You are on page 1of 32


College of Nursing
Cagayan de Oro City

A Case Study
Pleural Effusion
In Partial Fulfillment
Of the course

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

I. Introduction

II. Client’s Profile

III. Anatomy and Physiology

IV. Pathophysiology

V. Diagnostic Procedures and Lab Results

VI. Drug Study

VII. Nursing Care Plans

VIII. Discharge Plan

IX. Learning Insights

X. Reference

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
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.

Nonbacterial infectious agents, such as viruses and Mycoplasma pneumoniae,

cause more pleural effusion in children than do bacterial organisms. Although
bacteria are more likely than viruses to cause effusion, viral infections in children occur
more frequently than bacterial infections, explaining the observation above. As
many as 20% of the viral infections can cause small and transient effusions that
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 pleural-
fluid 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
Patient X is 43 years-old male, Filipino, Roman Catholic from Lapasan,
Cagayan de Oro City, Misamis Oriental. Admitted at Cagayan de Oro Medical
Center (COMC) last January 16, 2010 at 9:00 PM due to dyspnea and cough.
Patient’s vital signs are: Blood Pressure of 130/100 mmHG, temperature
of 36 degree Celsius, respiratory rate of 26 cpm and a pulse rate of 107 bpm. At
present he weighs 59 kls.


One week prior to admission, patient was admitted in Northern Mindanao
Medical Center for persistent cough and fever for one week until he is referred to
COMC because the patient continue on experiencing difficulty of breathing, thus


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 he’s 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.
He’s 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 don’t believe in superstitious beliefs. He said,
“God is our savior and he is our creator, he has a plan for me”.
BEFORE (SEPT 23, 09)
Color Fair
Temperature 37.1 º C
Turgor Good skin turgor
Texture Moist skin
Lesion (-) Lesions/Rash
Integrity Intact
Color Pinkish
Texture Smooth
Shape Concave
Others Poor capillary refill = 3 sec
Color Black
Texture Coarsely dry
Distribution Evenly distributed
Quantity Moderate

Shape Round
Size Normocephalic
Configuration Symmetrical
Headache None

Hearing Good
Tinnitus None
Vertigo No vertigo
Earaches No earaches
Infection No infection
DischargesS No discharges


Frequent colds None
Nasal stiffness None
Nose bleed None
Sinus trouble Sinuses are non tender


Condition of teeth Incomplete teeth
Bleeding gums No bleeding
Tongue Tongue is at midline,
Throat Throat Non-tender
Hoarseness None
Mucous membrane Pinkish


Symmetry Symmetrical
Condition of trachea Thyroid in the midline
Lymph nodes (-) nonpalpable
(-) nonpalpable

Symmetry Symmetrical
Shape A:P diameter 1:2
Respiratory movements Asymmetrical, use of accessory muscles
# of breath 26cpm

Character of respiration (+) rales on upper lung lields
Decrease breath sounds on left lung field
Apical Pulse
Cardiac Sounds 107 bpm
Apical/Radial pulse data (-) murmurs
Blood pressure Not assessed
Pulse pressure
Any special procedure
Symmetry Symmetrical
Contour Globular
Skin Lesion none
Masses (-) Masses
Bowel Sounds Normoactive bowel sounds
Tenderness none

abnormal postures aren’t present

ROM active-passive

Muscle Strength 4/5


Facial muscle symmetry Symmetrical
Swelling None
Scars None
Discoloration None
Weakness (+) Weakness
ROM can turn head from side to side
Posterior neck cervical spine
Muscle spasm
(-) Spasm
(-) Crepitus heard

Muscle tone Without hypertrophy or atrophy
Muscle strength is 4/5
Ability to move extremities against gravity
Spasticity, flaccidity or rigidity, tremors, lies none
LOC Conscious
Long term memory Not assessed
Short Term Memory


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.

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.


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


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.


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.


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.


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.


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.


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

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

Precipitating Factors:
Predisposing Factor
Lifestyle, environmental
Age, gender

Inflammation of airways wheezing

Bronchial edema Increased mucus Broncoconstrict Bronchial

secretion -ion spasm

Dsypnea, cold and

clammy skin,
Worsening of obstruction diaphoresis

Accumulation of fluids caused by over secretion

Multiplication of growth of organism

Inflammation in the epithelial wall

Fluid filled alveoli/lobar copartment

Shallow Excess fluid Rupture of inflamed endothelial cells

breathing, accumulate
RR d in
spaceperica Mismatch of ventilation and perfusion
Mismatch of ventilation dyspnea
and perfusion




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 Result Unit References

WBC 18.0 1O^3/uL 5.0-10.0
RBC 3.47 10^6/uL 4.2-5.4
HEMOGLOBIN 7.7 g/dL 12.0-16.0
HEMATOCRIT 25.6 % 37.0-47.0
MCV 73.8 fL 82.0-98.0
MCH 22.2 Pg 27.0-31.0
MCH-C 30.1 g/dL 31.5-35.0
RDW-CV 17.1 % 12.0-17.0

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 11.4 % 4.5-10.5

Eosinophils 0.9 % 1.0-3.0
Platelet 987 10^3/uL 1500-4000

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 Result Unit References

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

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 32.3 % 17.4-48.2

Neutrophil 53.5 % 43.4-76.2
Monocyte 13.0 % 4.5-10.5
Eosinophils 1.0 % 1.0-3.0
Basophils 0.2 % 0.0-2.0
Platelet 1085 10^3/uL 1500-4000

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
dosage, route,

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
Hematologic: Leukopenia,
anemia, thrombocytopenia,
fluid and electrolyte
imbalances, hyperglycemia

Other: Muscle cramps and

muscle spasms
name, classification, THE DRUG PRECAUTIONS
dosage, route,
dosage, route,

Generic Name: Bactericidal: inhibits  Severe  Contraindicated with CNS:Lethargy,

Generic Name: Bactericidal:Inhibits Infections due to  containdicated with CNS:  Culture infection
Amikacin sulfate protein synthesis in systemic allergy to any disorientation, Arrange
 before forculture
Oxacillin sodium cell wall synthesis of penicillinase-producing allergies to hallucinations, seizures treatment;
susciptible strains of infection aminoglycosides, depression,
sensitive organisms, staphylococci; may be penicillins, and sensitivity
reculture if response
Brand Name: gram-negative caused by renal or hepatic
Brand Name:
causing cell death.
bacteria, and the
used to initiate cephalosporins, or GI: stomatitis, glossitis, istesting
not as of infected
sensitive disease, preexisting
functional integrity of
treatment when a other allergens CV:
gastritis,nausea, vomiting, area before
 Reconstitite for IM
Penicillinase-resistant straints
staphylococci infection hearing loss, diarrhea, abdominal pain
Classification: bacterial cell  Use cautiously
myasthenia with
Palpitations,hypotension, treatment.
use to a dilution of
penicillin is suspected. renal disordes, hypertension 250
 Give mg/1.5 mL
IM dosage by
Anti-infective membrane appears to  Use cautiously with
pregnancy, lactation GU: Nephritis-oliguria, using sterile water
be disrupted, causing elderly patients, any deep injection
(may cause diarrhea proteinuria,
GI: Nausea, hematuria,
vomiting, for injection or
Dosage: cell death. apatient with  Ensure that patient
Dosage: or candidiasis in pyuria sodium chloride
95 mg deminished hearing, anorexia is well hydrated
600 mg infants). injection. Discard
decreased renal
Hematologic: Anemia, after 3 days atduring
before and room
Route: function, dehydration GU: nephrotoxicity
thrombocytopenia, therapy or after
IVTT temperature
IVTT leukopenia, prolonged 7 days if
bleeding time Report pain at
 refrigerated.
Granulocytosis, injection site,
q 12 hr
Frequency: leukopenia, Rash,
Hypersensitivity: TP: severe headache,
q 6 hr fever, wheezing,
dizziness, loss of
Hepatic: Hepatic toxicity;  You may changes
hepatomegaly experiencethese
in urine pattern,
Local: Pain, phlebitis, side effects: Upset
thrombosis at injection site difficulty breathing,
Hypersensitivity: Purpura, stomach, nausea,
rash or skin
diarrhea, (eat
rash, Superinfections,
Other: exfoliative lesions.small
dermatitisOther: frequent
sodium overload leading to meals), mouth
Superinfections, pain and
CHF ssores (perform
irritation at IM injection mouth care), pain at
sites the injection site
dosage, route,

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
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
 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
(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

- Evaluate changes in sleep pattern.

R. To assess changes.
(Subjective & Objective Cues) (Problem and Etiology) OBJECTIVES RATIONALE

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

- Administer medications as
R. To treat underlying conditions.
(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.
-Investigate report of chest pain
R. To note degree of impairment

-Administer medication as ordered
R. To maximize tissue perfusion

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 patient’s ability to cough effectively by splinting the patient’s chest

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

• 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.

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.

Regarding this case we chose, we found it out to be enjoyable. We thought we don’t

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, 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


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

Karch, Amy M. ; 2006 Lippicott’s 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.
Patient’s 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

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
and for helping us develop the right attitude while in this rotation.
Thank You so much, Mrs. Maria Rica Adane, RN.