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Pleural Effusion

~A Case Presentation~
As a partial requirement for Medical-Surgical Nursing I Presented By:
Aguado, John Prose Almarra, Edrianne Paul Antonino, Jelaine Bacena, Dianne Jamaica Marpa, Ian Rafael Marquez, Charmaine Ong, Julie Ann Taguba, Neilson John Villanueva, Irish Saligumba, Emyl Cyril Soliven, Kathlene Chelo Zacarias, Andrea III-CN

Presented To:

Dr. Concordia Eva Garcia RMT, RN, MD

Why Pleural Effusion?

1st time to encounter Secondary illness Secondary to Tuberculosis

What is Pleural Effusion?

It is the abnormal accumulation of fluid in the pleural space resulting from excess fluid production or decreased absorption . Normally, the pleural space approximately contains 1mL of fluid

Classifications of Pleural Effusion:

1. Transudative Effusion 2. Exudative Effusion

Transudative effusions
Clear, pale yellow, watery substance Influenced by systemic factors that alter the formation or absorption of fluid Contains few protein cells Common causes: CHF and liver or kidney disease

Exudative effusions
Pale yellow and cloudy substance Influenced by local factors where fluid absorption is altered (inflammation, infection, cancer) Rich in protein (serum protein greater than 0.5) Ratio of pleural fluid LDH and serum LDH is >0.6 Pleural fluid LDH is more the two-thirds normal upper limit for serum Rich in white blood cells and immune cells Always has a low pH Common causes: tuberculosis, pneumonia, cancer, and trauma

Lights criteria
Pleural fluid protein divided by serum protein is greater than 0.5. Pleural fluid LDH divided by serum LDH is greater than 0.6. Pleural fluid LDH is greater than two-thirds the upper limit of normal for the serum LDH. If none of these criteria is met, the patient has a transudative pleural effusion


According to WHO: The estimated prevalence of pleural effusion is 320 cases per 100,000 people in third world countries. In developed countries the common causes of pleural effusions in adults are cardiac failure, malignancy and pneumonia, pneumonia, whereas in developing countries are tuberculosis and parapneumonic effusions are more prevalent.


According to DOH: The Philippines currently has 250,000 cases of Tuberculosis, as of Tuberculosis, the year 2009. Pleural Effusion accounts to approximately 38% of patients with Tuberculosis.

NAME: ADDRESS: AGE: GENDER: BIRTHDATE: RELIGION: DATE OF ADMISSION: MODE OF ADMISSION: Mrs. M Brgy Cembo 42 y/o Female May 30, 1969 Roman Catholic July 17, 2011 Medicine Ward


Nahihirapan akong huminga, as verbalized by the client

History of Present Illness

Four months prior to admission, the client experienced productive cough with greenish phlegm, and night sweats. She failed to seek for consultation because she believed that it was just an ordinary cough that is self-limiting.

History of Present Illness

Three months prior to admission, the client still experienced productive cough (greenish phlegm) and night sweats. She also experienced fever (39C), chest tightness, and paroxysmal nocturnal dyspnea. She consulted a private doctor and was given Lagundi TID x 7days and Clarithromycin 500 mg BID x 7days. She had taken these drugs as prescribed by the physician. After a week, the patient still complains of the same symptoms. She failed to have a follow up check up due to lack of time

History of Present Illness

Two months prior to admission, the client still manifested symptoms such as productive cough (greenish phlegm), persistent fever (39C) in the afternoon, and night sweats. The client now had anorexia and lost a total of 3 kg from her previous weight of 47 kg. She began to experience orthopnea of 2 pillows, easy fatigability and paroxysmal nocturnal dyspnea.

History of Present Illness

She also began to complain of chest pain P: right thorax Q: Sharp pain R: non-radiating S: 4/10 T: upon deep inspiration, relieved after shallow breathing).

History of Present Illness

She now consulted a private doctor and was subjected for chest x-ray revealing pleural effusion of the right lung. The client had undergone thoracentesis and 450cc of fluids was collected from her right lung.

Normal CXR

Right Pleural Effusion


History of Present Illness

The patient was relieved from pain after the procedure and was sent home with stable vital signs. The patient was prescribed to take Acetylcystein 600 mg/tab TID, Paracetamol 500 mg/tab TID. She was advised to have a follow up chest x-ray after two weeks. The patient failed to have a follow up chest x-ray due to financial problem

History of Present Illness

One month prior to admission, the patient still experienced productive cough, chest pain on deep inspiration (P: right thorax, Q: Sharp pain R: non-radiating, S: 7/10, T: upon deep inspiration, relieved after shallow breathing). The client still had anorexia and lost 4 kg from her previous weight of 44 kg.

History of Present Illness

The patient consulted again a private MD. She was subjected again for chest x-ray and pleural effusion on the right lung was detected. Second thoracentesis was done and 1,000 mL of fluids was collected. She was relieved from pain after the procedure and was sent home with stable vital signs. The patient was advised to have a follow up chest x-ray after two weeks.

History of Present Illness

Two weeks prior to admission, the patient again experienced productive cough and dyspnea, and easy fatigability. She was subjected to chest x-ray. Third thoracentesis was done and 800ml of fluid from the right lung was collected. The patient finally decided to be subsequently admitted to Ospital ng Makati.

Neurological System Cardiovascular System Respiratory System none none (+) dyspnea (+) paroxysmal nocturnal dyspnea (+)chest pain (P-pain in right thorax during deep inspiration and movements Q- Sharp pain RNon-radiating S-7/10 T- relieved by shallow breathing (+) orthopnea of 2 pillows (+)night sweats none none none

Integumentary System Endocrine System Urinary System Reproductive System


The client only had hospitalization in the past due to child delivery. The client has no known allergies to certain kind of foods and medication. She had no history of injury or falls. She had also completed her immunizations.

The client has history of cancer, specifically; her mother has been diagnosed to have breast cancer while his father has been diagnosed to have prostate cancer.

GENOGRAM of Mrs. Ms Family:

Joe Therese

Mary 49

Maricar 45

Mrs. M 42

Mark 38

Mercy 36

Mr. Husband

LEGEND: Male Female Deceased prostate Ca breast Ca healthy Jeff 20

Marj 16

Personal and Social History

Health Perception and Health Management Pattern: Mrs. M described a healthy person as someone without an illness and still manages to do his/her daily activities. Mrs. M rated her general health status as 6/10, She added that she still has a positive outlook in life even though she has a disease. With regards to self breast examination, the client is familiar with it but doesn t have enough knowledge on how to perform it.

Health Perception and Health Management Pattern:

Mrs. M takes care of her body through bathing, trimming of fingernails, wearing of slippers at home, brushing teeth, and using deodorant. The patient doesn t smoke and doesn t drink any alcoholic beverage.

Health Perception and Health Management Pattern:

Mrs. M lives in Brgy. Cembo with her husband and two siblings. Her family is renting a half of a bungalow house situated along a road. The house has two rooms with a wall that divides it. The wall is not touching the roof, leaving an open space between the two rooms. Mrs M. suspected that one of the family members living in the other side of the house has tuberculosis. She admitted that the air is polluted around their area because she can even inhale the smoke around their compound. Their house is poorly-ventilated and poorly-lighted.

Nutritional and Metabolic Pattern 3-Day Diet Recall

August 30, 2011 August 29, 2011 August 28, 2011 bowl of goto 2pcs. Medium-sized pandesal 1 glass of milk bowl of ginataan 2 slices of tasty bread 1 glass of orange juice 2 glasses of water

Breakfast (7:30AM)

1 bowl of Arozcaldo 1 glass of milk 1 glass of water

1 bowl of soup 1 glass of milk

Lunch (12:30NN)

cup of steamed rice serving of menudo 1 glass of orange juice

1 bowl champorado 1 glass of water

Snack (3:00PM)

1 stick of bananaQ 1 glass of water

Dinner (7:00PM)

cup of steamed rice 1 serving of pakbet 2 glasses of water 1 glass of milk

cup of steamed rice serving of monggo 2 glasses of water

cup of steamed rice 1 pc. Lumpiang sariwa 1 glass of milk 1-2 glass of water

Nutritional and Metabolic Pattern 3-Day Diet Recall

Mrs. M is the one who prepares the food for her family before. Most of the time, she cooks Filipino dishes such as pork adobo & pork sinigang. Mrs. M does not forget to wash her hands everytime before she prepares the food. Mrs. M stated that she is not taking any vitamins since before. The patient lost a total of 7 kg in her weight before hospital admission.

Elimination Pattern:

Regarding her defecation, she usually defecates once a day and the stool is dark brown in color and the consistency is solid. The patient doesnt have any discomforts upon defecation. She seldom experiences constipation or diarrhea. Regarding her urinary elimination pattern, Mrs. M frequently urinates (4-5x/day) because she is taking Furosemide every night. She stated that she doesnt feel any discomfort or pain during micturition.

Activity-Exercise Pattern:
Mrs. M is a high school teacher. She goes to school in the morning and goes home at 1:00 pm. She said that before she felt the symptoms of easy fatigability, she exercises during weekend morning for 30 minutes using a waist twisting disc. She also considers walking to her school for work as an exercise.

Sleep and Rest Pattern:

Mrs. M had difficulty of sleeping in the hospital because she is not comfortable sleeping with the hospital environment and also, because of the pain she has been experiencing on the thoracostomy site upon trunk movements. She described the pain as sharp, and rated it as 7/10. During the interview, facial grimace is evident. She sometimes nods her head just to agree. She also speaks at a low-volume voice.

Sleep Diary
August 30, 2011 Hours of Sleep during Night Hours of Nap During Afternoon Quality of Sleep (12AM-5AM) 5 hours (1:30PM-3:00PM) 1 hours Continuous August 29, 2011 (11AM-4:30AM) 5 1/2 hours (4:30PM 6:00PM) 1 hours Continuous August 28, 2011 (12AM-4:30AM) 4 1/2 hours (1:00-3:00 PM) 2 hours Not Continuous.
Awakened at 3am due to pain on the thoracostomy site. Fell asleep after pain subsided.

Feeling upon waking up



Not Refreshed

General Appearance: During the interview, the client is conscious and coherent. The client has evident facial grimace. Anthropometric Measurement: Weight: Height: BMI: Vital Sign: Temperature : Cardiac Rate: Respiratory Rate: Blood Pressure: 40 kg 1.49 cm 18


39C 109bpm 26cpm 100/70

Abnormal Abnormal Abnormal Normal

ORGAN/ BODY PART(S) Head: Skin: METHODS USED Inspection Inspection Palpation FINDINGS normocephalic Intact (+) dry skin Warm to touch elastic skin turgor White sclera (-) sunken eyeball (-) pale conjunctiva (-) discharge Bilaterally equal in size (-) lesions (-) discharge No tenderness symmetric and straight (+) pink mucosal membrane (-) deviated septum (-) discharge (-) nasal flaring SIGNIFICANCE Normal Normal Abnormal Abnormal Normal Normal Normal Normal Normal Normal Normal Normal Norma Normal Normal Normal Normal Normal




Inspection Palpation






(+) dry lips pinkish tongue (-) lesions pink tonsils and buccal mucosa (-) cyanotic nailbeds capillary refill more than 3secs. Symmetric and head centered Thyroid gland moves upward upon swallowing Trachea is midline (+) tender lymphnodes

Abnormal Normal Normal Normal Normal Abnormal


Inspection Palpation


Inspection Palpation

Normal Normal. Normal Abnormal

ORGAN/ BODY PART(S) Thorax and Lungs METHODS USED Inspection Palpation Auscultation Percussion FINDINGS (-) Chest wall retractions asymmetric Tactile fremitus (absent on the right thorax) asymmetric respiratory excursion (movement only on the left thorax) asymmetric breathsounds (absent breathsounds on the right) (-) adventitious breath sound dull, flat sound over the right thorax (-) heart murmur Flat abdomen (+) ascites Normal bowel sounds No bruit heard Arms bilaterally symmetric (-) edema (-) lesions or ulcerations (+) palpable distal pulse SIGNIFICANCE Normal Abnormal Abnormal Abnormal Normal Abnormal

Heart Abdomen

Auscultation Inspection Auscultation

Normal Normal Abnormal Normal normal Normal Normal Normal Normal


Inspection Palpation

IV on Right Hand (PNSS 1L x 8hrs) CTT on Right Thorax at 8th ICS connected to a one-bottle water seal system With Foley Catheter


Medical Diagnosis: Pleural Effusion secondary to PTB Nursing Diagnoses: Ineffective Breathing Pattern r/t decreased lung volume capacity Acute Pain r/t accumulation of fluid in the pleural space and rubbing of thoracostomy tube to the lungs Imbalanced Nutrition: less than body requirement r/t inability to ingest adequate nutrients Hyperthermia r/t disease process Sleep Deprivation r/t Paroxysmal nocturnal dyspnea Risk for fluid volume deficit related to administration of diuretic drugs Risk for Injury related to thoracentesis Risk for infection r/t presence of ctt


Exposure to Air Pollutants

Exposure to TB

Living in Poorlylighted and overcrowded house

Inhalation of TB Bacilli

Tubercle Formation (Primary Infection)

Productive cough, Fever 39C, Anorexia, weight loss, easy fatigability

Formation of Granuloma



Not early detected

subpleural caseous focus in the lung ruptures into the pleural space

Mycobacterial antigens enter the pleural space

Vigorous inflammatory response associated with an exudation of white blood cells and proteins.

Increase WBC count (16.6 x 10^9 mm/ L) Increase Monocyte count (0.13 g/L)

Vigorous inflammatory response associated with an exudation of white blood cells and proteins.

Increase pulmonary interstitial fluid Low serum albumin level: 25 g/L

Intense inflammation obstructs the lymphatic pores in the parietal pleura

Changes in permeability of capillaries

Decrease in lymphatic drainage

PLEURAL EFFUSION (Accumulation of fluid in the pleural cavity)

Decrease breath sounds, stony dull sound when percussed PLEURAL EFFUSION (Accumulation of fluid in the pleural cavity)

Irritation of sensory nerves in the parietal pleura during deep inspiration

CXR: Opaque densities on the right lower lobe & blunting of costophrenic angle

Increase in intra-alveolar & intra-pleural pressure

Dyspnea, Pleuritic chest pain, Orthopnea, Paroxysmal nocturnal dyspnea

Dyspnea, Increase RR Decrease respiratory excursion

Decrease lung expansion

Prolonged pleural effusion

Lung collapse Risk for infection of pleural fluid



Complete Blood Count

Procedure/Item Hemoglobin Hematocrit RBC WBC Neutrophils Lymphocytes Monocytes Eosinophils Basophils *High *High Abnormal flags Result 16 45 5 16.6 0.77 0.39 0.13 0.03 -Units g/DL % Mil/mm^3 /mm^3 g/L g/L g/L g/L /mm^3 Reference Range ( 13.0 ( 40.0 ( 4.70 18.0 ) 52.0 ) 5.40 )

(4-11 x 10^9) (0.50-0.70) (0.20-0.40) ( 0.02 0.05 )

( 0.02-0.04 ) ( 10 100 )

Arterial Blood Gases

Result Normal Range


7.48 47 23 88

7.35-7.45 35-45mmHg 22-26mmHg 80-100%

Significance: The patient has respiratory alkalosis. This may be due to rapid & shallow breathing.

Procedure/Ite m

Abnormal flags *Low



Reference Range ( 34 - 50 ) ( 15 - 37 )

25 35

g/L u/L





( 30 - 65 )

Alkaline Phosphat ase




Acid-fast Bacillus (AFB)

(July 20, 2011) Specimen: Sputum Result: AFB (+)

Gram Stain
(August 20, 2011) Specimen: Pleural Fluid Result: Smear shows no presence of gram (-) bacilli.

(August 20, 2011) Specimen: Pleural Fluid Pathologic Diagnosis: Negative for malignant cells

Chest X-ray
(July 14, 2011) Impression: Consider moderate pleural effusion; right Right Lateral Decubitus: Evidence of minimal pleural fluid

Chest X-ray

Right Lateral Decubitus

CT-SCAN of Chest
Result: PTB with organizing Pneumonia, Superior and posteromedial right lower lobe with right hilar lymphadenopathies and right pleural effusion.

(August 11, 2011) Findings: Mediastinal lymphadenopathies Right pleural effusion with thick pleural density Heart not enlarged Pulmonary Fibrosis in Left Lower Lobes


AUGUST 31,2011 Wednesday (6:00AM 2:00 PM) y y y y y Patient received lying on bed, awake, calm and coherent Patient was febrile Patient was ambulatory Has an IVF of 1L PNSS at 31-32 gtts/min for 8 hours infusing well Patient s vital signs were taken and recorded Temperature: 39C Cardiac Rate: 109bpm Respiratory Rate: 22cpm Blood Pressure: 100/70 Tepid sponge bath was done to lower hyperthermic state Endorsed elevated temperature to the nurse-in-charge Bed rails were raise to promote patient s safety Instruct the significant other how to do the tepid sponge bath if fever is present Intake and output strictly monitored Intake Output Oral- 400 mL Urine- 500 mL IV- 500 mL Chest tube 60mL Total - 900mL Total - 560mL No. of stool 0 Checked thoracostomy tube for leak, kinks, patency and output. Noted fluctuations in every inspiration on the drainage bottlez Secured bottle lower than the client (under the bed).

y y y y y

y y

Drug Study

Drug Name Generic: Acetylcystein e

Classification Mucolytics

Action Breaksdown the link that binds mucus together

Dosage/Frequency 600 mg PO q4

Nursing responsibilities Evaluates clients respiratory status (respiratory rate, depth, rhythm) Check sputum for color, consistency and amount. If bronchospasm occurs, stop the treatment and notify the physician. Instruct patient to notify prescriber immediately about nausea, rash, or vomiting. Warn patient about acetylcysteines unpleasant smell; reassure him that it subsides as treatment progresses. To decrease mucus viscosity, urge patient to consume 2 to 3 L of fluid daily unless contraindicated by another condition.

Evaluation Evaluate the effectiveness of Acetylcysteine through assessing the respiratory status of the client and amount of sputum expectorated.

Liquifies mucus

Makes cough more productive

Drug Name Generic Name: Pyrazinamide + Ethambutol

Classification Anti-TB Agents

Action Inhibits cell action of Mycobacterium tuberculosis

Dosage/Frequency 400mg + 275mg PO

Nursing responsibilities Take it continously and never skip doses to avoid multi-drug resistance. Monitor Vision of patient. Ethambutol causes optic neuritis. Examine patients at regular intervals and question about possible signs of toxicity: Liver enlargement or tenderness, jaundice, fever, anorexia, malaise, impaired vascular integrity Report to physician onset of difficulty in voiding. Keep fluid intake at 2000 mL/d if possible.

Evaluation Evaluate effectiveness of medication through observing the clients coughing and coping mechanism with the drug


Drug Name Generic Name: Rifampicin

Classification Antituberculosi s agent

Action Inhibits DNA and RNA polymerase activity

Dosage/Frequency 300 mg PO OD

Nursing responsibilities Administer on an empty stomach, 1 hr before or 2 hr after meals. Administer in a single daily dose. Give with meals because it causes gastric irritation. Prepare patient for the reddish-orange coloring of body fluids (urine, sweat, sputum, tears, feces, saliva); soft contact lenses may be permanently stained; advise patients not to wear them during therapy. arrange for follow-up visits for liver and renal function tests, CBC, and ophthalmic examinatio ns. Advise client to avoid omission of dose to prevent drug resistance

Evaluation Evaluate effectiveness of medication through monitoring hemoptysis production, liver fxn test and CXR

Cell death

Drug Name Generic: Piperacillin + Tazobactam

Classification Antibiotic

Action Binds to bacterial cell membrane and inhibits betalactamase

Dosage/Frequency 4.5 g/ml TIV q6

Nursing responsibilities Perform skin test before giving the initial dose. Assess client for allergy to penicillin. Check C&S result. Monitor client for 30 mins when given parenterally; administer epinephrine if anaphylaxis occurs. Do not mix aminoglycosides with penicillin in the same IV infusion deactivates aminoglycoside Check for CBC result and Monitor for hemorrhagic manifestations because high doses may induce coagulation abnormalities.


Cell lysis

Drug Name Generic: Furosemide

Classification Loop diuretic

Action Acts in loop of Henle, proximal and distal tubule

Dosage/Frequency 10 mg/mL TIV q8

Nursing responsibilities Monitor for adequate intake and output and potassium loss. Monitor clients weight and vital signs esp BP Monitor for signs and symptoms of hearing loss, which may last from 1 to 24 hrs. Teach client to take Furosemide early in the day to decrease nocturia. Teach client to report any hearing loss or signs of gout. monitor for S/s of hypokalemia; such as muscle weakness and cramps Monitor for sideeffects such as dizziness, lightheadedness, or fainting spells, Signs of dehydration or low electrolytes,

Evaluation Evaluate effectiveness of Furosemide through frequently monitoring urinary output.

Inhibits Na and Cl reabsorption

Drug Name Generic Name: Cefixime

Classificatio n thirdgeneration cephalospor in antibiotic


Dosage/Freque ncy 200 mg PO

Nursing responsibilities Assess for infection at beginning of and throughout therapy. Ask patient for allergies to penicillin or cephalosporins. Perform skin test before the initial administration. Obtain specimens for culture and sensitivity before initiating therapy. Observe patient for signs and symptoms of anaphylaxis ( rash, pruritus, laryngeal edema, wheezing)

Evaluation Evaluate the effectiveness of medicine

Binds to PBPs

Inhibits bacterial cell wall synthesis Death of Bacteria

Drug Name Generic Name: Tramadol

Classification Opioids/anal gesic


Dosage/Freque ncy 50mg/2mL TIV

Nursing responsibilities Assess onset, type, location, and duration of pain. yEffect of medication is reduced if full pain recurs before next dose. y Assess drug history especially carbamazepine, CNS depressant medication, MAOIs. yReview past medical history, especially epilepsy or seizures. yAssess renal or hepatic function laboratory values. yGive without regards to meals yMonitor pulse and blood pressure. yAssist with ambulation if dizziness or vertigo occurs.

Evaluation Evaluate effectiveness of medication through monitoring vital signs of client and assessing pain recurrence.

binds to opiate receptors and inhibits reuptake of norepinephrin e and serotonin

reduces intensity of pain stimuli sponse to pain.

Drug Name Generic Name: Streptokina se

Classification Thrombolytic enzyme


Dosage/Freque ncy 250,000 units intrapleurally

Nursing responsibilities Continuous monitoring of HR and rhythm throughout thrombolytic administration. Vital observations : record 15 minutely for at least 1 hour from onset of infusion until stable. Notify physician if allergic reactions may include fever increased liver enzymes, reduced renal function, polyarthralgia, polyarthritis and rash.

Evaluation Evaluate effectiveness of Streptokinase through checking for blood in the chest tube drainage.

Produces plasmin Breaks down fibrin

Dissolves blood clots

Drug Name Generic Name: Paracetamol

Classification Anti-pyretic

Action inhibiting the hypothalamic heat-regulating centre.

Dosage/Frequency 300g TIV

Nursing responsibilities Check vital signs of the client esp temperature. Inspect IM and IVinjection sitesfrequently for signs of phlebitis. Report onset of loose stools or diarrhea Monitor I&O rates and pattern:

Evaluation Evaluate effectiveness of Paracetamol through monitoring a decrease in the temperature of the client.

Inhibits fever

Medication: After handling the patient for one day, we advice the client and significant others that the client should continue the prescribed medications as follows: Rifampicin 300 mg PO OD, Pyrazinamide + Ethambutol 400mg + 275mg PO as ordered by the doctor. Exercise: We have encouraged the client to perform mild exercise such as jogging for 30 minutes each day after the woundcompletely healed. Treatment: Health Teaching: Teach the client to avoid omission of doses of antituberculosis drugs such as Rifampicin, Pyrazinamide and Ethambutol. We have advised the client to expect reddish to orange color of urine, sweats, etc. We have advised the client to seek for consultation if she experienced blurring of vision and jaundice. We also taught the client that Mycobacterium Tuberculosis is killed by heat and sunshine thats why appropriate lighting and ventilation of the house is important. Out-Patient Follow-up Care: Advised the client for a follow up check up and for chest xray. Diet: We advised the client to increase intake of protein to increase healing of wound brought about by chest tube thoracostomy. We also advised to take 8-10 glasses of water everyday to avoid dehydration.