College of Nursing
Cagayan de Oro City
A Case Study
On
Pleural Effusion
In Partial Fulfillment
Of the course
RLE 7
Submitted to:
Clinical Instructor
Mrs. Maria Rica Adane, RN
Submitted by:
Caralde, Maricar
Cardoza, Roxanne
Carlos, Mary Rose
Carpo, Jennifer
Carreon, Rizza Mae
Castillejos, Maryjes
Castillo, Bryan
Cervantes, Bryle Gil
Chavez, Eren Son
Chavez, Kirk Don
Cimacio, Hannah Lee
Cirera, Marlon
RLE 7 Group 7
THFS 3:00 pm – 11:00 pm
TABLE OF CONTENTS
I. Introduction
IV. Pathophysiology
X. Reference
I. INTRODUCTION
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
usually classified as transudates and exudates. Diseases that affect the filtration of
pleural fluid result in transudate formation, such as in congestive heart failure and
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.
PRE-HOSPITALIZATION
Cognitive-perceptual pattern:
Patient was calm, responsive, conscious, well oriented with time and place
and with normal behavior of communication.
Value-Belief Pattern
He is a Roman Catholic and don’t believe in superstitious beliefs. He said,
“God is our savior and he is our creator, he has a plan for me”.
PHYSICAL ASSESSMENT
ASSESSMENT FINDINGS
ASSESSMENT DATA
BEFORE (SEPT 23, 09)
SKIN
Color Fair
Temperature 37.1 º C
Turgor Good skin turgor
Texture Moist skin
Lesion (-) Lesions/Rash
Integrity Intact
Others
NAILS
Color Pinkish
Texture Smooth
Shape Concave
Others Poor capillary refill = 3 sec
HAIR
Color Black
Texture Coarsely dry
Distribution Evenly distributed
Quantity Moderate
Others
HEAD
Shape Round
Size Normocephalic
Configuration Symmetrical
Headache None
ASSESSMENT DATA
EARS
Hearing Good
Tinnitus None
Vertigo No vertigo
Earaches No earaches
Infection No infection
DischargesS No discharges
Others
LUNG
Symmetry Symmetrical
Shape A:P diameter 1:2
Respiratory movements Asymmetrical, use of accessory muscles
# of breath 26cpm
AUSCULTATION:
Character of respiration (+) rales on upper lung lields
Decrease breath sounds on left lung field
HEART AND NECK VESSELS:
Apical Pulse
Cardiac Sounds 107 bpm
Apical/Radial pulse data (-) murmurs
Blood pressure Not assessed
Pulse pressure
Any special procedure
Done
MUSCULOSKELETAL SYSTEM:
Posture
abnormal postures aren’t present
ROM active-passive
MENTAL STATUS:
LOC Conscious
Long term memory Not assessed
Short Term Memory
III. ANATOMY AND PHYSIOLOGY
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 non-
digestive 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 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.
Trachea
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
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 0.2–0.3 mm, with an increase in diameter during
inhalation.
IV. PATHOPHYSIOLOGY
Precipitating Factors:
Predisposing Factor
Lifestyle, environmental
Age, gender
hypoxia
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.
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.
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
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.
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 MECHANISM OF NURSING
(Generic name, brand ACTION CONTRAINDICATIONS ADVERSE EFFECTS OF RESPONSIBILITIES/
name, classification, INDICATIONS THE DRUG PRECAUTIONS
dosage, route,
frequency)
Generic Name: Inhibits the Acute Contraindicated with CNS: Dizziness, Adminiser with food
Furosemide reabsorption of Pulmonary allergy to furosemide, weakness,headache, or milk to prevent GI
sodium and chloride edema sulfonamides; allergy drowsiness,fatigue upset
Brand Name: from the ascneding to tartrazine (in oral CV: Orthostatic Reduce dosage if
Apo-Furosemide, limb of the loop of solution0; hypotension, given with other
Furosemide special, Lasix Henle, leading to a anuria,severe renal thrombophlebitis antihypertensives;
sodium-rich diresis failure; hepatic coma; readjust dosae
Classification: pregnancy; lactation Dermatologic: gradually as BP
Loop diuretic Use cautiously with Photosensitivity, responds
Sle, gout, diabetes rash,pruritus,purpura Give early in the day
Dosage: mellitus. so that increased
1 mg/kg GI: Nausea, urination will not
anorexia,vomiting, oral and disturb sleep
Route: gastric irritation, Avoid IV use of oral
IVTT constipation, use is at all possible
Arrange for
Frequency: GU: Polyuria, nocturia, potassium-rich diet
2 hr glycosuria, urinary bladder or supplemental
spasm potassium as
needed.
Hematologic: Leukopenia,
anemia, thrombocytopenia,
fluid and electrolyte
imbalances, hyperglycemia
Generic Name: Bactericidal:Inhibits Infections due to containdicated with CNS: Lethargy, Culture infection
Oxacillin sodium cell wall synthesis of penicillinase-producing allergies to hallucinations, seizures before treatment;
sensitive organisms, staphylococci; may be penicillins, reculture if response
Brand Name: causing cell death. used to initiate cephalosporins, or GI: stomatitis, glossitis, is not as expected
Antibiotic; treatment when a other allergens gastritis,nausea, vomiting, Reconstitite for IM
Penicillinase-resistant staphylococci infection Use cautiously with diarrhea, abdominal pain use to a dilution of
penicillin is suspected. renal disordes, 250 mg/1.5 mL
pregnancy, lactation GU: Nephritis-oliguria, using sterile water
(may cause diarrhea proteinuria, hematuria, for injection or
Dosage: or candidiasis in pyuria sodium chloride
600 mg infants). injection. Discard
Hematologic: Anemia, after 3 days at room
Route: thrombocytopenia, temperature or after
IVTT leukopenia, prolonged 7 days if
bleeding time refrigerated.
Generic Name: Bactericidal: Inhibits Lower contraindicated with CNS: Headache, NR:
Cefuroxime synthesis of respiratory allergy to dizziness, lethargy
bacterial cell wall, infections cephalosporins or Culture infection,
Brand Name: causing cell death penicillins GI: Nausea, vomiting, nd arrange for
Cefuroxime sodium Use cautiously with diarrhea, anorexia, sensitivity tests
(Zinacef) enal failure, abdominal pain, before and during
lactation, flatulence, liver toxicity therapy if
Classification: pregnancy expected,
Antibiotic GU: Nephrotoxicity response is not
seen
Hematologic: Bone Give oral drug with
Dosage: marrow deppression food to decrease
385 mg ( decreased WBC, GI upset and
decreased platelets, enhance
Route: decreased Hct). absorption
IVTT
Give oral drug to
Hypersensitivity: Ranging children who can
Frequency: from rash to fever to swallow tablets:
q.8 hr anaphylaxis, serum crushing the drug
sickness reaction results in a bitter,
unpleasant taste
Local: Pain, abscess at
injection site, phlebitis,
inflammation at IV site
ASSESSMENT DATA GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) NURSING DIAGNOSIS OBJECTIVES RATIONALE
(Problem and Etiology)
Subjective: Ineffective airway clearance After 8 hours of care Independent: After 8 hours of care
“Ga sige rako ug ubo-ubo sir” as related to retained secretions. patient will be able to: - Elevate head of the bed/change goals partially met.
verbalized by the patient. position every 2 hours. Patient was able to:
a. maintain airway R. To take advantage of gravity
Objective: patency decreasing pressure on the a. Maintain airway
b. expectorate/clear diaphragm. patency.
- cough secretions readily b. Expectorate
- restlessness - Encouraged deep-breathing and clear secretions
- yellowish sputum coughing exercises. readily as
- tachycardia (PR=107 R. To mobilize secretions. evidenced by
bpm) less secretions
- pale - Auscultate breath sounds and retained.
- RR=26 cpm assess air movement.
R. To ascertain status and note
progress.
Subjective: Impaired gas exchange After 8 hours of care Independent: After 8 hours of duty
“Galisud ko ug ginhawa kung related to alveolar-capillary patient will be able to: - Monitor vital signs and cardiac goals met. Patient was
mahago ko” as verbalized by the membrane changes. rhythm. able to:
patient. a. Participate in R. To evaluate degree of
treatment regimen compromise. a. Participate in
b. Demonstrate treatment regimen.
Objective: improve - Elevate head of bed/position client b. Demonstrate
- RR=26 ventilation. appropriately. improve ventilation.
- Dyspnea R. To maintain airway.
- Restlessness
- Tachycardia (PR=107 - Maintain adequate I/O.
bpm) R. For mobilization of secretions.
- Pale
- Encourage frequent position
changes and deep-breathing
coughing exercises.
R. To correct/improve existing
deficiencies.
Dependent:
- Administer medications as
indicated.
R. To treat underlying conditions.
ASSESSMENT DATA GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) NURSING DIAGNOSIS OBJECTIVES RATIONALE
(Problem and Etiology)
Subjective: Ineffective tissue perfusion After 8 hours of care Independent: After 8 hours of care
“Galisod ko ug ginhawa” as (cardiopulmonary) related to patient will be able to: goals met. Patient
verbalized by the patient. impaired transportation of -Identify changes related to systemic was able to:
the oxygen across the a. Demonstrate or peripheral alterations in
Objective: alveolar and/or capillary behaviors/lifestyle circulation. a. Demonstrate
membrane. changes to R. To assess contributing factors behaviors/lifestyle
- RR=26 cpm improve changes to improve
- Irritability circulation. -Determine duration of problem. circulation
- Restlessness b. Demonstrate R. To note degree of impairment b. Demonstrate
increased increased perfusion as
perfusion as -Monitor vital signs individually
individually R. To maximize tissue perfusion appropriate.
appropriate.
-Investigate report of chest pain
R. To note degree of impairment
Dependent:
-Administer medication as ordered
R. To maximize tissue perfusion
ASSESSMENT DATA GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) NURSING DIAGNOSIS OBJECTIVES RATIONALE
(Problem and Etiology)
Subjective: Imbalanced nutrition, less After 8 hours of care Independent: After 8 hours of care
“Wala ko’y gana mo kaon sir” as than body requirement patient will be able to -Identify underlying condition goals met. Patient
verbalized by the mother. related to illness. demonstrate progressive involved. was able to
good appetite. R. To assess causative factors. demonstrate
progressive good
Objective: -Identify clients at risk for appetite.
malnutrition.
- Poor muscle tone R. to assess contributing factors.
- Pale
- Weakness - Discuss eating habits, including
food preferences, intolerance.
R. To appeal to clients like and
dislike.
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.
• Augment the patient’s ability to cough effectively by splinting the patient’s 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. That’s why we have to treat everyone as such,
despite the consequences we might to commit, that wouldn’t 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 don’t have to wait for the time to come when it’s too late for
you to do such actions. It would be your lose and at the end you’ll realized that you acquire
worse. Another thing is to establish a therapeutic and a trusting relationship to each patient
because that’s 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.
At the end, we’re still thankful because God never put us down. All these things
wouldn’t 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. It’s 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). Nurse’s 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
Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr.
Patient’s Chart
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.