OURLADY OF FATIMA UNIVERSITY

College of Nursing Valenzuela City

A Case Study
On

Pleural Effusion
In Partial Fulfillment Of the course NCM 103 Submitted to:

THFS 6:00 pm 2:00 pm

TABLE OF CONTENTS

I. II. III.

Introduction Clients Profile Anatomy and Physiology

IV. Pathophysiology Diagnostic Procedures and Lab Result

V.

VI. Drug Study VII. Nursing Care Plans VIII. Discharge Plan IX. Learning Insights X. Reference

I. INTRODUCTION
Our group chose this case as interesting to us because it is a common disease entity that is usually underestimated as a cause of mortality and morbidity to patients. We would like to make an outlook of what this case is and gather information that can help us learn how it occurs, manifest, develop and cause a disease. It is our goal to identify the risk factors that affects people making them at risk for the disease. How is the disease being treated. And by learning from the inputs we gather from out patient. We discuss pleural effusion as its definition as the collection of at least 10-20 mL of fluid in the pleural space. Pleural effusion develops because of excessive filtration or defective absorption of accumulated fluid. Pleural effusion may be a primary manifestation or a secondary complication of many disorders. Pleural effusions are failure and usually classified as transudates and exudates. Diseases that affect the filtration of pleural fluid result in transudate formation, such as in congestive heart nephritis. Transudates usually occur bilaterally because of the systemic nature of the

causative disorders. Inflammation or injury increases pleural membrane permeability to proteins and various types of cells and leads to the formation of exudative effusion Infectious effusions are usually unilateral. However, a recent large Turkish study revealed bilateral effusion in 5% of 515 children. Its frequency occurs, as in the US: American and international frequencies are similar. The prevalence of pleural infections appears to be increasing in some developed countries; this could be partly due to increased referral of patients with these conditions to tertiary-care pediatric hospitals. Nonbacterial infectious agents, such as viruses and Mycoplasma pneumoniae, cause more pleural effusion in children than do bacterial organisms. more frequently than bacterial infections, explaining the observation Although above. that As bacteria are more likely than viruses to cause effusion, viral infections in children occur many as 20% of the viral infections can cause small and transient effusions

resolve spontaneously, affects internationally and more frequently on developed nations. Several decades ago, pleural effusion was a complication of 70% of all cases of Staphylococcus aureus pneumonia, with positive cultures resulting from 80% of pleuralfluid specimens. In the late 1970s, pleural effusion occurred in 75% of cases of pneumonia secondary to Haemophilus influenzae type b. In a report by Murphy et al, empyema complicated the course of pneumonia in 9 of 21 patients with Streptococcus pneumoniae pneumonia. Chartrand and McCracken indicated that empyema complicated the course of pneumonia in 57 of 79 patients with S aureus infections.

Pleural effusion occurs in 6-12% of all cases of pulmonary tuberculosis (TB) in children. Of 175 Spanish children with pulmonary TB, 39 (22.1%) had pleural effusion. Congenital effusions, including chylothorax, occur in 1 per 10,000-15,000 live births annually. In a review of 74 patients with intrathoracic lymphomas, Chaignaud et al found pleural effusions in 10 (71%) of 14 children with lymphoblastic lymphoma and in 7 (12%) of 60 children with non-Hodgkin lymphoma. The outcome of this condition affects the morbidity and mortality of patients. Most effusions caused by viral and mycoplasmal infections resolve spontaneously. Empyema has a complicated course if not treated early, especially in children younger than 2 years. Thirty years ago, the mortality rate from empyema was 100%. At present, the mortality rate from empyema is 6-12% in infants younger than 1 year. Malignant effusion worsens the patient's prognosis depending on the underlying tumor. With regards to its ratio. Pleural effusions may be more common in boys than in girls.

II. CLIENTs PROFILES Patient is 52 years-old female, Filipino, Roman Catholic from the province of Jasaan, Misamis Oriental. She was admitted at Northern Mindanao Medical Center last August 17, 2010 at 3:00 PM due to shortness of breath, Tightness of the chest, dry cough and abdominal enlargement. Patients vital signs are: Blood Pressure of 130/90 mmHG, temperature of 36.7 degree Celsius, respiratory rate of 29 cpm and a heart rate of 110 bpm. At present she weighs 58 kls. HISTORY OF PRESENT ILLNESS One week Prior to admission, patient submitted self for a medical check One month prior to admission, patient started having shortness of breath. She endured that condition for a month. up by Dr. Alejo at a polyclinic due to body malaise and was diagnosed as having U.T.I. She was then referred to an Internal Medicine specialist, Dr. Ampong for further assessment. Dr. Ampong Diagnosed her as having Pleural Effusion, Massive Ascites and some abnormalities in her ovary. She was again referred to another specialist, an OB-GYNE, Dr. Mangganges. The OB-GYNE found some abnormal growth in her ovary and suggested her to undergo a treatment. But The OB-GYNE refused to start the treatment unless pleurais cleared from the edema. So, She then was admitted at the Northern Mindanao Medical Center Payward, Annex 3 floor 2 to undergo Chest Thoracostomy for Excessive Pleural Fluid clearance. PRE-HOSPITALIZATION Health Perception-health management pattern: Patient X is a 43 years-old male that is dependent to his own decision and care. Patient X was not active to his daily routine. During onset of coughing the patient verbalizes, Gasige lng kog ubo-ubo sir. Due to his illness, he cannot perform his daily routine that he is usually doing when he is still not sick. Nutritional metabolic pattern: (While confined) Patient X said he takes 1500cc of water a day, and takes 3 meals in a day with a combination of 1-2 cups rice with different viand. He has poor appetite that sometimes he cannot consume his meal. Wala koy gana mo kaun sir as verbalized by the patient. He was ordered to have a Low-salt and Low-Fat Diet.

He is also fond of drinking alcoholic beverages for 15 years and a smoker for 10 years. He can consumed 1 pack of cigarette per day. Elimination pattern: (while confined) Patient X has a normal elimination pattern. He defecates one time a day with moderate amount, soft stool, and light-brown in color. There was no problem on his urination; he can urinate 3-5 times per day. . Activity exercise pattern: (while confined) Prior to confinement, the patient was be able to do the activities of daily living by himself not until a day prior to confinement he always ask for assistance in doing his activities of daily living because hes anxious he might fall down. Patient was advice to refrain from doing strenuous activity because of his condition. Galisud ko ug ginhawa kung mahago ko as verbalized by the patient. Sleep-rest pattern: (while confined) Patient X has a normal sleeping pattern and would sleep at most 6-8 hrs per day, he was easily get distracted and awaken by any environmental stimuli, especially when taking his medications. Watching TV makes him fall asleep. Cognitive-perceptual pattern: Patient was calm, responsive, conscious, well oriented with time and place and with normal behavior of communication. Role-relationship pattern: (while confined) Patient X is married, a good provider and was happy being with his family. Hes been wishing that everybody is well, so that it would not add to his daily financial needs. Sexuality and Reproductive Pattern Patient X said that he is not so much active in his sexual patterns. Coping-Stress Tolerance Pattern Having this condition makes him challenge, and think that everything will be alright, though he remains to be calm but he is a bit worried. Value-Belief Pattern

He is a Roman Catholic and dont believe in superstitious beliefs. He said, God is our savior and he is our creator, he has a plan for me.

PHYSICAL ASSESSMENT ASSESSMENT DATA SKIN Color Temperature Turgor Texture Lesion Integrity Others NAILS Color Texture Shape Others HAIR Color Texture Distribution Quantity Others HEAD Shape Size Configuration Headache Round Normocephalic Symmetrical None Pinkish Smooth Concave Poor capillary refill = 3 sec Black Coarsely dry Evenly distributed Moderate Fair 37.1 C Good skin turgor Moist skin (-) Lesions/Rash Intact ASSESSMENT FINDINGS BEFORE (SEPT 23, 09)

ASSESSMENT DATA EARS Hearing Tinnitus Vertigo Earaches Infection DischargesS Others Good None No vertigo No earaches No infection No discharges

NOSE AND SINUSES Frequent colds Nasal stiffness Nose bleed Sinus trouble MOUTH & THROAT Condition of teeth Bleeding gums Tongue Throat Hoarseness Mucous membrane ASSESSMENT DATA NECK Symmetry Condition of trachea Thyroid Lymph nodes None None None Sinuses are non tender Incomplete teeth No bleeding Tongue is at midline, Throat Non-tender None Pinkish ASSESSMENT FINDING Symmetrical in the midline (-) nonpalpable (-) nonpalpable LUNG Symmetry Shape Respiratory movements # of breath Symmetrical A:P diameter 1:2 Asymmetrical, use of accessory muscles 26cpm

AUSCULTATION: Character of respiration HEART AND NECK VESSELS: Apical Pulse Cardiac Sounds Apical/Radial pulse data Blood pressure Pulse pressure Any special procedure Done ASSESSMENT DATA ABDOMEN: Symmetry Contour Skin Lesion Masses Bowel Sounds Tenderness MUSCULOSKELETAL SYSTEM: Posture abnormal postures arent present ROM Muscle Strength active-passive 4/5 ASSESSMENT FINDING Symmetrical Globular none (-) Masses Normoactive bowel sounds none 107 bpm (-) murmurs Not assessed (+) rales on upper lung lields Decrease breath sounds on left lung field

HEAD AND NECK: Facial muscle symmetry Swelling Scars Discoloration Weakness ROM Posterior neck cervical spine Muscle spasm Crepitus Symmetrical None None None (+) Weakness

can turn head from side to side

Non-tender (-) Spasm (-) Crepitus heard

MOTOR SYSTEM: Muscle tone Ability to move extremities against gravity Spasticity, flaccidity or rigidity, tremors, lies none Without hypertrophy or atrophy Muscle strength is 4/5

MENTAL STATUS: LOC Long term memory Short Term Memory Conscious Not assessed

III. ANATOMY AND PHYSIOLOGY

Human Respiratory System

The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain.

Nose A nose is a protuberance in vertebrates that houses the nostrils, or nares, which admit and expel air for respiration in conjunction with the mouth. Behind the nose are the olfactory mucosa and the sinuses. Behind the nasal cavity, air next passes through the pharynx, shared with the digestive system, and then into the rest of the respiratory system. In humans, the nose is located centrally on the face; on most other mammals, it is on the upper tip of the snout. In cetaceans, the nose has been reduced to the nostrils, which have migrated to the top of the head, producing a more streamlined body shape and the ability to

breathe while mostly submerged. Conversely, the elephant's nose has elaborated into a long, muscular, manipulative organ called the trunk.

Mouth The mouth, buccal cavity, or oral cavity is the first portion of the alimentary canal that receives food and begins digestion by mechanically breaking up the solid food particles into smaller pieces and mixing them with saliva.[1] The oral mucosa is the mucous membrane epithelium lining the inside of the mouth.In addition to its primary role as the beginning of the digestive system, in humans the mouth also plays a significant role in communication. While primary aspects of the voice are produced in the throat, the tongue, lips, and jaw are also needed to produce the range of sounds included in human language. Another nondigestive function of the mouth is its role in secondary social and/or sexual activity, such as kissing. The physical appearance of the mouth and lips play a part in defining sexual attractiveness. The mouth is normally moist, and is lined with a mucous membrane. The lips mark the transition from mucous membrane to skin, which covers most of the body. Pharynx The pharynx (plural: pharynges) is the part of the neck and throat situated immediately posterior to (behind) the mouth and nasal cavity, and cranial, or superior, to the esophagus, larynx, and trachea. The pharynx is part of the digestive system and respiratory system of many organisms.Because both food and air pass through the pharynx, a flap of connective tissue called the epiglottis closes over the trachea when food is swallowed to prevent choking or aspiration. In humans the pharynx is important in vocalization.

Epiglottis The epiglottis is a flap of elastic cartilage tissue covered with a mucus membrane, attached to the root of the tongue. It projects obliquely upwards behind the tongue and the hyoid bone. The term is, like tonsils, often incorrectly used to refer to the uvula. The epiglottis guards the entrance of the glottis, the opening between the vocal folds. It is normally pointed upward during breathing with its underside functioning as part of the pharynx, but during swallowing, elevation of the hyoid bone draws the larynx upward; as a result, the epiglottis folds down to a more horizontal position, with its upper side functioning as part of the pharynx. In this manner it prevents food from going into the trachea and instead directs it to the esophagus, which is more posterior. The epiglottis is one of nine cartilaginous structures that make up the larynx (voice box). While breathing, it lies completely within the pharynx. When swallowing it serves as part of the anterior of the larynx. Larynx The larynx (plural larynges), colloquially known as the voicebox, is an organ in the neck of mammals involved in protection of the trachea and sound production. The larynx houses the vocal folds, and is situated just below where the tract of the pharynx splits into the trachea and the esophagus. Sound is generated in the larynx, and that is where pitch and volume are manipulated. The strength of expiration from the lungs also contributes to loudness. Fine manipulation of the larynx is used to generate a source sound with a particular fundamental frequency, or pitch. This source sound is altered as it travels through the vocal tract, configured differently based on the position of the tongue, lips, mouth, and pharynx. The process of altering a source sound as it passes through the filter of the vocal tract creates the many different vowel and consonant sounds of the world's languages as well as tone, certain realizations of stress and other types of linguistic prosody. The larynx also has a similar function as the lungs in creating pressure differences required for sound production; a constricted larynx can be raised or lowered affecting the volume of the oral cavity as necessary in glottalic consonants. Trachea

The trachea, or windpipe, is a tube that connects to the pharynx or larynx, allowing the passage of air to the lungs. It is lined with pseudostratified ciliated columnar epithelium cells with mucosal goblet cells which produce mucus. This mucus lines the cells of the trachea to trap inhaled foreign particles which the cilia then waft upwards towards their larynx and then the pharynx where it can either be swallowed into the stomach or expelled as phlegm.

Bronchi The trachea (windpipe) divides into two main bronchi (also mainstem bronchi), the left and the right, at the level of the sternal angle at the anatomical point known as the carina. The right main bronchus is wider, shorter, and more vertical than the left main bronchus. The right main bronchus subdivides into three lobar bronchi while the left main bronchus divides into two. The lobar bronchi divide into tertiary bronchi, also known as segmental bronchi, each of which supplies a bronchopulmonary segment. A bronchopulmonary segment is a division of a lung that is separated from the rest of the lung by a connective tissue septum. This property allows a bronchopulmonary segment to be surgically removed without affecting other segments. There are ten segments per lung, but due to anatomic development, several segmental bronchi in the left lung fuse, giving rise to eight. The segmental bronchi divide into many primary bronchioles which divide into terminal bronchioles, each of which then gives rise to several respiratory bronchioles, which go on to divide into 2 to 11 alveolar ducts. There are 5 or 6 alveolar sacs associated with each alveolar duct. The alveolus is the basic anatomical unit of gas exchange in the lung.

Alveoli An alveolus (plural: alveoli, from Latin alveolus, "little cavity") is an anatomical structure that has the form of a hollow cavity. Found in the lung, the pulmonary alveoli are spherical outcroppings of the respiratory bronchioles and are the primary sites of gas exchange with the blood. Alveoli are particular to mammalian lungs. Different structures are involved in gas exchange in other vertebrates. Each human lung contains about 150 million alveoli. Each alveolus is wrapped in a fine mesh of capillaries covering about 70% of its area. An adult alveolus has an average diameter of 0.20.3 mm, with an increase in diameter during inhalation.

IV. PATHOPHYSIOLOGY

Predisposing Factor Age, gender

Precipitating Factors: Lifestyle, environmental

Inflammation of airways

wheezing

Bronchial edema

Increased mucus secretion

Broncoconstrict -ion

Bronchial spasm

Worsening of obstruction

Dsypnea, cold and clammy skin, diaphoresis

Accumulation of fluids caused by over secretion

Multiplication of growth of organism Inflammation in the epithelial wall Fluid filled alveoli/lobar copartment Shallow breathing, RR increase Excess fluid accumulate d in spaceperica rdial Pleural effusion Rupture of inflamed endothelial cells Mismatch of ventilation and perfusion Mismatch of ventilation and perfusion Hypoxemia Hypoxia Dyspnea

V. DIAGNOSTIC PROCEDURE AND LABORATORY RESULT

CBC The CBC is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood. September 24, 2009 Test WBC RBC HEMOGLOBIN HEMATOCRIT MCV MCH MCH-C RDW-CV Result 18.0 3.47 7.7 25.6 73.8 22.2 30.1 17.1 Unit 1O^3/uL 10^6/uL g/dL % fL Pg g/dL % References 5.0-10.0 4.2-5.4 12.0-16.0 37.0-47.0 82.0-98.0 27.0-31.0 31.5-35.0 12.0-17.0

IMPRESSION: Increased White Blood Cells may be with infections and inflammation. Red Blood Cell decreased with anemia also with Hemoglobin and Hematocrit because this mirrors RBC results. Mean Corpuscular Volume decreased with iron deficiency and thalassemia. MCH mirrors MCV results. MCHC may be decreased when MCV is decreased. Increased RDW indicates mixed population of RBCs; immature RBCs tend to be larger. Differential Count The white blood cell differential count determines the number of each type of white blood cell, present in the blood. Monocyte Eosinophils Platelet 11.4 0.9 987 % % 10^3/uL 4.5-10.5 1.0-3.0 1500-4000

IMPRESSION: Monocyte levels can increase in response to infection of all kinds as well as to inflammatory disorders. Monocyte counts are also increased in certain malignant disorders, including leukemia. Decreased levels of eosinophils can occur as a result of infection. Platelet decreased when greater numbers used, as with bleeding; decreased with some inherited disorders.

September 25, 2009 Test WBC RBC HEMOGLOBIN HEMATOCRIT MCV MCH MCH-C RDW-CV PDW MPV Result 21.5 3.65 8.1 27.1 74.2 22.2 29.2 17.2 9.0 8.7 Unit 1O^3/uL 10^6/uL g/dL % fL Pg g/dL % fL fL References 5.0-10.0 4.2-5.4 12.0-16.0 37.0-47.0 82.0-98.0 27.0-31.0 31.5-35.0 12.0-17.0 9.0-16.0 8.0-12.0

IMPRESSION: Based on the table above it was interpreted that the significant elevation of WBC means that an infection occurred inside the body. RBC is below normal, which could reflect the body's inability to produce enough red cells to replenish what, has been lost out of the blood stream. Decreased hemoglobin and hematocrit mirrors RBC results. MCH mirrors MCV results. MCHC may be decreased when MCV is decreased. Increased RDW indicates mixed population of RBCs; immature RBCs tend to be larger.

Differential Count The white blood cell differential count determines the number of each type of white blood cell, present in the blood. Lymphocyte Neutrophil Monocyte Eosinophils Basophils Platelet 32.3 53.5 13.0 1.0 0.2 1085 % % % % % 10^3/uL 17.4-48.2 43.4-76.2 4.5-10.5 1.0-3.0 0.0-2.0 1500-4000

IMPRESSION: Monocyte levels can increase in response to infection of all kinds as well as to inflammatory disorders. Monocyte counts are also increased in certain malignant disorders, including leukemia. On the other hand, platelet decreased when greater numbers used, as with bleeding; decreased with some inherited disorders.

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: Furosemide Brand Name: Apo-Furosemide, Furosemide special, Lasix Classification: Loop diuretic Dosage: 1 mg/kg Route: IVTT Frequency: 2 hr

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/ PRECAUTIONS

Inhibits the reabsorption of sodium and chloride from the ascneding limb of the loop of Henle, leading to a sodium-rich diresis

Acute
Pulmonary edema

Contraindicated with allergy to furosemide, sulfonamides; allergy to tartrazine (in oral solution0; anuria,severe renal failure; hepatic coma; pregnancy; lactation Use cautiously with Sle, gout, diabetes mellitus.

CNS: Dizziness, weakness,headache, drowsiness,fatigue CV: Orthostatic hypotension, thrombophlebitis Dermatologic: Photosensitivity, rash,pruritus,purpura GI: Nausea, anorexia,vomiting, oral and gastric irritation, constipation, GU: Polyuria, nocturia, glycosuria, urinary bladder spasm Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and electrolyte imbalances, hyperglycemia Other: Muscle cramps and muscle spasms

Adminiser with food or milk to prevent GI upset Reduce dosage if given with other antihypertensives; readjust dosae gradually as BP responds Give early in the day so that increased urination will not disturb sleep Avoid IV use of oral use is at all possible Arrange for potassium-rich diet or supplemental potassium as needed.

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: Oxacillin sodium Brand Name: Antibiotic; Penicillinase-resistant penicillin Dosage: 600 mg Route: IVTT Frequency: q 6 hr

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/ PRECAUTIONS

Bactericidal:Inhibits cell wall synthesis of sensitive organisms, causing cell death.

Infections due to penicillinase-producing staphylococci; may be used to initiate treatment when a staphylococci infection is suspected.

containdicated with allergies to penicillins, cephalosporins, or other allergens Use cautiously with renal disordes, pregnancy, lactation (may cause diarrhea or candidiasis in infants).

CNS: Lethargy, hallucinations, seizures GI: stomatitis, glossitis, gastritis,nausea, vomiting, diarrhea, abdominal pain GU: Nephritis-oliguria, proteinuria, hematuria, pyuria Hematologic: Anemia, thrombocytopenia, leukopenia, prolonged bleeding time Hypersensitivity: Rash, fever, wheezing, anaphylaxis Local: Pain, phlebitis, thrombosis at injection site Other: Superinfections, sodium overload leading to CHF

Culture infection before treatment; reculture if response is not as expected Reconstitite for IM use to a dilution of 250 mg/1.5 mL using sterile water for injection or sodium chloride injection. Discard after 3 days at room temperature or after 7 days if refrigerated. TP: You may experiencethese side effects: Upset stomach, nausea, diarrhea, (eat frequent small meals), mouth ssores (perform mouth care), pain at the injection site

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: Cefuroxime Brand Name: Cefuroxime sodium (Zinacef) Classification: Antibiotic Dosage: 385 mg Route: IVTT Frequency: q.8 hr

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/ PRECAUTIONS

Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death

Lower respiratory infections

contraindicated with allergy to cephalosporins or penicillins Use cautiously with enal failure, lactation, pregnancy

CNS: Headache, dizziness, lethargy GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, liver toxicity GU: Nephrotoxicity Hematologic: Bone marrow deppression ( decreased WBC, decreased platelets, decreased Hct). Hypersensitivity: Ranging from rash to fever to anaphylaxis, serum sickness reaction Local: Pain, abscess at injection site, phlebitis,

NR: Culture infection, nd arrange for sensitivity tests before and during therapy if expected, response is not seen Give oral drug with food to decrease GI upset and enhance absorption Give oral drug to children who can swallow tablets: crushing the drug results in a bitter, unpleasant taste

inflammation at IV site

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective: Ineffective airway Ga sige rako ug ubo-ubo sir as related to retained verbalized by the patient. as manifested by coughing and Objective: sputum. (+) cough restlessness yellowish sputum tachycardia (PR=107 bpm) pale RR=26 cpm

clearance After 8 hours of care secretions patient will be able to: persistent yellowish a. maintain airway patency b. expectorate/clear secretions readily

Independent: After 8 hours of care - Elevate head of the bed/change goals partially met. position every 2 hours. Patient was able to: R. To take advantage of gravity decreasing pressure on the a. Maintain airway diaphragm. patency. b. Expectorate - Encouraged deep-breathing and clear secretions coughing exercises. readily as R. To mobilize secretions. evidenced by less secretions - Auscultate breath sounds and retained. assess air movement. R. To ascertain status and note progress. - Evaluate changes in sleep pattern.

R. To assess changes.

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective: Impaired gas exchange After 8 hours of care Galisud ko ug ginhawa kung related to alveolar-capillary patient will be able to: mahago ko as verbalized by the membrane changes. patient. a. Participate in treatment regimen b. Demonstrate Objective: improve - RR=26 ventilation. - Dyspnea - Restlessness - Tachycardia (PR=107 bpm) - Pale

Independent: - Monitor vital signs and cardiac rhythm. R. To evaluate degree of compromise.

After 8 hours of duty goals met. Patient was able to:

a. Participate in treatment regimen. - Elevate head of bed/position client b. Demonstrate appropriately. improve ventilation. R. To maintain airway. - Maintain adequate I/O. R. For mobilization of secretions. - Encourage frequent position changes and deep-breathing coughing exercises. R. To correct/improve existing deficiencies.

Dependent: Administer medications indicated. R. To treat underlying conditions.

as

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE Independent:

EVALUATION

Subjective: Ineffective tissue perfusion Within 2-3 hours of care Nahihirapan akong huminga (cardiopulmonary) related to patient will be able to: as verbalized by the patient. impaired transportation of the oxygen across the a. Demonstrate Objective: alveolar and/or capillary behaviors/lifestyle membrane. changes to - RR=26 cpm improve - Irritability circulation. b. Demonstrate - Restlessness increased perfusion as individually appropriate.

After 3 hours of care goals met. Patient -Identify changes related to systemic was able to: or peripheral alterations in circulation. a. Demonstrate R. To assess contributing factors behaviors/lifestyle changes to improve -Determine duration of problem. circulation R. To note degree of impairment b. Demonstrate increased perfusion as -Monitor vital signs individually R. To maximize tissue perfusion appropriate. -Investigate report of chest pain R. To note degree of impairment Dependent:

-Administer medication as ordered R. To maximize tissue perfusion

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE Independent: -Identify underlying condition involved. R. To assess causative factors. -Identify clients at risk malnutrition. R. to assess contributing factors.

EVALUATION

Subjective: Imbalanced nutrition, less After 8 hours of care Wala koy gana mo kaon sir as than body requirement patient will be able to verbalized by the mother. related to illness. demonstrate progressive good appetite. Objective: Poor muscle tone Pale Weakness

After 8 hours of care goals met. Patient was able to demonstrate progressive good for appetite.

- Discuss eating habits, including food preferences, intolerance. R. To appeal to clients like and dislike. -Assess weight, age, body build, and strength of the client.

R. To evaluate degree of deficit. Dependent: -Administer pharmaceutical agents as indicated. R. To evaluate degree deficit.

VIII. DISCHARGE PLAN M- Medication Medication includes Amikacin, Cefuroxime, Oxacilin, Furosemide. These medicines are taken depending on severity and kind of pleural effusion. E- E xercise Teaching breathing retaining exercise to increase diaphragmatic excursion and reduce work of breathing. Teach relaxation techniques to reduce anxiety with dyspnea. Augment the patients ability to cough effectively by splinting the patients chest manually. T- Treatment Follow strict compliance to treatment regimen given to improve condition especially medications, diet and lifestyle. H- Health Teachings Keep a list of your medicines: Keep a written list of the medicines you take, the amounts and when and why you take them. Bring the list of your medicines or the pill bottles when you see your caregivers. Do not take any medicines, over the counter drugs, vitamins, herbs or food supplements without first talking to caregivers. To decrease your pain; when coughing, hold a pillow over your chest where the pain is. Quit smoking. Do not smoke and do not allow others to smoke around you. Smoking increases your risk of lung infections such as pneumonia. Smoking also makes it harder for you to get better after having a lung problem. Talk to your caregiver if you need help quitting smoking. Drink enough liquids and get plenty of rest. Be sure to drink enough liquids every day. Most people should drink at least 8(oz.) Cups of water a day. This help to keep your air passages moist and better able to get rid of germs and other irritants. You may feel like resting more. Slowly start to do more each day. Rest when you feel it is needed. Exercise your lungs. The discomfort of pleural effusion may cause you to avoid breathing as deeply as you should. Coughing and deep breathing can help prevent a new or worsening lung infection. Take a deep breath and hold the breath as long as you can then push the air out of your lungs with a deep, strong cough. Take 10 deep breaths in a row every hour that you are awake. Remember to follow each deep breathe with a cough. O- Out patient Compliance to home medication regimen. D- Diet Ensure adequate protein intake such as milk, eggs, oral nutritional supplements, chicken, and fish if other treatments not tolerated.

Advice patient to eat small amounts of high-calorie and protein foods frequently rather than three daily large meals.

IX. LEARNING EXPERIENCE

Caring is our major responsibility. Thats why we have to treat everyone as such, despite the consequences we might to commit, that wouldnt matter. We learned to always have a presence of mind while on duty.

For all those times, time management best thump us a lot. We learned to adjust and manage time exactly as possible because when you say you are going to do something, you have do it right away! You dont have to wait for the time to come when its too late for you to do such actions. It would be your lose and at the end youll realized that you acquire worse. Another thing is to establish a therapeutic and a trusting relationship to each patient because thats one of the ways a person can feel free to open lines communication. And the best experience we had is to be in one piece, helping each other and persevering. Regarding this case we chose, we found it out to be enjoyable. We thought we dont have enough time focusing on this one especially that we still have other subjects to be tackled. Surfing the net and printing is money consuming but we still feel happy because doing these things helps us improved our learning about the disease and makes us think of possible task that can also be helpful to the patients At the end, were still thankful because God never put us down. All these things wouldnt be possible if nobody helps us find ways to finish this requirement. There goes the time we learned to value our selves, we learned how to be flexible, and we learn how to adjust things somehow. Its never easy but we have to be with our selves to make things possible.

X. REFERENCES BOOKS: Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurses pocket Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.). Philadelphia, Pennsylvania Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN, (2004). Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia Karch, Amy M. ; 2006 Lippicotts Nursing Drug Guide, 8th edition. Lippincott Williams & Wilkins. Nurses Pocket Guide, 10th edition F.A. Davis. Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr. Patients Chart Black, Joyce M. et. al, Medical-Surgican Nursing: Clinical Management for Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005 Malseed, Roger T. ; Springhouse Nurses Drug Guide 2004, 5th edition. Davis drug handbook, 10th edition Drug handbook by Saunders INTERNET: http://cpmcnet.columbia.edu/dept/gi/.html http://digestive.niddk.nih.gov/ddiseases/pubs/_ez/ http://www.angelfire.com/scifi2/lnuphysiology/Blood_Physiology_1.pdf http://www.drstandley.com/labvalues http://www.google.com.ph/search http://www.google.com.ph/search?anatomy&meta= http://www.merck.com/ l

ACKNOWLEDGEMENT
In behalf of our group, we would like to thank each member for their unending support and cooperation and for being patient in making this case study possible. For the sleepless nights that we have been together, that despite of each our own differences we were able to stand united through thick and thin.. To our PCI who guides us as we go along in our duties, Thank you Mrs Helen Yorong. To our diligent and responsible CI, who provides us with ample knowledge and skills to make us efficient student nurses, and for helping us develop the right attitude while in this rotation. Thank You so much, Mrs. Maria Rica Adane, RN.