Union Christian College

School of Health Sciences

CASE STUDY:
PLEURAL
EFFUSION

SUBMITTED TO:
Mrs. Elnora A. Uyso, RN, MAN
Clinical Instructor

SUBMITTED BY:
ACENA, Jobelle C.
CALUZA, Zhyraine Iraj D.
CRISTINO, Lynn Holly B.
SALES, Mary Ann E.
VELASCO, Janelle Mica SD.
ABAD, Princess Diane D.
CUARESMA, Abegail A.
JUBILO, Shydl Febrienne M.
RACELES, Madonna E.
RIVERA, John Clyde J.
 October 28, 2019
INTRODUCTION

This is the case of Patient X, year-old male who was admitted at Bethany Hospital last

October 15, 2019 at 9:34 am due to chief complaint of dyspnea and body pain, and an

admitting diagnoses of Sepsis, Nasocomial Pneumonia VS CAP high risk and Pleural Effusion,

Left Secondary.

Pleural Effusion, a collection of fluid in the pleural 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 infections (particularly viral infections), nephrotic syndrome, connective tissue

disease, pulmonary embolus, and neoplastic tumors. The most common malignancy associated

with a pleural effusion is bronchogenic carcinoma.

In certain disorders, fluid may accumulate in the pleural space to a point at which it

becomes clinically evident. This almost always has pathologic significance. The effusion can be a

relatively clear fluid, or it can be bloody or purulent. An effusion of clear fluid may be a

transudate or an exudate. A transudate (filtrate of plasma that moves across intact capillary

walls) occurs when factors influencing the formation and reabsorption of pleural fluid are

altered, usually by imbalances in hydrostatic or oncotic pressures. The finding of a transudative

effusion generally implies that the pleural membranes are not diseased. A transudative effusion

most commonly results from heart failure. An exudate (extravasation of fluid into tissues or

cavity) usually results from inflammation by bacterial products or tumors involving the pleural

surfaces.

Usually, the clinical manifestations are caused by the underlying disease. Pneumonia

cause fever, chills, and pleuritic chest pain, whereas malignant effusion may result in dyspnea,
difficulty lying flat, and coughing. The severity of symptoms is determined by the size of

effusion, the speed of its formation, and the underlying lung disease. A large pleural effusion

causes dyspnea. A small to moderate pleural effusion causes a minimal or no dyspnea.

PATIENT’S PROFILE

NAME: Patient X
GENDER: Male
AGE: 79 YEARS/OLD
BIRTHDATE: NOVEMBER 22, 1939
BIRTHPLACE: Bauang La Union
NATIONALITY: Filipino
CIVIL STATUS: Married
ADDRESS: #386, Quinavite, Bauang, La Union
RELIGION: Roman Catholic

ADMISSION:
DATE: October 15, 2019
TIME: 9:24 AM
ADMITTING PHYSICIAN: Dr. Mendoza

DIAGNOSIS:
ADMITTING DIAGNOSIS
 Sepsis
 Nosocomial Pneumonia vs CAP high risk
FINAL DIAGNOSIS
 Massive Pleural effusion

FAMILY HISTORY
( + ) HYPERTENSION
( + ) DIABETES
PREVIOUS MEDICAL HISTORY
 Enlargement of the heart ( 2008 )
 Prostate enlargement stage 3 benign ( 2016 )

VITAL SIGNS UPON ADMISSION

Tᵒ: 36ᵒC
RR: 72 beats per minute
PR: 32 cycles per minute
BP: 120/70 mmHg

ANATOMY AND PHYSIOLOGY

LUNGS

The lungs are pyramid-shaped, paired

organs that are connected to the trachea by
the right and left bronchi; on the inferior
surface, the lungs are bordered by the
diaphragm. The diaphragm is the flat, dome-
shaped muscle located at the base of the
lungs and thoracic cavity. The lungs are enclosed by the pleurae, which are attached to the
mediastinum. The right lung is shorter and wider than the left lung, and the left lung occupies a
smaller volume than the right. The cardiac notch is an indentation on the surface of the left
lung, and it allows space for the heart. The apex of the lung is the superior region, whereas the
base is the opposite region near the diaphragm. The costal surface of the lung borders the ribs.
The mediastinal surface faces the midline.

Each lung is composed of smaller units called lobes. Fissures separate these lobes from
each other. The right lung consists of three lobes: the superior, middle, and inferior lobes. The
left lung consists of two lobes: the superior and inferior lobes. A bronchopulmonary segment is
a division of a lobe, and each lobe houses multiple bronchopulmonary segments. Each segment
receives air from its own tertiary bronchus and is supplied with blood by its own artery. Some
diseases of the lungs typically affect one or more bronchopulmonary segments, and in some
cases, the diseased segments can be surgically removed with little influence on neighboring
segments. A pulmonary lobule is a subdivision formed as the bronchi branch into bronchioles.
Each lobule receives its own large bronchiole that has multiple branches. An interlobular
septum is a wall, composed of connective
tissue, which separates lobules from one
another.

PLEURAL SPACE

A shiny, thin, transparent

membrane called the serous coat, or
pleura, covers each lung. The inner
(visceral) layer of the pleura is attached to
the lungs and the outer (parietal) layer is
attached to the chest wall. Both layers are
covered with mesothelial cells, which secrete a small amount of fluid (i.e., less than 2
tablespoons) that provides lubrication between the chest wall and the lung. Both layers are
held in place by a film of pleural fluid, like two glass microscope slides that are wetted and stuck
together. The pleural space is called a potential space because it is virtually nonexistent. The
pleural membranes prevent the lung from making direct contact with the chest wall and the
diaphragm. Cells in the pleural space are primarily mesothelial cells that line the surfaces of the
pleural membranes and some white blood cells. The pleural membranes are semipermeable. A
small amount of fluid continuously seeps out of the blood vessels through the parietal pleura.
The visceral pleura absorbs fluid, which then drains into the lymphatic system and returns to
the blood. Protein in the circulation and balanced pressures keep excessive amounts of fluid
from seeping out of the blood vessels into the pleural space.
Each lung is enclosed within a cavity that is surrounded by the pleura. The pleura is a serous
membrane that surrounds the lung. The right and left pleurae, which enclose the right and left
lungs, respectively, are separated by the mediastinum. The pleurae consist of two layers.
The visceral pleura is the layer that is superficial to the lungs, and extends into and lines the
lung fissures. In contrast, the parietal pleura is the outer layer that connects to the thoracic
wall, the mediastinum, and the diaphragm. The visceral and parietal pleurae connect to each
other at the hilum. The pleural cavity is the space between the visceral and parietal layers.

The pleurae perform two major functions: They produce pleural fluid and create cavities
that separate the major organs. Pleural fluid is secreted by mesothelial cells from both pleural
layers and acts to lubricate their surfaces. This lubrication reduces friction between the two
layers to prevent trauma during breathing, and creates surface tension that helps maintain the
position of the lungs against the thoracic wall. This adhesive characteristic of the pleural fluid
causes the lungs to enlarge when the thoracic wall expands during ventilation, allowing the
lungs to fill with air. The pleurae also create a division between major organs that prevents
interference due to the movement of the organs, while preventing the spread of infection.

Mechanisms of Pleural Fluid Accumulation

An excessive amount of pleural fluid probably results from a combination of fluid
draining into the tissues from the blood vessels and the overproduction of fluid by the
mesothelial cells. Fluid accumulates in the pleural space by three mechanisms: increased
drainage of fluid into the space, increased production of fluid by cells in the space, and
decreased drainage of fluid from the space. Increased amounts of fluid drain from the
circulation when there is hypertension in the venous system (creating pressure imbalance) or
when there is too little protein in the blood. Ascites (fluid in the peritoneal space, or abdominal
cavity) can drain through small perforations in the diaphragm. A large amount of fluid can drain
directly into the pleural space this way. Abnormal mesothelial cells (as in asbestosis) can
produce large amounts of fluid. White blood cells can accumulate in response to infection
and inflammation in the pleural space (empyema). These cells produce fluid that is difficult to
drain or that are in such large quantities that normal drainage through the lymphatic system
simply cannot keep up. Malignant tumor cells can migrate (or metastasize) to the pleural space
from essentially any type of tumor in the body. These cells can attach to either the visceral or
parietal pleural surfaces or float freely in the pleural space and produce large amounts of fluid.
When tumor cells block lymphatic drainage, fluid accumulates. If the blockage is located in the
central lymphatic drainage system that drains chyle (milky fluid consisting of lymph and fat) to
the thoracic duct, fluid rich in chyle accumulates in the pleural space.
INITIAL ASSESSMENT

General Survey
Vital signs are: body temperature of 36.0 C; pulse rate 72 beats per minute with regular
rhythm upon palpitation; respiratory rate of 32 cycles per minute with regular rhythm; with
equal expansion of the chest; blood pressure of systolic 120 and diastolic of 70 mmHg noted
upon auscultation; oxygen saturation of 95%. Patient is awake, conscious and coherent. Speech
was slightly inadequate, but converses are well oriented. Client is responsive to questions both
verbally and physically. Chief complaint of difficulty breathing and body pain with presence of
facial grimace.

Skin
Patient has light brown skin complexion upon inspection. The patient’s skin on the left upper
arm has blister wound approximately 2-3 inches wide. Skin on the left arm is punctured due to
intravenous fluid infusion with noted edema, but no reddening, heat, nor pain. Puncture site at
the left posterolateral side of the thorax due to thoracentesis procedure done. Allover skin is
warm to touch, with good skin turgor, and with adequate moisture upon palpation.

Hair
The hair of the client is thin, unevenly distributed. There are no signs of infection and
infestation observed.

Nails
The client has a whitish color nails and has the shape of convex curve. It is smooth and is
intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails
return to usual color in less than 4 seconds.

Head
Head is symmetrical upon inspection. Fine, black, wavy hair noted in thin distribution.
Nodular lesions with brown color and equally distributed noted on the face upon inspection. No
masses noted upon palpitation. The client doesn’t complain of dizziness, vertigo and headache
upon the interview. She has no family history of mental disorders noted upon assessment of
her/his family background.

Eyes and Vision

Eyebrows: The client’s eyebrows are symmetrically aligned and showed equal
movement when asked to raise and lower eyebrows. Eyelids: There were no presence of
discharges, no discoloration and lids close symmetrically with involuntary blinks approximately
15-20 times per minute. Eyes: The sclera appeared white. The palpebral conjunctiva appeared
shiny, smooth and pink. There is no edema or tearing of the lacrimal gland. Cornea is
translucent, smooth and shiny and the details of the iris are slightly cloudy. Positive blurred
vision. Wears eyeglasses for daily use and reading. The client blinks when the cornea was
touched. The pupils of the eyes are black and equal in size. The iris is flat and round.
Ears and Hearing
The Auricles are symmetrical and has the same color with his facial skin. The auricles are
aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile,
firm and not tender. The pinna recoils when folded. The patient uses no hearing aids to
facilitate hearing.

Neck
The neck muscles are equal in size. The client showed coordinated, smooth head
movement with no discomfort. The lymph nodes of the client are not palpable. The trachea is
placed in the midline of the neck. The thyroid gland is not visible on inspection and the glands
ascend during swallowing but are not visible.

Nose and Breathing

Nose is symmetrical with good septal deviation noted upon inspection. No lesions and
scars noted. Nasal mucosa is red with adequate nasal hair and accumulated mucus secretions
noted upon inspection. Client is breathing with visual difficulties when one nostril is occluded
suggesting nares on both side of the nose are patent. Client is able to smell pleasant and foul
odors suggesting good olfaction.

Lungs
Respiratory rate of 32 cycles per minute, regular in rhythm, with noted exertion and use
of accessory muscle upon inspection. Asymmetry chest expansion and diminished breath sound
on the left lobe of the lungs. Positive Bibasilar crackles when auscultated. Frequent coughing
accompanied by expectoration. Resonant sounds heard upon percussion of the anterior and
posterior chest. On oxygen.

Abdomen
The abdomen of the client has an unblemished skin and is uniform in color. The
abdomen has a symmetric contour. There were symmetric movements caused associated with
client’s respiration.

Extremities
The extremities are symmetrical in size and length. Muscles: The muscles are not
palpable with the absence of tremors but positive in pain when palpated. They are normally
firm and showed smooth, coordinated movements. Bones: There were no presence of bone
deformities, tenderness and swelling. Joints: There were no swelling, tenderness and joints
move smoothly. Patient is ambulatory with assistance.
 IMPLICATION

A. NURSING PRACTICE

After the case presentation, the study will equip the nurse to grasp and comprehend a
deep understanding on the nature of the disease in terms of the risk factors, signs and
symptoms and management, to be able for them to handle patients and to- carry out
appropriate nursing intervention in the realization of nursing practice with regards to pleural
effusion and its predisposing factors.

B. NURSING EDUCATION

This case study would help in sharing data or information about the disease condition,
which is body pain, difficulty of breathing and chest pain and its management as well as needed
for the promotion of patient’s recovery. With these, the students as well as the instructors
would gain additional information about the disease in order to be efficiently equipped in
rendering nursing care in the future. The study will be informative to nursing students; it will
enable them to have prior knowledge and understanding about the disease. They will be able to
dictate signs and symptoms and possible nursing interventions/treatment of the disease.

C. NURSING RESEARCH

This case study would help in the nursing research as a source of data for example, in
tracking the population of persons with this condition. This information would help in creating
awareness and knowledge on the disease and the need for treatment, sharing importance
information on the early detection and prevention of the disease condition.

RECOMMENDATION

A patient with Pleural Effusion requires repeated assessments, which may range from bedside
observations to the use of invasive monitoring. These patients should be admitted to a facility
where close observation can be provided.

 Have a regular check-up and follow therapeutic regimen.

 Provide an extra effort in managing his disease.
 Instruct the client on how to promote and maintain nutritional status.
 Advise the client to avoid alcoholic beverages or to limit his intake because alcohol
interference with the utilization of essential nutrients.
 Advise the client to ensure adequate protein intake such as milk, eggs, oral nutritional
supplemental, 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.