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1

Capitol University

Corrales Extension, Cagayan de Oro City

College of Nursing

PLEURAL EFFUSION

SUBMITTED TO:

MR. RICK WILSON BUNAO, RN MN

(Clinical Instructor)

SUBMITTED BY:

KRISTINE MAE U. SUGAROL

RLE 7 GROUP 21

January 19, 2010


2

TABLE OF CONTENTS

I. Introduction………………………………………………..…………….…3

A. General objective…………………………………………………6
B. Specific objectives………………………………………………..6
C. Scope and limitations……………………………………………6

II. Assessment

A. Patient demographic data………………………………………7


B. Assessment tool…………………………………………………8
C. Laboratory results……………………………………………….13

III. Anatomy and physiology…………………………………………….…17

IV. Pathophysiology

A. Narrative form…………………………………………………….24
B. Schematic Diagram………………………………………………26

V. Medical management

A. Nursing Care Plan……………………………………………….28


B. Drug study………………………………………………..………34

VI. Health Teaching ……………….…………………………..……………37

VII. Learning Experience ……………………………………….…….…...38

VIII. Discharge Planning….…………………………………….….………39

IX. Doctor’s Order …………………….……………………………………41

X. References ……………………….………………………………...……42

I. INTRODUCTION
3

Approximately 1 million pleural effusions are diagnosed in the United


States each year. The clinical importance of pleural effusions ranges from incidental
manifestations of cardiopulmonary diseases to symptomatic inflammatory or malignant
diseases (as shown in the image below) requiring urgent evaluation and treatment.

Anteroposterior
upright chest
radiograph shows a
massive left-sided
pleural effusion
with contralateral
mediastinal shift.

Pleural effusion is excess fluid that accumulates in the pleural cavity, the
fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair
breathing by limiting the expansion of the lungs during inhalation.

Pleural fluid normally seeps continually into the pleural space from the
capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries
and lymphatic system. Any condition that interferes with either secretion or drainage of
this fluid leads to pleural effusion.

Causes of pleural effusion can be grouped into four major categories:

 Increased systemic hydrostatic pressure (e.g., heart failure)

 Reduced capillary oncotic pressure (e.g., liver or renal failure)

 Increased capillary permeability (e.g., infections or trauma)

 Impaired lymphatic function (e.g., lymphatic obstruction caused by tumor)


4

A pleural effusion is an abnormal collection of


fluid in the pleural space resulting from excess fluid
production or decreased absorption. It is the most
common manifestation of pleural disease. The pleural
space is bordered by the parietal and visceral pleurae.
The parietal pleura covers the inner surface of the
thoracic cavity, including the mediastinum, diaphragm,
and ribs. The visceral pleura envelops all lung
surfaces, including the interlobar fissures. The right
and left pleural spaces are separated by the
mediastinum.

The pleural space plays an important role in


respiration by coupling the movement of the chest wall
with that of the lungs in two ways. First, a relative
vacuum in the space keeps the visceral and parietal
pleurae in close proximity. Second, the small volume
of pleural fluid, which has been calculated at 0.13
mL/kg of body weight under normal circumstances, serves as a lubricant to facilitate
movement of the pleural surfaces against each other in the course of respirations. This
small volume of fluid is maintained through the balance of hydrostatic and oncotic
pressure and lymphatic drainage, a disturbance of which may lead to pathology.

Clinical manifestations depend on the amount of fluid present and the


severity of lung compression. If the effusion is small (i.e., 250ml), its presence may be
discovered only on a chest radiograph. With 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. Tactile fremitus
may be decreased or absent, and percussion notes dull or flat.

Dyspnea is the most common symptom associated with pleural effusion


and is related more to distortion of the diaphragm and chest wall during respiration
than to hypoxemia. In many patients, drainage of pleural fluid alleviates symptoms
despite limited improvement in gas exchange.

Underlying intrinsic lung or heart disease, obstructing endobronchial


lesions or diaphragmatic paralysis can also cause dyspnea, especially after coronary
artery bypass surgery. Drainage of pleural fluid may partially relieve symptoms but also
may allow the underlying disease to be recognized on repeat chest radiographs.
5

Less common symptoms of pleural effusions include mild, nonproductive


cough or chest pain. Other symptoms may suggest the etiology of the pleural effusion.
More severe cough or production of purulent or bloody sputum suggests an underlying
pneumonia or endobronchial lesion. Constant chest wall pain may reflect chest wall
invasion by bronchogenic carcinoma or malignant mesothelioma. Pleuritic chest pain
suggests either pulmonary embolism or an inflammatory pleural process. Systemic
toxicity evidenced by fever, weight loss, and inanition suggests empyema.

Thoracentesis is used to remove excess pleural fluid. The removed fluid is


analyzed to determine whether it is transudate or exudate. Transudates are
substances that have passed through a membrane or tissue surface. They occur
primarily in conditions in which there are protein loss and low protein content (e.g.,
hypoalbuminemia, criihosis, nephrosis) or increased hydrostatic pressure (e.g., heart
failure). Exudates are substances that have escaped from blood vessels. They contain
an accumulation of cells, have a high specific gravity and a high lactate dehydrogenase
(LDH) level, and occur in response to malignancies, infections or inflammatory
processes. Exudates occur when there is an increase in capillary permeability.
Differentiating between transudates and exudates helps establish a specific diagnosis.
Diagnosis may also require analysis of the fluid for white and red blood cells, malignant
cells, bacteria, glucose content, pH, and LDH.

Pleural fluid may be (1) hemorrhagic (or bloody), such as when a tumor is
present or after trauma or pulmonary embolus with infarction; (2) chylous (or thick and
white), such as after lymphatic obstruction or trauma to the thoracic duct; or (3) rich in
cholesterol, such as in chronic, recurrent effusions caused by tuberculosis or
rheumatoid arthritis. If there is a high in WBC count and the pleural fluid is purulent, the
effusion is called emphysema. Emphysema of any volume requires drainage and
treatment of the infection.

If the pus is not drained, it may become thick and almost solidified or
loculated (containing cavities), a condition called fibrothorax.

After the thoracentesis, closed-chest drainage with suction is used to re-


expand the lung rapidly and fill the pleural space. If the fibrous material has restricted
the lung for some time, the lung may not re-expand effectively and further intervention
(usually thoracoplasty) may be needed.
6

A. GENERAL OBJECTIVE

At the end of this case presentation, I will be able to improve knowledge in


various concepts related to my patient’s condition, and skills in careful assessment and
rendering of nursing interventions involved in the management of the client’s case; and
develop positive attitudes as I accomplish my case study using concepts that I have
acquired from our RLE, theory classes and previous related subjects in the BSN
curriculum.

B. SPECIFIC OBJECTIVES

1. Perform a thorough assessment and careful gathering of data that are clinically
significant and will be utilized as reliable cues for our care plans.

2. Further completion of data that will supplement our assessment.

3. Trace and familiarize the pathophysiology of our patient’s disease process.

4. Design individualized nursing care plans based on nursing diagnoses that are
suitable and feasible to carry out.

5. Carry out nursing interventions that are effective, reality based, time-bounded,
achievable and beneficial for our client.

6. Develop a sense of positive thinking in coming up with the case study.

C. SCOPE AND LIMITATION

The study focuses on the assessment, anatomy, and pathophysiology and


its diagram, nursing care plans, discharge plan, prognosis, recommendation and
conclusion revolving around the diagnosis of the patient which is Pleural Effusion
probably secondary to pneumonia.

This study is limited only to the available records found on the patient’s
chart and the information being provided for by the family members present at the
patient’s room during the time of assessment. Other factors that will also be considered
7

as limitations to this study would include the short-duration of time given for ICU
rotation.

II. ASSESSMENT

A. PATIENT DEMOGRAPHIC PROFILE

Patient Demographic Profile

Name of patient: Panugaling, Jonathan Castro

Age: 27 years old

Birthday: July 2, 1982

Sex: Male

Address: Purok 3-C Baloy, Tablon, Cagayan de Oro


City, Misamis Oriental

Civil status: Single

Height: NA

Weight: NA

Language spoken: Visayan

Educational Attainment: Elementary Graduate

Religion: Roman Catholic

Nationality: Filipino

Name of Father: Felipe Panugaling

Name of Mother: Saturnina Monte Castro

Occupation: barber

Income: P1700/month

Chief complaint: cough and fever

Name of Hospital: Northern Mindanao Medical Center

Date of Admission: January 7, 2010 (11:00pm)

Name of Attending Physician: Dr. Sarmiento


8

Admitting Diagnosis:
Pleural Effusion probably secondary to Pneumonia
B. ASSESSMENT TOOL

VITAL SIGNS:

Temperature: 36.7°c

Pulse Rate: 64 BPM

Respiratory Rate: 24 CPM

Blood Pressure: 120/190 mmHg

Weight: NA

Height: NA

GENERAL DATA:

A case of 27 y.o., male, single, Roman Catholic from Tablon, Cagayan de


Oro City, admitted for the 1st time due to cough

Source of information:

Patient: 90% reliability

HISTORY OF PRESENT ILLNESS:

5 days PTA, noted to have cough, productive of whitish phlegm


associated with fever, on and off, low to moderate grade and back pains on the left.
Consult done at the Family Medicine OPD. Work up done with CXR which revealed
pleural effusion L. Patient refused in our institution for further evaluation and
management. Hence this admission,

( + ) occasional SOB ( + ) easy fatigue ability

( - ) chest pain

PAST MEDICAL HISTORY:

 Previous admission due to vehicular accident 2007  Head injury  sutured


 ( - ) operation

 Non asthmatic
9

Non diabetic

Non hypertensive

 ( - ) food/drug allergy

 ( - ) illness

FAMILY HISTORY:

( + ) HPN (paternal)

PERSONAL / SOCIAL HISTORY:

 Non smoker but occasional alcoholic beverage drinks

 Single, barber

FUNCTION HEALTH PATTERNS

ACTIVITY-EXERCISE PATTERN

Pt.X pericordial area is flat; PMI is best heard at 5th ICS midclavicular line with
apical rate of 142bpm. Her peripheral pulse is symmetrical, palpable, and regular & her
capillary refill is 2sec. No pacemaker attached & hemodynamic monitoring but Chest
Thoracostomy Tube (CTT) is attached at the left mid-axillary line of the patient’s body.
Has O2 inhalation attached to patient’s nose upon assessment.

Pt. X is in irregular breathing pattern of 33cpm upon assessment. The lung


expansion is asymmetrical, with diminished or delayed expansion on the side of effusion
which is at the left.

Pt. X ADL is in total dependence and mobility status is limited because of fear of
injury to the site of the CTT. Pt. X back & extremities has no deformities but ROM is
also limited. The spine is in the midline.
10

NUTRITION & METABOLIC PATTERN

Prior to admission pt. X has no special diet. Does not have any supplement
rather than Ferrous sulfate.

Pt. X mouth & mucosa are pinkish; tongue is in the midline. Uvula is in the
midline & pinkish, tonsils are not inflamed. The trachea is in the midline with non-
palpable thyroids & minimal ROM on bed.

Pt. X skin general color is pallor, rough, firm, warm to touch. Patient has an
ongoing IVF of PNSS 940cc regulated at 30gtts/min. Patient has also a surgical wound
(suture) in the left mid-axillary line where Chest Thoracostomy Tube is attached with
drainage of 590 level in bloody color.

ELIMINATION PATTERN

During admission pt. X defecates 1 time with yellow, slightly firm stool at medium
amount. Last bowel movement on January 13, 2010; and the day of assessment was
January 14, 2010. No incontinence & any method use to manage bowel movement
noted.

The abdomen is symmetrical but flat and normoactive without any abnormal
findings upon palpation. Pt. X usually urinates 1-2 times a day, appeared in yellow color
and has no problem in urinating. Patient also sweats minimally during afternoon but no
noted excessive perspiration.

SLEEP-REST PATTERN

Pt. X sleeps 7-8 hours at night. There were no histories of sleep disturbances of
the patient. Pt. X is always at the bed and easily drops to sleep.

COGNITIVE-PERCEPTION PATTERN
11

Pt. X is conscious and calm upon assessment and disoriented to time. The head
is normocephalic with symmetrical facial movements & sunken fontanels. Hair is dry
with dandruff seen in the scalp. Pt. X eyelids are asymmetrical, with pink conjunctiva.
No lesions in the cornea & lens & anecteric sclera. Pupils are at equal size with 4mm in
diameter.

Pt. X external pinnae of ears is normoset with cerumen discharge & intact
tympanic membrane. The nasal septum is in the midline with pinkish mucosa & both
patent.

SELF-PERCEPTION & SELF CONCEPT PATTERN

Pt. X feels fine about himself but I observed that he is not. Pt. X is depressed
about himself for being sick and hospitalized.

ROLE-RELATIONSHIP PATTERN

Pt. X lives with his mother, father and younger siblings. When it comes to the
feelings of his family members regarding her illness, pt. X mother felt so sad about her
son’s condition but she tries to understand the nature of the problem and accepts the
fact about the condition of her son. The mother also verbalized that her son needs
support about his present condition.

DAY 1: PHYSICAL ASSESSMENT (Jan. 14, 2010)

SKIN
- General color is pallor, rough, firm, and warm to touch.
NAILS
- His nails were pallor but it is firm and convex-shape.
HAIR
- Her hair is dry and black, with dandruff.
HEAD
- Normocephalic  head and facial movements are symmetrical in size
- Sunken fontanels.
EYES
- He has no edema. Both eyes are coordinated with parallel alignment.
- Anicteric sclera and conjunctiva and no abnormal tears noted.
EARS
- Normal voice tones audible.
12

- Her ears were symmetrical


- There was cerumen noted
NOSE AND SINUSES
- There is nasal flaring upon assessment due to SOB
- No tender sinuses noted
- Gross smell is symmetrical
MOUTH AND THROAT
- He has pallor lips, pinkish mucosa
- Tongue is in midline with missing teeth
- Has pinkish gums
NECK
- Trachea is placed midline. Lymph nodes are not palpable.
LUNGS-CHEST WALL
- Asymmetric chest expansion, with diminished or delayed expansion on the side
of the effusion
- Breaths per minute is 33cpm (abnormal).

Drainage Color: (according to 3-11 shift)

1. Bloody about 320 cc level Jan. 14, 2010

2. Yellowish about 10cc level + 110 water from bottle Jan. 15, 2010

3. Clear yellow about 190 cc level from previous bottle Jan. 16, 2010
13

C. LABORATORY RESULTS:

Hematology Report: Jan. 12, 2010 7:24pm

Test Result Unit Reference Interpretation


WBC 5.7 10^3/uL 5.0-10.0 NORMAL
RBC 4.22 10^6/uL 4.2-5.4 NORMAL
Hemoglobin 11.7 y/dL 12.0-16.0 LOW
Hematocrit 35.2 % 37.0-47.0 ANEMIA
MCV 83.4 fL 82.0-98.0 NORMAL
MCH 27.7 fL 27.0-31.0 NORMAL
MCHC 33.2 g/dL 31.5-35.0 NORMAL
RDW-CV 12.8 % 12.0-17.0 NORMAL
PDW 9.3 fL 9.0-16.0 NORMAL
MPV 8.1 fL 8.0-12.0 NORMAL
Differential
Count
Lymphocyte (%) 20.8 % 17.4-48.2 NORMAL
Neutrophil 57.3 % 43.4-76.2 NORMAL
Monocyte 21.9 % 4.5-10.5 HIGH
Eosinophil % 1.0-3.0
Basophils % 0.0-2.0
Bands/Stabs % 1.0-2.0
Platelets 513 10^3/uL 150-400 HIGH

Hematology Result: Jan. 10, 2010 5:11pm

Test Result Unit Reference Interpretation


WBC 5.8 10^3/uL 5.0-10.0 NORMAL
RBC 4.34 10^6/uL 4.2-5.4 NORMAL
Hemoglobin 12.2 y/dL 12.0-16.0 NORMAL
Hematocrit 36.2 % 37.0-47.0 LOW
MCV 83.4 fL 82.0-98.0 NORMAL
MCH 28.1 fL 27.0-31.0 NORMAL
MCHC 33.7 g/dL 31.5-35.0 NORMAL
RDW-CV - % 12.0-17.0
PDW - fL 9.0-16.0
MPV - fL 8.0-12.0
Differential
Count
Lymphocyte (%) 18.3 % 17.4-48.2 NORMAL
14

Neutrophil 21.7 % 43.4-76.2 LOW


Monocyte 30.0 % 4.5-10.5 HIGH
Eosinophil - % 1.0-3.0
Basophils - % 0.0-2.0
Bands/Stabs - % 1.0-2.0
Platelets 452 10^3/uL 150-400 HIGH

Hematology Result: Jan. 7, 2010 3:33pm

Test Result Unit Reference Interpretation


WBC 7.2 10^3/uL 5.0-10.0 NORMAL
RBC 4.71 10^6/uL 4.2-5.4 NORMAL
Hemoglobin 13.0 y/dL 12.0-16.0 NORMAL
Hematocrit 38.4 % 37.0-47.0 NORMAL
MCV 81.5 fL 82.0-98.0 NORMAL
MCH 27.6 fL 27.0-31.0 NORMAL
MCHC 33.9 g/dL 31.5-35.0 NORMAL
RDW-CV 12.6 % 12.0-17.0 NORMAL
PDW 9.9 fL 9.0-16.0 NORMAL
MPV 8.8 fL 8.0-12.0 NORMAL
Differential
Count
Lymphocyte (%) 18.2 % 17.4-48.2 NORMAL
Neutrophil 56.3 % 43.4-76.2 NORMAL
Monocyte 24.5 % 4.5-10.5 HIGH
Eosinophil 0.7 % 1.0-3.0
Basophils 0.3 % 0.0-2.0 NORMAL
Bands/Stabs - % 1.0-2.0
Platelets 406 10^3/uL 150-400 HIGH

January 10, 2010

Serous Effusions & Synovial Fluid Analysis

Gross Examination:

Volume: 10 ml
Color: yellow
Clarity: hazy

Microscopic Examination:

RBC count: 3697/mm3


WBC count: 1238/mm3

Differential count (%):

Segmenters: 15%
Lymphocytes: 85%
15

Mononuclear cells: -
Other types: -

Others:
Specific gravity: 1.005
Rivaltas Test: positive
Glucose: trace

January 7, 2010

BLOOD CHEMISTRY SIGNIFICANCE

Blood sugar (Rbs): 103.2 (60-110) mgs% NORMAL


Blood Urea Nitrogen: (4.6-23.4) -
Creatinine: 6.75 (0.6-1.2) NORMAL
Electrolyte: 3.93 (3.5-5.3)mmol/L NORMAL
Potassium: 139.55 (135-148)mmol/L NORMAL

EXAM: CHEST, PA Jan. 7, 2010

Radiographic Report:
Chest in PA projections shows homogenous density occupying the lower 2/3 of
the left hemithorax eccentric upper border. Heart shadow is slightly deviated to
the right. No right parenchymal infiltrate. Right hemidiaphragm and its
corresponding sinuses are intact.

Impression:
Consider Pneumonia, Left w/ Pleural Effusion.

Suggest: UTS of the left hemithorax to determine the amount of fluid within the
pleural activity.

SONOGRAPHIC REPORT: Jan. 7, 2010


There is fluid collection in the left lower hemithorax measuring 11.6cm x
11.9cm x 5.5cm, approximately 395cc. No sepatations, no debris noted within the fluid.
At the marked area, skin to parietal pleural is 2.2cm & interpleural distance is 4.7cm.

Impression:
16

Pleural Effusion, left, as described

January 11, 2010

Panugaling, Jonathan C.
27/M

NMMC Specimen #: pf 0008


Date of Birth: July, 2, 1982 Specimen Date: Jan. 11, 2010
Date of Admission: Jan. 7, 2010 Specimen Type: Pleural Fluid

Organism: No Growth
Comment: No growth after 72 hours incubation

January 15, 2010


MICROBIOLOGY EXAMINATION
Specimen Sputum
Acid-Fast Stain: First Taking (Negative)
17

III. ANATOMY AND PHYSIOLOGY

Anatomy and Physiology

Anatomy of the lower respiratory tract: Lungs

Lungs

The lungs are paired elastic structures enclosed in the thoracic cage, which is an
airtight chamber with distensible walls. Ventilation requires movement of the walls of the
thoracic cage and of its floor, the diaphragm. The effect of these movements is
alternately to increase and decrease the capacity of the chest. When the capacity of the
chest is increased, air enters through the trachea (inspiration) because of the lowered
pressure within and inflates the lungs. When the chest wall and diaphragm return to
their previous positions (expiration), the lungs recoil and force the air out through the
bronchi and trachea. The inspiratory phase of respiration normally requires energy; the
expiratory phase is normally passive. Inspiration occurs during the first third of the
respiratory cycle, expiration during the latter two thirds.
18

Pleura

The lungs and wall of the thorax are lined with a serous membrane called the
pleura. The visceral pleura cover the lungs; the parietal pleura lines the thorax. The
visceral and parietal pleura and the small amount of pleural fluid between these two
membranes serve to lubricate the thorax and lungs and permit smooth motion of the
lungs within the thoracic cavity with each breath.

Mediastinum

The mediastinum is in the middle of the thorax, between the pleural sacs that
contain the two lungs. It extends from the sternum to the vertebral column and contains
all the thoracic tissue outside the lungs.

Lobes

Each lung is divided into lobes. The left lung consists of an upper and lower lobe,
whereas the right lung has an upper, middle, and lower lobe. Each lobe is further
subdivided into two to five segments separated by fissures, which are extensions of the
pleura.

Bronchi and Bronchioles

These are several divisions of the bronchi within each lobe of the lung. First are
the lobar bronchi (three in the right lung and two in the left lung). Lobar bronchi divide
into segmental bronchi (10 on the right and 8 on the left), which are the structures
identified when choosing the most effective postural drainage position for a given
patient. Segmental bronchi then divide into subsegmental bronchi. These bronchi are
surrounded by connective tissue that contains arteries, lymphatics and nerves. The
19

subsegmental bronchi then branch into bronchioles, which have no cartilage in their
walls. Their patency depends entirely on the elastic recoil of the surrounding smooth
muscle and on the alveolar pressure. The bronchioles contain submucosal glands,
which produce mucus that covers the inside lining of the airways. The bronchi and
bronchioles are lined also with cells that have surfaces covered with cilia. These cilia
create a constant whipping motion that propels mucus and foreign substances away
from the lung toward the larynx. The bronchioles then branch into terminal bronchioles
then become respiratory bronchioles, which are considered to be the transitional
passageways between the conducting airways and the gas exchange airways. Up to
this point, the conducting airways contain about 150 ml of air in the tracheobronchial
tree that does not participate in gas exchange. This is known as physiologic dead
space. The respiratory bronchioles then lead into alveolar ducts and alveolar sacs and
then alveoli. Oxygen and carbon dioxide exchange takes place on the alveoli.

Alveoli

The lung is made up of about 300 million alveoli, which are arranged in clusters
of 15 to 20. These alveoli are so numerous that if their surfaces were united to form one
sheet, it would cover 70 square meters- the size of a tennis court. There are three types
of alveolar cells. Type I alveolar cells are epithelial cells that form the alveolar walls.
Type II alveolar cells are metabolically active. These cells secrete surfactant, a
phospholipid that lines the inner surface and prevents alveolar collapse. Type III
alveolar cell macrophages are large phagocytic cells that ingest foreign matter (eg.
mucus, bacteria) and act as an important defense mechanism).

Function of the Respiratory System

The cells of the body derive the energy they need from the oxidation of
carbohydrates, fats, and proteins. As with any type of combustion, this process requires
oxygen. Certain vital tissues, such as those of the brain and the heart, cannot survive
for long without a continuing supply of oxygen. However, as a result of oxidation in the
body tissues, carbon dioxide is produce and must be remove from the cell to prevent
the build of acid waste products. The respiratory system performs this functions by
facilitating life sustaining processes such oxygen transport, respiration and ventilation,
and gas exchange.

Oxygen transport

Oxygen is supplied to and carbon dioxide is remove from cell by way of


circulating blood cells are enclosed contact with capillaries, and oxygen diffuses from
the capillary through the capillary wall to the interstitial fluid.
20

Respiration

After this, tissue capillary exchanges blood enters systemic veins and travels to
pulmonary circulation. The oxygen diffuses from the alveoli from the blood. Carbon
dioxide diffuses from the blood to alveoli movement of air in and out of the airways
continually replenishes the oxygen and removes the carbon dioxide from the airways in
the lungs this whole process of gas exchange is called respiration.

Ventilation

During inspiration, air flows from the environment into the trachea, bronchi,
bronchioles and alveoli. During expiration, alveolar gas travels the same route in
reverse.

Anatomy of the Pancreas

In humans, the pancreas is a 15-25 cm (6-10 inch) elongated organ in the


abdomen. One of the organs behind the abdominal cavity, it is located posterior to the
stomach and in close association with the duodenum.

It is often described as having three regions: a head, body and tail.

• The pancreatic head abuts the second part of the duodenum.


• The body of the pancreas lies at the level of L2 on the spine.
• The tail of the pancreas extends towards the spleen.

The pancreatic duct (also called the duct of Wirsung) runs the length of the
pancreas and empties into the second part of the duodenum at the ampulla of Vater.
The common bile duct usually joins the pancreatic duct at or near this point. Many
people also have a small accessory duct, the duct of Santorini, which extends from the
main duct more upstream (towards the tail) to the duodenum, joining it more proximal
than the ampulla of Vater.

Arteries and veins

The pancreas is supplied arterially by the Pancreaticoduodenal arteries and the


splenic artery:

• the splenic artery supplies the neck, body, and tail of the pancreas.

• the superior mesenteric artery provides the inferior pancreaticoduodenal artery

• the gastroduodenal artery provides the superior pancreaticoduodenal artery


21

Venous drainage is via the pancreaticoduodenal veins which end up in the portal
vein. The splenic vein passes posterior to the pancreas but is said to not drain the
pancreas itself. The portal vein is formed by the union of the superior mesenteric vein
and splenic vein posterior to the neck of the pancreas. In some people (some books say
40% of people), the inferior mesenteric vein also joins with the splenic vein behind the
pancreas (in others it simply joins with the superior mesenteric vein instead).

Nerves

The pancreas is innervated by the pancreatic plexus; a subdivision of the celiac


plexus that accompanies pancreatic arteries.

Physiology of the Pancreas

Under a microscope, when properly stained, it is easy to distinguish two different


tissue types in the pancreas. These regions correspond to the main pancreatic
functions:

Appearance Region Function

light staining circles (islets of endocrine secretes hormones that regulate blood
Langerhans) pancreas glucose levels

Darker surrounding tissue exocrine produces enzymes that break down


pancreas digestible foods

Endocrine

There are four main types of cells in the islets of Langerhans. They are relatively
difficult to distinguish using standard staining techniques, but they can be classified by
their secretion:

Name of Endocrine % of islet Representative


cells product cells function

beta cells Insulin and Amylin 50-80% lower blood sugar

alpha cells Glucagon 15-20% raise blood sugar

delta cells Somatostatin 3-10% inhibit endocrine pancreas

PP cells Pancreatic polypeptide 1% inhibit exocrine pancreas


22

The islets are a compact collection of endocrine cells arranged in clusters and
cords and are crisscrossed by a dense network of capillaries. The capillaries of the
islets are lined by layers of endocrine cells in direct contact with vessels, and most
endocrine cells are in direct contact with blood vessels, by either cytoplasmic processes
or by direct apposition. According to the volume The Body, by Alan E. Nourse, in the
Time-Life Science Library Series, the islets are "busily manufacturing their hormone and
generally disregarding the pancreatic cells all around them, as though they were located
in some completely different part of the body.

Anatomy of the Heart

Position

The heart is a hallow organ positioned left of the center in the chest cavity within
the pericardial cavity. The base of the heart is located superiorly in and the apex is
directed downward and leftward and formed by the lateral tip of the left ventricle

Physiology of the Heart

The essential function of the heart is to pump blood to various parts of the body.
The mammalian heart has four chambers: right and left atria and right and left
ventricles. The two atria act as collecting reservoirs for blood returning to the heart while
the two ventricles act as pumps to eject the blood to the body. As in any pumping
system, the heart comes complete with valves to prevent the back flow of blood.
Deoxygenated blood returns to the heart via the major veins (superior and inferior vena
cava), enters the right atrium, passes into the right ventricle, and from there is ejected to
the pulmonary artery on the way to the lungs. Oxygenated blood returning from the
lungs enters the left atrium via the pulmonary veins, passes into the left ventricle, and is
then ejected to the aorta. In the frontal view of the heart shown below, the right atrium is
in blue, the left atrium in yellow, the right ventricle in purple, and the left ventricle in red.
The chambers are semi-transparent so that the valves, drawn in white, can be seen.

The large valve in the foreground is the tricuspid valve that prevents backflow
from the right ventricle to the right atrium. The small round valve you see near the top is
the pulmonary valve, where the pulmonary artery comes out of the right ventricle.

The inner edge of the tricuspid and the mitral valves end in filamentous
connective tissue (chordae tendineae). These are attached to small columns of muscle
(papillary muscles) arising out of the inner surface of the ventricles. As the pressure
builds in the ventricles, the valves snap shut, and the papillary muscles prevent the
valves from blowing into the atrium and opening.
23

Pumping Action of the Heart

The pumping action starts with the simultaneous contraction of the two atria. This
contraction serves to give an added push to get the blood into the ventricles at the end
of the slow-filling portion of the pumping cycle called "diastole." Shortly after that, the
ventricles contract, marking the beginning of "systole." The aortic and pulmonary valves
open and blood is forcibly ejected from the ventricles, while the mitral and tricuspid
valves close to prevent backflow. At the same time, the atria start to fill with blood again.
After a while, the ventricles relax, the aortic and pulmonary valves close, and the mitral
and tricuspid valves open and the ventricles start to fill with blood again, marking the
end of systole and the beginning of diastole. It should be noted that even though equal
volumes are ejected from the right and the left heart, the left ventricle generates a much
higher pressure than does the right ventricle.

Electrical Activity of the Heart

When vertebrate muscles are excited, an electrical signal (called an "action


potential") is produced and spreads to the rest of the muscle cell, causing an increase in
the level of calcium ions inside the cell. The calcium ions bind and interact with
molecules associated with the cell's contractile machinery, the end result being a
mechanical contraction. Even though the heart is a specialized muscle, this
fundamental principle still applies.

One thing that distinguishes the heart from other muscles is that the heart muscle
is a "syncytium," meaning a meshwork of muscle cells interconnected by contiguous
cytoplasmic bridges. Thus, an electrical excitation occurring in one cell can spread to
neighboring cells. Another defining characteristic is the presence of pacemaker cells.
These are specialized muscle cells that can generate action potentials rhythmically.

Under normal circumstances, a wave of electrical excitation originates in the


pacemaker cells in the sinoatrial (S-A) node, located on top of the right atrium.
Specialized muscle fibers transmit this excitation throughout the atria and initiate a
coordinated contraction of the atrial walls. Meanwhile, some of these fibers excite a
group of cells located at the border of the left atrium and ventricle known as the
atrioventricular (A-V) node. The A-V node is responsible for spreading the excitation
throughout the two ventricles and causing a coordinated ventricular contraction.
24

IV. PATHOPHYSIOLOGY

A. NARRATIVE FORM

Microorganisms that produce pneumonia can end up in air sacs in several ways.
In some cases, people inhale microorganisms (which are present in tiny droplets) when
they are near someone already infected. Spread in hospitals and nursing homes often
occurs this way. More common among older people, however, is the presence of
bacteria in their throat (colonization). These bacteria may remain there harmlessly or
suddenly cause pneumonia if mucus or food is inhaled into the airway (aspiration)
instead of passed into the esophagus. When aspiration occurs, the food or mucus can
make its way into the lungs, carrying the bacteria from the throat along for the ride.
Rarely, microorganisms from elsewhere in the body reach the lungs by traveling through
the bloodstream. These are usually blood borne microorganisms that enter the
pulmonary circulation and are trapped in the capillary bed, becoming a potential source
of pneumonia.

Pneumonia often affects both ventilation and diffusion. An inflammatory reaction


can occur in the alveoli, producing an exudate that interferes with the diffusion of
oxygen and carbon dioxide. White blood cells, mostly neutrophils, also migrate into the
alveoli and fill the normally air-containing spaces. Areas of the lung are not adequately
ventilated because of secretions and mucosal edema that cause partial occlusion of the
bronchi or alveoli, with a resultant decrease in the alveolar oxygen tension. Because of
hypoventilation, a ventilation-perfusion mismatch occurs in the affected area of the lung.
Venous blood entering the pulmonary circulation passes through the underventilated
area and exits to the left side of the heart poorly oxygenated. The mixture of oxygenated
and unoxygenated blood eventually results in arterial hypoxemia.

Pleural effusion is an indicator of an underlying disease process that may be


pulmonary or nonpulmonary in origin, acute or chronic.

 Normal pleural fluid has the following characteristics:


o Clear ultrafiltrate of plasma that originates from the parietal pleura
25

o pH 7.60-7.64
o Protein content less than 2% (1-2 g/dL)
o Fewer than 1000 WBCs per cubic millimeter
o Glucose content similar to that of plasma
o Lactate dehydrogenase (LDH) less than 50% of plasma
o Sodium, potassium, and calcium concentration similar to that of the
interstitial fluid

 The following mechanisms play a role in the formation of pleural effusion:


o Altered permeability of the pleural membranes (eg, inflammation,
malignancy, pulmonary embolus)
o Reduction in intravascular oncotic pressure (e.g., hypoalbuminemia,
cirrhosis)
o Increased capillary permeability or vascular disruption (e.g., trauma,
malignancy, inflammation, infection, pulmonary infarction, drug
hypersensitivity, uremia, pancreatitis)
o Increased capillary hydrostatic pressure in the systemic and/or pulmonary
circulation (eg, congestive heart failure, superior vena cava syndrome)
o Reduction of pressure in the pleural space, preventing full lung expansion
(eg, extensive atelectasis, mesothelioma)
o Decreased lymphatic drainage or complete blockage, including thoracic
duct obstruction or rupture (eg, malignancy, trauma)
o Increased peritoneal fluid, with migration across the diaphragm via the
lymphatics or structural defect (eg, cirrhosis, peritoneal dialysis)
o Movement of fluid from pulmonary edema across the visceral pleura
o Persistent increase in pleural fluid oncotic pressure from an existing
pleural effusion, causing further fluid accumulation

The net result of effusion formation is a flattening or inversion of the diaphragm,


mechanical dissociation of the visceral and parietal pleura, and a restrictive ventilatory
defect.
26

B. SCHEMATIC DIAGRAM

Precipitating factor: Predisposing factor:


>prolonged back rest >stress
>aspiration >exposure to polluted air
>inhaled microorganism (Bacteria) >depressed cough reflex

Inhalation of causative agents (CA):


Streptococcus pneumoniae

Inhaled in the alveolus

Reproduction of CA in the lungs

Activation of first line of defense


S/sx: cough, mucus production

Partial occlusion of bronchus alveoli

Inflammation
27

Increased capillary permeability or vascular disruption

Exudates
SIGNS AND SYMPTOMS:
Dyspnea Complication:
chest pain Atelectasis
decreased tactile fremitus Pleural Effusion Infection
diminished or absent breath sounds hypoxemia
pleural friction rub during both inspiration and expiration
dry nonproductive cough
shortness of breath
Treated Not treated

Prevents serious Metastasis of


Complications Complications

Recovery Danger to health


(serious)
28

NURSING CARE PLAN

NURSING DIAGNOSIS

Ineffective Breathing Pattern related to difficulty of breathing secondary to pneumonia

ASSESSMENT DATA (SUBJECTIVE AND OJECTIVE CUES)

Subjective Cue:

“Maglisod ko ug ginhawa usahay, murag dili ko kaginhawa”, as verbalized by the


patient.

Objective Cue:

- Nonproductive cough noted

- Dyspnea on exertion

- Pursed-lip breathing

- Nasal flaring

- Chest pain, scale of 6/10

GOALS AND OBJECTIVE

Short Term Goal:

After 1 hour of Nursing Intervention, the patient will:

- Deep breathing exercises

- Use of relaxation techniques

- Verbalize understanding of technique in doing deep breathing exercise

- maintain adequate ventilation and oxygenation

- maintain a patent airway

Long Term Goal:

After 4-5 days of Nursing Care, the patient will be able to establish a
normal/effective respiratory pattern.
29

NURSING INTERVENTION

Independent:

 Instruct the patient to do deep breathing exercises

R> to assist the patient in “taking control” of the situation/inspiration

 Assist for discomfort and place patient in a high back position

R> This would limit/restrict respiratory effort.

 Monitor pulse oximetry as indicated.

R> To verify maintenance of O2 saturation

Dependent:

 Medicate with analgesics as appropriate to promote deeper respiration and


cough.

R> Tramadol 50mg IVTT q8h is given

Collaborative:

 Assist with Chest Thoracentesis Tube insertion as indicated

R> To drain fluid in the pleural space.

EVALUATION

Short Term Goal = Goals met

The patient was able to participate and perform deep breathing exercises and
verbalizes understanding about the relaxation techniques when the patient has
dyspnea.

Long Term Goals = Goals not met

The goal in not yet met since the patient still has pneumonia and needs for
further evaluation.
30

NURSING DIAGNOSIS
Acute Pain related to inflammatory process of the Pleural Effusion due to infectious
process from pneumonia.

ASSESSMENT DATA (SUBJECTIVE AND OJECTIVE CUES)

Subjective Cue:

“Sakit akong dughan duol sa bangag didto sa nay tubo”, as verbalized by the
patient.

Objective Cue:

- Chest pain, scale of 6/10

- Guarding behavior noted

- Positioning to avoid injury near CTT observed

- Reduced interaction to people observed

- Flaccid muscle tone of the left arm near CTT noted

- Localized pain identified by the patient

GOALS AND OBJECTIVE

Short Term Goal:

After 8 hours of Nursing Intervention, the patient will:

- Report relief of pain or controlled

- report reduced levels of concern to attached tubing

Long Term Goal:

After 3-4 days of Nursing Care, the patient will experience controlled pain
regarding the draining of the pleural fluid.

NURSING INTERVENTION

Independent:

 Assess the client’s description of pain

R> Pain is a subjective experience & cannot be felt by others but can be
objective when assessed in scale of 0-10

 Observe non verbal cues/pain behaviors

R> To determine the congruency of pain reactions to client’s verbalization of


pain.
31

 Instructed to do relaxation techniques, such as focused breathing.

R> To distract attention & reduce tension from pain.

 Monitor the skin color/temperature & vital signs.

R> These are usually altered in severe pain.

Dependent:

 Administer analgesics, as indicated to maximum dosage, as needed.

R> To maintain acceptable level of pain. Given with Tramadol every 8 hours
50mg via IVTT route.

EVALUATION

Short Term Goal = Goals met

The patient reported relief or controlled pain from pain scale of 6/10 to 4/10 after
given with the medication in given intervals. Also used relaxation techniques and
followed treatment regimens.

Long Term Goals = Goals not met

The goal is not met as it has to be evaluated yet.


32

NURSING DIAGNOSIS
Risk for Infection related to, damaged tissue integrity due to insertion of CTT.

ASSESSMENT DATA (SUBJECTIVE AND OJECTIVE CUES)

Objective Cue:

- Has attached Chest Thoracostomy Tube on the left mid-axillary line noted

GOALS AND OBJECTIVE

Short Term Goal:

After 8 hours of Nursing Intervention, the patient will:

- Be free of purulent drainage

- Prevent or decrease the risk of infection

- Be placed with a new dressing to the wound

- Provide clean environment for the patient’s safety to infection

Long Term Goal:

After 2-3 days of Nursing Care, the will maintain an infection free environment
from harmful pathogens.

NURSING INTERVENTION

Independent:

 Note the risk factors of occurrence of infection like skin/tissue wounds

R> to assess causative or contributing factors of infection

 Observe for localized signs of infection at insertion site of invasive lines,


surgical incision or wound.

R> to determine the portal of entry causing infection

 Change surgical wound dressing as indicated using proper technique for


changing or disposing the contaminated materials.

R> to reduce the risk for infection

Dependent:

 Discuss importance of not taking antibiotic or using left over drugs unless
specifically instructed by the health care provider.

R> inappropriate use can lead to drug-resistant strains.


33

EVALUATION

Short Term Goal = Goals met

Providing a clean environment for the patient was given in order to prevent
infection from the damaged tissue due to CTT draining of pleural fluid. The surgical
dressing was not advised to be replaced since the chest was totally covered or no
openings were noted for risk of infection.

Provision of clean clothes was given in order to prevent infection of the CTT site.

Long Term Goals = Goals not met

The goal is not met as it has to be evaluated yet.


34

DRUG STUDY
NURSING
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS
DRUG ORDER INDICATIONS RESPONSIBILITIES/
ACTION OF THE DRUG
PRECAUTIONS

Generic name: A second – generation Treatment of History of Antibiotic – associated Question for history of
Cefuroxime cephalosporin that susceptible infections anaphylactic reaction colitis and other supr allergies, particularly
binds to bacterial cell due to group B to penicillins or infections may result cephalosporins,
membranes and streptococci, hypersensitivity to from altered bacterial penicillins. Assess
Brand name: inhibits cell wall pneumococci, cephalosporins. balance. oral cavity for white
Ceftin synthesis staphylococci, H. patches on mucous
Influinzae, E.coli. Cautions: renal membranes, tongue,
Classification: Therapeutic Effect: impairment, history of monitor bowel activity
Antibiotic Bactericidal GI disease (especially and stool consistency
ulcerative colitis, carefully; mild GI
antibiotic – associated effects ,may be
Dosage: colitis), concurrent tolerable, but
750 mg use of nephrotoxic increasing severity
medications. may indicate onset of
antibiotic associated
colitis. Monitor I&O,
renal function reports
Route: for nephrotoxicity. Be
IVTT alert for
superinfection: severe
Frequency: genital/anal pruritus,
q8h severe mouth
soreness, moderate to
severe diarrhea.
35

NURSING
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS
DRUG ORDER INDICATIONS RESPONSIBILITIES/
ACTION OF THE DRUG
PRECAUTIONS

Generic name: An analgesic that Management of Acute alcohol Seizures have been Check the prescribed
Tramadol binds to mu-opioid moderate to intoxication, reported in patients medication for 3 time
hydrochloride receptors and inhibits moderately severe concurrent use of receiving tramadol on the first encounter,
reuptake of pain. centrally acting within the before and after
norepinephrine and analgesics, hypnotics, recommended dosage withdrawing the med
Brand name: serotonin reduces the opioids, or range. Overdose R> so that the
Ultram intensity of pain psychotropic drugs, results in respiratory medicine is properly
stimuli reaching hypersensitivity to depression and checked according to
sensory nerve opioids. seizures. Tramadol the doctor’s
Classification: endings. may not have prescription.
Analgesic prolonged duration of
Therapeutic Effect: action and cumulative Give first health
Alters the perception effect in patients with teaching before giving
Dosage: of and emotional hepatic or renal the patient.
50mg response to pain. impairment. R> to make the patient
prepare and know
what to expect

Route: The med should be


IVTT given in IVTT route
according to the
Frequency: doctor
q8h R> Follow the doctor’s
order as prescribed to
the patient.
36

NURSING
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS
DRUG ORDER INDICATIONS RESPONSIBILITIES/
ACTION OF THE DRUG
PRECAUTIONS

Generic name: Paracetamol exhibits For treatment of mild No known Nausea, allergic The medication should
Paracetamol analgesic action by to moderate pain and contraindications. reaction, skin rashes, be given in IVTT.
peripheral blockage of fever. acute renal tubular R> this is according to
Brand name: pain impulse necrosis. the doctor’s order.
- generation. It
produces antipyresis Potentially Fatal: Very Assess patient for any
by inhibiting the rare, blood dyscrasias drug allergy to the
Classification: hypothalamic heat – (e.g., medicine.
Analgesics and regulating center. Its thrombocytopenia, R> to determine if the
Antipyretics weak anti- leukopenia, patient is allergic to
inflammatory activity neutropenia, drug
is related to inhibition agranulocytosis); liver
Dosage: of prostaglandin damage. Intruct the patient/
300mg synthesis in the CNS. give first health
teaching before giving
the patient.
Route: R> to make the patient
IVTT prepare and know
what to expect
Frequency:
PRN
37

HEALTH TEACHING

The patient with Pleural Effusion needs to be given attention especially if the
patient has experienced pain in the site if CTT, had dyspnea, chest pain, nonproductive
cough.

The following are some Nursing Management on Pleural Effusion:

Management:

1. Assess for associated problems.

2. Administer medications which may be prescribed for associated problems such


like Tramadol 50mg IVTT for management of pain.

3. Implement a plan of care that is teaching the client to do deep breathing exercise
since the client has shortness of breath.

4. Encourage the patient and the significant others to do counseling.

5. Explain to the significant others the limitation of the patient’s mobility due to
attached chest thoracostomy tube.

6. Explain tests and procedures to the patient, including thoracentesis, and answer
questions he has.

7. Before thoracentesis, tell the patient to expect a stinging sensation from the local
anesthetic and a feeling of pressure when the needle is inserted. Instruct him to tell you
immediately if he feels uncomfortable or has trouble breathing during the procedure.

8. If the patient developed pleural effusion because of pneumonia or influenza, tell him to
seek medical attention promptly whenever he gets a chest cold.

9. Teach the patient the signs and symptoms of respiratory distress. If any of these
develop, tell him to notify his physician.

10. Fully explain the drug regimen, including adverse effects. Emphasize the importance of
completing the prescribed drug regimen.

11. If the patient smokes, urge him to stop.


38

LEARNING EXPERIENCE

As part of the learning process, there are things that you need to discover
yourself and need to explore in order to fulfill the things that you are curious about. And
I have learned something from this. Although there are hard times and mistakes that we
may encounter, there is only one thing that you can appreciate more which is the
experience. I have learned that through this individual case study, I was able cope
myself in doing the requirement alone without the assistance of anybody, which makes
me feel joyous since this is a tough thing to make a case study. I have learned from this
case the hardship and the joy of fulfilling the requirement and it is a one way step of
developing my skills in doing the case study.

I realized that one should work hard amidst of your limits and accomplish
the things that you are ought to do. Not by just passing a requirement but also learning
from it as part of you dream to become an effective nurse in the future. One must have
focus and not to left the things unappreciated for nurses deals with the lives of many
individuals and thus must be accountable for the patient’s life in alleviating the pain,
restoring the health, etc as possible it may be.

Lastly, as a student nurse, I have learned and kept in mind the most
important thing to do for our patient and that is not to get mistakes in rendering care for
our patient for one slip could end up the life of your patient and that could be your
hardest thing that could happen for you and the patient’s family of losing one’s life in just
a minor mistake. So I guess that I should practice myself to seek for perfection in giving
care to patients and diminish the faulty errors in the clinical area when you are on duty.

At a short period stay at NMMC Medical Ward, I am a student nurses on


action. It is where I put all of what I am in extreme preparation. You should not waste
time doing senseless distractions, rather gain from your opportunities, reading, handling
cases and interactions are just a few that we have mastered. Although change does not
happen overnight, it is a good feeling to know that you have controlled yourself and
leading it to make a difference. As our duty progresses, we have established a great
bond among our group mates. We learn together, we work together and care for each
other and that is the beauty in our group. We never fail to be concerned towards each
other as it is just more than a group but a family.
39

DISCHARGE PLAN

M-MEDICATION

Explain the purpose, dosage, schedule, and route of administration of any prescribed
drugs, as well as side effects to report to the physician or nurse.

Instruct the watcher to refer any abnormalities about the pt. to the nurse or physician to
prevent complications. (The patient is not yet discharged and there were no PO meds
given in the hospital except for IVTT meds).

Outpatient medication therapy is directed at the underlying etiology of the effusion.

A social services professional should be consulted when a patient cannot afford


prescribed medications.

E-EXERCISE

The patient is advised to take rest after discharge in order to prevent injury and to
regain strength. The site of effusion needs proper attention and careful not to be
strained. The patient is not advised to do hard and stressful work yet he can still take
walking exercise that he is capable of doing.

T-TREATMENT

Patient is advised to consult his physician if he cannot afford the treatment. It is best
that the health care provider is aware so that he can make adjustments. Instruct
significant others to monitor patients condition.

H-HEALTH TEACHINGS
Teach the significant others on the simple pathology and physiology of the disease to
help them understand and to clarify misconceptions of the disease. Discuss the possible
causes of the disease, prognosis, and describe the disorder. Demonstrate to significant
others the proper wound care, administration of medicines and how to care for the
patient. Explain the effects of the treatment of the patient and what to do when side
effects occur. Aware the patient and significant others the importance of knowing the
40

Do’s and Don’ts while the effusion is still present. Determine the patient’s expectations
to alleviate fear and anxiety.

OUT-PATIENT CHECK-UP
Follow-up with the patient's primary care physician or a pulmonary specialist within 2-3
days is advisable, especially if thoracentesis is deferred.

If early follow-up seems unlikely, the patient should be given clear instructions to return
to the ED in 2-3 days for reevaluation.

Patient is instructed to have a regular check up in the hospital if there are any signs of
complications of risks and if there is also improvement or progress regarding his case.

DIET

Instruct patient’s family, significant other to follow recommended diet provided by her
dietician if any.

SPIRITUAL

Patient’s family is very religious that is why we always continue to encourage him to
remain that faithful and strong to God. Continue praying and reading the bible and never
forget that during times of difficulties, God carries our burden. It is about putting our trust
in him and never giving up.

DOCTOR’S ORDER
41

January 7, 2010 Thursday


11pm
 Please admit pt at P1F2 (male charity ward)
 Secure consent to care
 DAT
 Venolysis with PNSS 1L @ 30gtts/min
 IVFTT PNSS 1L @ 30gtts/min
 Nursing
1. VS q4h & record
Refer if BP ≥ 130/90 < 90/60mmHg
HR > 100 < 60 beats/min
RR > 24 < 12 beats/min
2. I&O q shift
3. Refer for signs of respiratory distress
Chest pain, SOB and cyanosis

CXR: Consider, Pneumonia


L
PA w/ Pleural eff.
 Diagnostics
1. CBC with pH ct
2. URA
3. CXR – PA view (attached)
 Therapeutics
1. Cefuroxime 750mg IVTT q8h ANST
2. Paracetamol 300mg IVTT q4h for fever 38.5 0C
o For thoracenthesis w/ local anesthesia
o Refer for unsualities

January 14, 2010 Thursday


11:40 am
> anemia > CTT drainage monitoring of output
> asthmatic > continue meds
> SOB > repeat CBC with pH today
> refer
> IVF with PNSS 1L @ 30gtts/min x 3

January 15, 2010 Friday


11:45am
> - SOB > for Sputum AFB 3x
> C/L: ECE, CBR > encourage breathing exercise
> DTB – murmur > continue present meds
> good posture > may D/C O2 inhalation, standby PRN
> IVF w/ PNSS 1L @ 30gtts/min x3 cycle
> continue CTT bottle draining monitoring
42

January 16, 2010 Saturday


10:00am
> - SOB > for Sputum AFB
> - chest pain > continue present meds
> C/L: ECE, CBR > continue CTT bottle drainage monitoring
> DTB, - murmur > refer
> good posture, > IVF w/ PNSS 1L @ 30gtts/min x3 cycle
- edema

CTT drainage
reading

REFERENCE:

 www.wisegeek.com

 www.wikipedia.com

 www.emedicine.medscape.com
 Black & Hawks. Medical – Surgical Nursing Clinical Management for Positive
Outcomes. Saunders Elsevier 8th edition.

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