University of Luzon

College of Nursing
Dagupan, Pangasinan

A Case Study on
Pleural Effusion

Angela Obiora

Trisha Mae Malicdem

Lorelee Casingal

Elsa Clores

Charlet Dela Cruz

Quina Marie Menes

Jade Qi

Prof. Divinagracia Corigan

Clinical Instructor
INTRODUCTION

Pleural effusion a collection of fluid in the space is rarely a primary

disease process it is usually secondary to other diseases. Normally the pleural
space contains a small amount of fluid (5 TO 15ML) which acts as a lubricant
that allows the pleural surfaces to move without friction. Pleural effusion may
be a complication of heart failure, TB, pneumonia, pulmonary infection
( particularly viral infection ) nephrotic syndrome, connective tissue disease, PE
and neoplastic tumors. The most common malignancy associated with a
pleural effusion is bronchogenic carcinoma.

PATIENT’S PROFILE

– Name : Mr. X

– Age : 50 years old

– Gender : Male

– Birthday : April 20, 1969

– Address : Laoac, Pangasinan

– Nationality : Filipino

– Occupation : Jeepney Driver

– Religion : Roman Catholic

– Admitting Diagnosis : Pleural effusion

– Final Diagnosis : Pleural effusion right secondary to

Parapneumonic process,
hypertensive, Cardiovascular disease

– Date of admission : September 11, 2019

– Place of admission : Region 1 Medical Center

Family history

According to the patent there's no history if Rheumatic heart diseases

hypertension On their family.
Present history

Last September 11, 2019, the patient was accompanied by his wife in the
Region 1 Medical Center for check up because the patient was complaining of
difficulty of breathing and fatigue for a week. He have asthma and pneumonia.
The client is a jeepney driver route to Dagupan - Manaoag. He has 4 children
and all of them is in highschool in a public school. His wife is just staying at
home to take care of their children and do household chores.

Past history

In the year 2017 client was diagnosed with Rheumatic heart disease with
cardiomegaly. He also have hypertension for 30 years. The patient was a
smoker and driking alcohol for 30 years he had stop after he diagnosed. He has
no known allergy, and haven't experienced any injury or surgeries. He also
doesn't have Diabetes nor Tuberculosis.

ETIOLOGY

Rheumatic Heart Disease – Rheumatic Heart Disease is damage to one or

more heart valves that remains after an episode of acute rheumatic fever (ARF)
is resolved.

CAUSE

– rheumatic fever

– an inflammatory disease that can affect many connective tissue

– in the heart

– joints

– skin

– or brain

SIGNS AND SYMPTOMS

– shortness of breath (especially with activity or when lying down)

– chest pain

– swelling

– fainting
 – stroke

– Heart palpitations

COMPLICATION

– Heart failure – this can occur from either a severely narrowed or leaking
heart valve

– Bacterial endocarditis – this is an infection of the inner lining of the

heart, and may occur when rheumatic fever has damaged the heart
valves.

–  Ruptured heart valve – this is a medical emergency that must be treated

with surgery to replace or repair the heart valve.

RISK FACTORS

– POVERTY

– OVERCROWDING

– REDUCED ACCESS TO MEDICAL CARE

- RHD- if not treated it will be deteriorate

ANATOMY AND PHYSIOLOGY

Pleura

The lungs and wall of the thoracic cavity are lined with a serous membrane
called pleura. The visceral pleura cover the lungs; the parietal pleura line the
thoracic cavity, lateral wall of the mediastinum, diaphragm, and inner aspects
of the ribs. The visceral and pleura and the small amount of pleura fluid
between these two membranes serve to lubricate the thorax and the lungs and
permit smooth motion of the lungs within the thoracic cavity during inspiration
and expiration.
Visceral pleura contain the pulmonary capillary and alveoli. The parietal space
is a thoracic wall where systemic capillaries are found and also lymph vessels
which drain the pleural fluid from the pleural space that helps maintain
normal pressure in the pleural space. The pleural fluid comes from three main
sources: systemic capillaries, fluid that can enter from the pulmonary
capillaries, and also from the abdomen where fluid can come in through small
tiny holes in the diaphragm.
PATHOPHYSIOLOGY

Pleural Effusion is the accumulation of fluid in the pleural space. When this
happens the heart expand resulting to shortness of breath. One of the
mechanisms for developing pleural effusion is when you have increase fluid
formation.
Here, you have pulmonary capillary that are part of the visceral space and
systemic capillary which are part of the parietal space. When inflammation
happen, it will trigger the vessel cells to contract causing an increase in
vascular permeability when there is an increased vascular permeability fluid
and proteins will leak from the vessels into the pleural space which increases
fluid formation essentially in the pleural space and so leads to pleural effusions
the capillaries leaving the pleural membrane will return to the heart eventually
via the veins if there’s an increase in venous pressure.

DIAGNOSTIC PROCEDURE

1. Percussion: A clinical assessment method of tapping the thoracic region

that showed dull sound, when auscultated with stethoscope showed
diminished breath sound and pleural friction rub (grating sounds of the pleural
linings rubbing together when inflamed)

2. Chest radiograph: It gives a detailed image of the chest. It can find some
symptoms like breathing difficulties, persistent cough, fever, and chest pain.

3. Ultrasonography: It creates an image of the lungs which detected fluid in

the lungs and adjacent atelectasis.

4. Thoracentesis: It is an invasive procedure done to remove fluid or air from

the pleural space for diagnostic or therapeutic purposes.
LABORATORY RESULTS

Complete blood count Results Units Reference ranges

White blood cell 5.7 *10^9/L 4.0 -10.0
differential count
Neutrophils 66.0 % 55.0 -65.0
Lymphocytes 24.1 % 25.0 -35.0
Monocytes 7.4 % 3.0 -6.0
Eosinophil 2.5 % 2.0 -4.0
Basophils 0.1 % 0.0 -1.0
Erythrocytes 6.0 *10^12/L 4.5 -6.2
Hemoglobin 172 g/l 130 – 180
Hematocrit 0.53 % 0.40 -0.54
MCV 87.3 Fl 80.0 -100.0
MCH 28.5 Pg 27.0 -34.0
MCHC 327 g/l 310 -370
RDW-CV 11.4 % 11.0 -16.0
RDW-SD 57.8 Fl 35.0 -56.0
Platelet Count 292 *10^9/L 150 -450
MPV 7.5 Fl 6.5 -12.0
PDW 10.2 Fl 9.0 -17.0
PCT 0.210 Ml/l 0.108 -0.282
CLINICAL CHEMISTRY

TEST RESULT UNIT REFERENCE RANGE

Sodium 140 .80 mmol/l 135.00 -148.00

Potassium 3.70 mmol/l 3.50 -5.30

Chloride 104.70 mmol/l 98.00 -107.00

Ionized 1.16 mmol/l 1.13 -1.32

Calcium

Creatinine 88.40 mmol/l 61.89 -123.79

Cholesterol 4.36 mmol/l 3.89 -5.70

Triglyceride 1.05 mmol/l 0.68 -1.86

HDL 1.20 mmol/l 0.91 -2.07

LDL 2.68 mmol/l 0 – 3.37

Fasting blood 6.11 Mmol/l 3.89 -5.83

sugar

CULTURE AND SENSITIVITY

SAMPLE: SPUTUM

RESULT: No important Pathogen isolated

GRAM STAIN

SAMPLE: SPUTUM

RESULTS: Gram-positive cocci in Pairs, Chains, and Tetrad

Gram Negative Bacilli: +

Pus cells: ++

Epithelial cell: ++

ULTRASOUND
 – - Massive right pleural effusion (2807 ml) with adjacent compressive
atelectasis

– -Minimal left pleural effusion (129ml)

CHEST XRAY RESULT:

– Dense opacity was noted in the right hemi thorax

– Heart not enlarged

– Pulmonary vascularity is within normal

– Both Hemi diaphragm and coat phrenic sulci are intact

– Bone is unremarkable
 GENERIC INDICATIOn ACTION ADVERSE INTERAC CONTRAINDICATI PATIENT NURSING
NAME REACTION TION ON RESPONSIBILITIES
TEACHING

LOSARTAN Antihyperten- Inhibits No adverse No Lithium –may Patient should Monitor patient’s BP
SODIUM tion vasoconstriction reaction. adverse increased lithium avoid salt closely to evaluate
and aldosterone- reaction level and toxicity. substitute; these effectiveness of
secreting action products may
therapy.
of angiotensin II contain potassium,
by blocking which can cause
angiotensin II high potassium
BRAND receptor on the level in patients
NAME surface of taking losartan.
vascular Monitor renal
COZAAR smoothmuscle. function and
potassium levels,
especially during
first few weeks of
DOSAGE,
therapy and after
R0UTE AND dosage adjustments.
FREQUENCY

50mg

Oral

GENERIC INDICATIOn ACTION ADVERSE INTERACTION CONTRAINDICAT PATIENT NURSING

NAME REACTION ION RESPONSIBILITIE
 TEACHING S

Prevent It relieves Tachycardia Epinephrine other No Notify physician Monitor heart

reversible nasal sympathomimetic contraindication if albuterol fails
ALBUTEROL rate
airway congestion bronchodilators to provide relief
obstruction and possible additive because this can
due to reversible effects signify worsening
bronchospasm. bronchospas of pulmonary Consult physician
m by relaxing function and about giving
BRAND
the smooth reevaluation of albuterol dose
NAME Tricylic
muscle of the therapy may be several hours
Quick relief for antidepressant
bronchioles. indicated. before bedtime if
bronchospasm
SALBUTAMO drug induced
L insomnia is a
problem.
DOSAGE,
ROUTE, AND

FREQUENCY

2-4 mg

3-4 times a
day,
 Assessment Diagnosis Planning Intervention Ratonale Evaluation
Subjective: Ineffective STG, determine : Independent STG
“hirap ako breathing causative Auscultate chest to evaluate character of breath Diminished breath sound noted
huminga” as pattern rt fluid factors causing sounds or presence of
verbalized by accumulation in fluid secretions
the patient the pleural accumulation. Moist cough, no indication of
space on both Evaluate cough- to know if there is indicating possible obstruction
lungs as possible obstruction
Objective: evidenced by
Dyspnea, dyspnea Review results of necessary testing like to help diagnose severity of lung Test results was reviewed
pursed lip chest x-ray, & pulmonary function disease
breathing,
use of accessory Review laboratory data like ABGs to determine degree of Laboratory data was reviewed
muscle to oxygenation of carbon dioxide
breathe, retention
RR: 24 LTG: establish Independent LTG Oxygen via nasal cannula was
effective Administer oxygen at lowest - for Management of underlying administered 2L/min
respiratory concentration pulmonary conditions-
pattern
-to promote Client was placed in semi
Elevate HOB 30-45 degrees physiological/psychological ease fowler position
of maximal inspiration

- to assist client in taking control Pursed lip technique was used

Encourage slower or deeper respiration
Monitor pulse oximetry
of the situation
O2 saturation maintained 94-
-to verify maintenance or 97% during the entire shift
improvement in oxygen
saturation

Stress importance of good posture and to maximize respiratory effort Proper use of accessory muscle
effective use of accessory muscles in breathing was taught to the
patient
DISCHARGE PLANNING

Medications

– The patient and the patient’s significant others were informed about the
importance of taking the prescribe medications (on the right dose, route,
and time) and the required therapies as ordered by the physician.

Environment

– Encouraged the patient’s significant others to provide a quiet

environment to promote faster healing and recovery.

Hand-washing

– Emphasized handwashing and personal hygiene, and encouraged good

grooming to promote selt-esteem.

OPD

– Reminded the patient about his follow-up check up and discussed its
importance in monitoring his health status.

Diet

– Instructed the patient to have the diet as ordered by the physician and
explained its importance on his present situation.

Ambulation

– Instructed patient to ambulate frequently and instructed the family

members to assist the patient to prevent accidents that could make the
clients condition worse.

Other Heath Teaching

– Instructed the patient to call physician or immediately call physician if

any adverse conditions develop such as blood soaking through the
bandage or if the experience any chest pain or difficulty of breathing

– Avoid strenuous activity like using the stairs.