest x-ray which showed results of Left
Hilar fullness. She was then prescribed by her fellow physician with
Levofloxacin. 23 days after consultation, previous complaints pursued and
she underwent a repeat chest x-ray. The next day to fully complete
diagnosis she underwent Chest CT scan. 4 days after undergoing CT
scan, patient still had previous complaints. Then 6 days before being
admitted, she had a 12 lead ECG which showed sinus rhythm, normal
axis, and introventricular delay, she was then prescribed to have
 medication of Clarithromycin. and soon she was then admitted to
DLSUMC for a scheduled operation of Thymectomy.
According to patient’s past medical history, in the year 2000, patient
underwent ESWL for having Uterolithiasis. During her college days, she
had Hepatitis A. Her Obstetric history showed G1P1 by LTCS.

III. PATHOPHYSIOLOGY AND EVENTS

Factor: Infection Assoc. syndromes:

UNKNOWN • Neuromyotonia
• LEMS
• Red cell aplasia
• Dermatomyositis
• SLE
cross-immunity of
• Cushing
antigens syndrome
• SIDHS
• Myasthenia
Gravis

Autoimmunity

Formation of mass CBC, Quantitative

vague chest pain, immunoglobulins (Igs),
cough, dyspnea, stridor, Chest radiography, Chest,
hemoptysis, dysphagia, CT scanning or MRI, Fine-
pleural effusion, needle aspiration
paraplegia, Compression or
diaphragmatic paralysis, obstruction of portions
of the airway

Thymoma is a neoplasm of thymic epithelial cells. This definition

excludes other tumors that may affect the thymus, such as lymphoma and
germ cell tumors. Although rare, thymoma is the most common tumor of
the anterior superior mediastinum. The term lymphoepithelioma has been
used in cases in which the thymoma contains a large number of lymphoid
cells
The thymus is a lymphoid organ located in the anterior
mediastinum. In early life, the thymus is responsible for the development
and maturation of cell-mediated immunological functions. The thymus is
composed predominantly of epithelial cells and lymphocytes. Precursor
cells migrate to the thymus and differentiate into lymphocytes. Most of
these lymphocytes are destroyed, with the remainder of these cells
migrating to tissues to become T lymphocytes. The thymus gland is
located behind the sternum in front of the great vessels; it reaches its
maximum weight at puberty and undergoes involution thereafter.
Peak incidence of thymoma occurs in the fourth to fifth decade of
life; mean age of patients is 52 years. No sexual predilection exists.
Although development of a thymoma in childhood is rare, children are
more likely than adults to have symptoms. Several explanations for the
prevalence of symptoms in children have been proposed, including the
following: (1) children are more likely to have malignancy, (2) lesions are
more likely to cause symptoms by compression or invasion in the smaller
thoracic cavity of a child, and (3) the most common location for
mediastinal tumors in children is near the trachea, resulting in respiratory
symptoms.
Patients with thymoma may experience dysregulation of the
lymphocyte negative and positive selection process leading to abnormal
proliferation, autoimmunity, and/or immunodeficiency. Autoimmunity also
may be caused by cross-immunity of antigens in other tissues with
thymoma-associated antigens.Seventy percent of thymomas are
associated with paraneoplastic syndromes such as myasthenia gravis
(MG), red cell aplasia, pemphigus, and immunoglobulin (Ig) deficiency.
Compression or obstruction of portions of the airway, the
esophagus, or the right heart and great veins by an enlarging tumor or
cyst easily can occur and can result in a number of symptoms. Infection
can occur primarily within some of these mediastinal lesions, particularly
those of a cystic nature, or can result secondarily in nearby structures (eg,
lungs) as a result of local compression or obstruction.
Malignant mediastinal tumors can cause all of the same local
effects as those associated with benign lesions, but they also can produce
abnormalities by invasion of local structures. Local structures most
commonly subject to invasion by malignant tumors include the
tracheobronchial tree and lungs, esophagus, superior vena cava, pleura,
and chest wall, as well as any adjacent intrathoracic nerves.
Pathophysiologic changes that can be produced by invasion of specific
structures are obstructive pneumonia and hemoptysis, dysphagia,
superior vena cava syndrome, and pleural effusion, as well as various
neurologic abnormalities such as vocal cord paralysis, Horner syndrome,
paraplegia, diaphragmatic paralysis, and pain in the distribution of specific
sensory nerves.
Symptoms associated with compression of some portion of the
respiratory tract can be produced in adults by benign lesions as well, but
this occurs much less frequently than in children. However, malignant
lesions are more likely to produce signs and symptoms of obstruction
and/or compression because they invade or transfix normal mediastinal
structures.
Clinical findings commonly associated with malignancy include
cough, dyspnea, stridor, and dysphagia, as well as more dramatic findings
such as superior vena cava syndrome. Invasion of the chest wall or pleura
by a malignant neoplasm can produce persistent pleural effusions and a
significant amount of local pain. Invasion of nearby nerves within the
thorax also can produce local and referred pain, as well as various other
findings such as hoarseness from recurrent nerve involvement,
diaphragmatic paralysis from phrenic nerve involvement, Horner
syndrome from autonomic nerve invasion, and even motor paralysis from
direct spinal cord involvement. Pain in the shoulder or upper extremity can
occur from invasion of the ipsilateral brachial plexus. Invasion or extrinsic
compression of the superior vena cava can produce superior vena cava
syndrome.

IV. LABORATORY/ DIAGNOSTIC RESULT, INTERPRETATION AND

NURSING IMPLICATION
Procedure / Date Indication Normal Results/ Analysis Nursing
Results Implication
Hematology A test that Hgb: 123 – Hgb: 145 Pre:
gives 153 g/l  Inform the
May 16, 2010 information Hct: 0.36 – Hct: 0.46 client about
about the cells 0.45 the procedure
in a patient's WBC: 5 – 10 WBC: 9.1  Obtain an
blood. ^9/L informed
Segmenters: Segmenters: 0.64 consent
0.36 –  Prepare
0.66 necessary
Lymphocytes: Lymphocytes: materials
0.22 – 0.22 Intra:
0.40  Clean the site
Eosinophil: Eosinophils: 0.12 with wet
Monocytes: Monocytes: 0.01 cotton balls
 Inject the
syringe and
pull the
amount of
blood needed.
 While
removing the
syringe,
position a dry
cotton ball
and then put it
with pressure
after the
syringe has
been
removed.
Post:
 Bring the
specimen to
the lab
immediately
 Document
after the
results are
released
 Inform patient
and AP
LIPID PROFILE help Cholesterol: Cholesterol: 4.10 Pre:
TEST determine 5.2 mmol/l  Inform the
your risk of Triglycerides Triglycerides: 0.92 client about
May 16, 2010 heart disease : 1.7 mmol/l the procedure
HDL: 1.0 HDL: 1.20  Obtain an
mmol/l informed
 V. MEDICATIONS AND SURGERY

BN/GN Dosage/ Indication/ CI S/E and A/R Nursing

Frequency/ Responsibilities
Route
Versed/ 15 mg/ tab Preprocedural Apnea, headache,  Follow the 10
midazolam @8:30 pre sedation and drwosiness, R’s of proper
op balances bronchospasm, N/V medication
PO anesthesia and respiratory  Assessed
depression LOC prior to
administratio
n
 Monitired BP,
PR and RR
 Oxygen and
resuscitative
equipment
should be
readily
available
 Do not
overdose
Rocephin/ 2gm ANST Perioperative Diarrhea, N/V,  Follow the 10
ceftriaxon (-) prophylaxis rashes, anaphylaxis, R’s of proper
e 1 hr prior to pseudomembranous medication
OR colitis  Assessed for
IV infection
 Obtained
history of
previous use
of antibiotics
 Observed for
signs and
symptoms of
anaphylaxis
 Administered
around the
clock

Thymectomy
A thymectomy is an operation to remove the thymus. It
usually results in remission of myasthenia gravis with the help of
medication including steroids. However, this remission may not be
permanent.
As patient. ADT, arrived at the operating room, she was
already half asleep, when she was inducted with, spinal-GA
anesthesia. Soon then skin preparation was done and IFC was
inserted. All done aspetically. A thyroidectomy set and basic major
set with additionals, such as bone cutter, bone retractor, bone
curette, perioschner, mallet. Also additional, de bakeys, bobcocks,
mixter and needle holders were added and prepared. As soon as
all three surgeons have gowned and gloved, the operation started
at 10:30 with an excision biopsy first at the left chest area, above
the breast. Considering the site of incision it as at the 3rd or 4th ICS,
where a horizontal incision was made. Surgeons thoroughly
opened the ICS to have a better view of the peritoneal cavity. A
bone cutter was used to cut on the ribs that blocks the opening.
Soon a small amount of specimen, the mediastinal mass detected
during CT scan was taken. It was placed on a sterile vial, where it
was sent immediately to the histopathology laboratory. As soon as
the specimen was taken. The surgeon then ordered to close the
incision with suture of Vicryl 2.0 SH and Monosyn 3.0. After the
excision biopsy has ended. The surgeon sought referral from a
consultant in pursuing the operation. Half an hour later, the surgeon
ordered to pursue the operation with another colleague. A vertical
incision was then made at the mid-sternal area, using the 1st knife.
As soon as the muscles and fascia were incised and the sternum
was exposed, a bone cutter was used to split the sternum. And
then a retractor was used to hold the splitted sternum in place. As
soon as the cavity was exposed, cautery was used to coagulate
blood vessels and the surgeon palpated the thymus gland and the
other masses. On through palpation, the surgeon found out that the
mass was greater than expected, extending from the pericardial
cavity to the pleural cavity. Surgeons were careful in incising the
mass since there are major organs that might be hit. Ties of silk 4.0
and 2.0 was the prepared. Mixters was asked to clamp vessels and
to cut on fascia. Soon ties were asked for continuous bleeding
vessels. A vascular clamp was used to hold unto a big vessel since
the operation was around the heart where the area is highly
vascular. And then as soon as blocking fascia was cut, the gland
was then incised carefully, using the 2nd knife, but then since the
opening was deep, the surgeons asked for a blade 7 handle to use
in incising the gland. Bobcocks was used to hold the incised mass
in place. Soon other masses where even palpated and incised.
Vicryl 4.0 was then requested in suturing opened cavities. During
the operation, a part of the incised mass was then asked to be
placed on a vial for another stat biopsy, and then incision of the
mass continued. The palpated mass was incised from around the
pericardial cavity and partially around the pleural cavity to avoid
trauma to the lungs. CTT equipments were prepared before hand
during the operation and to close the splinted sternum, bone wax
and bone staplers were prepared. As soon as the right amount of
the mass was removed, considering that the extent was
 unexpected and the area is around great organs, the operation
ended, with continuous coagulation of vessels and tying. And then
carefully pulling back the splinted sternum, placing an area for CTT
to easily prevent trauma and effusion to cavities that were hit during
the operation. The sternum was then attached together by staplers
and then wound was closed using sutures. After initial and final
count was complete the closing of the wound continued and
bandage and dressing were placed around the area. The mass
extracted was saved as specimen for further examination and after
all abdominal bandage was placed. Patient ADT was sent to RR for
continuous monitoring.

VI. NURSING PRIORITIES

 ABC
Airway and Breathing – due to depressed respiratory function
secondary to sedation
Circulation – due to tissue trauma on skin and organs and blood
loss during the operation
 Vital Signs
Monitored every 15 hours at PACU until normalized
 Infection
Proper wound dressing and care on surgical wound sites and
administration of medications
 Comfort
Alleviation of pain on wound sites
 Anxiety
Provide comfort and relation post-operatively
VII. NURSING CARE PLAN
Assessment Evaluation/
Subjective/ Nursing Diagnosis Short Term Goal Long Term Goal Intervention Rationale Expected
Objective Outcome
O: Ineffective Airway After the 8 hour After 3 weeks,  Assessed rate  Post-op Goal met:
 CTT attached at Clearance r/t shift, patient will patient will be of respiration and patients normally patient was able
surgical wound immobility secondary not be able to able to return to chest movement have depressed to experience no
site draining well to general experience maximum every 15 minutes respiratory aspiration during
 Productive cough anesthesia aspiration. pulmonary at RR function making the 8 hour shift
 Yellowish phlegm function them invincible to

 Left sided chest aspiration Expected

pain  Elevated head  Helps in Outcome:

 Surgical wound of bed and tilted to mobilization and patient was able

site at midsternal side expectoration of to return to

secretions maximum
area, intact and
 Suctioned as  Prevents pulmonary
dry
 Weakness ordered stasis of function
secretions and
 Immobility
mechanically
 Administered 02 clears airway
inhalation as  Since
indicated respiratory
 function is
depressed, help
in 02 inhalation is
needed fopr
 Demonstrated proper gas
and assisted on exchange
deep breathing  Helps in
exercise with expectoration of
pillow after patient secretions and
has waken up clearing of major
airways for good
breathing

Assessment Evaluation/
Subjective/ Nursing Diagnosis Short Term Goal Long Term Goal Intervention Rationale Expected
Objective Outcome
O: Impaired skin After the 8 hour After 3 weeks,  Assessed wound  Determines if Goal met: patient
 CTT attached at integrity r/t imposed shift, patient will patient will be site for redness, there is positive was able to show
surgical wound immobility with not be able to able to achieve swelling or rashes infection on no signs of
site, draining well decreased blood and have signs of timely wound wound site and infection during
 Surgical wound at nutrients to tissues infection at healing interventions to the 8 hour shift
midsternal area, secondary to surgery wound site. be done
intact and dry  Assessed patency  This type of
 wound dress of CTT and wound contraptions near Expected
 Surgical wound at drains wound site can be outcome: patient
left upper chest sites of was able to
dry and intact microorganism achieve timely
wound dress invasion when wound healing
 Immobility stasis occurs.

 Weakness  Checked for  Prevents

intactness and occurrence of
condition of wound infection
dressing especially since
moisture alters
microbial integrity
 Changed wound  Protects wound
dressings when from mechanical
moisture has injury and
developed and contamination
once a day
 Cleaned wound site  Prevents bacterial
with betadine every contamination
change
 Instructed client to  Prevents
have CBR and not mechanical injury
 to mobilize wound to wound site
frequently
 Promoted adequate  Helps in
nutritional intake maintaining
after diet has been cellular energy
returned requirements to
facilitate tissue
regeneration

Assessment Evaluation/
Subjective/ Nursing Diagnosis Short Term Goal Long Term Goal Intervention Rationale Expected
Objective Outcome
O: Acute pain r/t two After the 8 hour After 3 weeks,  Assessed wound  Determines if Goal met:
 CTT attached surgical wounds at shift, patient will patient will be site for redness, there is positive patient was able
near wound site midsternal area and be able to able to achieve swelling or rashes infection on to experience
patent and left upper chest experience relief timely wound wound site and relief with a pain
draining well secondary to surgery as evidenced by healing and interventions to grade of 5/10
 Surgical wound at a pain grade of comfort be done from previous
midsternal area, 5/10 from 8/10,  Monitored RR and  An increase of 8/10 during the
wound dress dry on a scale of 1 as PR both due to shift
and intact the lowest and 10 alteration in
 Surgical wound at as the highest comfort may Expected
left upper chest, pain cause problem on Outcome:
 wound dress dry still depressed Patient was able
and intact respiratory to achieve timely
 Weakness function wound healing
 Immobility  Assessed pain  Determines the and comfort

 Restlessness grade intensity and

 Pain grade of frequency of pain

8/10  Instructed to do  Promotes

deep breathing relaxation and
exercises when in normalizes RR
pain
 Encouraged client  Mobility
to have CBR introduces
mechanical
trauma to wound
causing pain
 Instructed to do  Diverts attention
activities that may to pain
divert attention
such as reading, or
humming
 Administered pain  Relieves pain
medications PRN
 as doctor ordered

VIII. DISCHARGE PLAN

Medications
• Instructed patient and relative on the prescribed medications to be taken at home
• Instructed the patient to the proper dosage, frequency and route that the medications should be taken
• Instruct not to miss medications
• Inform the adverse reactions and side effects on the course of the drug therapy

Diet
• Instruct to continue the Full diet order
• Encourage to provide adequate nutritious food, rich in vitamins to promote wound healing
• Encourage the patient not to skip meals
• Also, encourage to increase hydration

Exercise
• Encourage the patient to ambulate moderately since it helps in wound healing
• Instruct the relative to watch out and assist patient on times
• Encourage patient to return to normal simple activities of daily living
• Provide an exercise pattern to the patient to help return weakened reflexes and promote circulation

Health Teachings
 • Proper wound care
• Proper Diet

Follow-up/Check up
• Instruct the patient and relative to visit their attending physician to the appointed date
• Inform them that it is important to follow the appointed dates of follow-up check up
 DE LA SALLE HEALTH SCIENCES INSTITUTE
COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY
LEVEL III

NURSING CASE STUDY:

THYMECTOMY
OF PATIENT A.D.T
AT THE OPERATING ROOM
OF DLSUMC

Submitted by:
Valdueza, Jana Klarissa Angela C.
BSN 31 Grp 1

Submitted to:
Ms. Mercy Quiambao, RN, MAN
Clinical Instructor

MAY 24, 2010