TUBERCULOSIS

INTRODUCTION

PULMONARY TUBERCULOSIS

Pulmonary tuberculosis (PTB) is a chronic respiratory disease common among crowded and
poorly ventilated areas. An acute or chronic infection caused by Mycobacterium tuberculosis,
tuberculosis is characterized by pulmonary infiltrates, formation of granulomas with caseation,
fibrosis, and cavitation. Tuberculosis is an infectious disease that primarily affects the lung
parenchyma. It also may be transmitted to other parts of the body, including the meninges,
kidneys, bones, and lymph nodes. The primary infectious agent, M. tuberculosis, is an acid-fast
aerobic rod that grows slowly and is sensitive to heat and ultraviolet light.

Tuberculosis is a worldwide public health problem that is closely associated with

poverty, malnutrition, overcrowding, substandard housing, and inadequate health care.
M. tuberculosis infects an estimated one-third of the world’s population and remains the
leading cause of death from infectious disease in the world. According to the WHO, an
estimated 1.6 million deaths resulted from TB in 2005.In the United States,
almost 15,000 cases of TB are reported annually to the CDC. After exposure to M.
tuberculosis, roughly 5% of infected people develop active TB within a year.
PATIENT’S INFORMATION

Mr. X is a 50-year-old married man, living in P5 Borabod Daet Camarines Norte,

currently working as a painter of a vehicle for 10 years and a smoker since 18 years old
and a mild to moderate alcohol drinker.

CHIEF COMPLAINT

The patient was admitted to Camarines Norte Provincial Hospital last July 30, 2020, at
7:00 in the evening due to the complaint of difficulty of breathing (DOB). He was
attended at the Emergency Department and had taken a clinical history and physical
assessment. He was transferred to Medical Ward. He has admitting diagnosis of
Pulmonary Tuberculosis (PTB), pleural effusion at the right lung. His attending physician
was Dr. Mirana, a resident physician of the said hospital.

HISTORY OF PRESENT ILLNESS

Two weeks prior to admission patient experienced cough and easy fatigability
with an episode of difficulty of breathing (DOB). He also experienced the difficulty of
breathing (DOB) when lying flat on the bed and according to him it was relieved by
using 2 pillows on a moderate-high backrest position. He consulted a private physician
chest x-ray was done with findings of Pulmonary Tuberculosis (PTB), pleural effusion at
the right lung. In that time, he refused to admit to Camarines Norte Provincial Hospital
as what his private physician ordered.
Two days prior to admission the patient experienced a worsening of this
condition. He decided to seek medical care and admit to Camarines Norte Provincial
Hospital.

VITAL SIGNS

 Temp – 37.8C
 HR – 100 beats per minute
 RR – 30 beats per minute
 BP – 180/90 mmHg
 O2sat – 93%
PHYSICAL EXAMINATION

 General
o Lethargic
o Facial grimacing while inhaling
o Chest pain

 HEENT –
o pale conjunctiva, anicteric sclera, PERRLA (pupils round, equal,
round, reactive to light and accommodation)

 Neck – supple

 Respiratory
o Decrease chest expansion at right chest,
o Dullness to percussion

 Cardio – adynamic precurduim

 Abd – soft not tender abdomen

 Ext – no edema

 Skin – Excoriated

 Neuro – slightly altered, but baseline

LABORATORY RESULT

 Na – 133 low 135 - 145

 K – 4.1 normal
 Cl – 96 normal 95 – 105
 Platelets – 149 10 9/L 150 400 low

Creatinine – 1.8 elevated 0.6 to 1.3 mg/dL



 WBC – 9.48 x 10 9/L White Blood Cell (WBC) Count: 4,500 to 11,000

cells/mm³
 normal
 Hgb – 11.4 g/dL (114g/L) Low Male: 14-16.5 g/dL; Female: 12-15 g/dL
  HIV test: Negative

CHEST X-RAY

 Chest x-ray showed infiltrate in the middle of right lung with diameter of 1.7cm
with signs of cavitation.
 Costophrenic angle of the right lung (angle between ribs and diaphragm) blunted.
(Pleural fluid is obscuring the vision).
 Diaphragm: Obscure (Pleural fluid is obscuring the vision).
PATHOPHYSIOLOGY

Tuberculosis is a highly infectious, airborne disease.

 Inhalation. Tuberculosis begins when a susceptible person inhales mycobacteria

and becomes infected.
 Transmission. The bacteria are transmitted through the airways to the alveoli, and
are also transported via lymph system and bloodstream to other parts of the body.
 Defense. The body’s immune system responds by initiating an inflammatory reaction
and phagocytes engulf many of the bacteria, and TB-specific lymphocytes lyse the
bacilli and normal tissue.
 Protection. Granulomas new tissue masses of live and dead bacilli, ate surrounded
by macrophages, which form a protective wall.
 Ghon’s tubercle. They are then transformed to a fibrous tissue mass, the central
portion of which is called a Ghon tubercle.
 Scarring. The bacteria and macrophages turns into a cheesy mass that may become
calcified and form a collagenous scar.
 Dormancy. At this point, the bacteria become dormant, and there is no further
progression of active disease.
 Activation. After initial exposure and infection, active disease may develop because
of a compromised or inadequate immune system response.
ANATOMY OF THE LUNGS

The lungs are a pair of spongy, air-filled organs located on either side of the chest
(thorax). The trachea (windpipe) conducts inhaled air into the lungs through its tubular
branches, called bronchi. The bronchi then divide into smaller and smaller branches
(bronchioles), finally becoming microscopic.
The bronchioles eventually end in clusters of microscopic air sacs called alveoli. In the
alveoli, oxygen from the air is absorbed into the blood. Carbon dioxide, a waste product
of metabolism, travels from the blood to the alveoli, where it can be exhaled. Between
the alveoli is a thin layer of cells called the interstitium, which contains blood vessels
and cells that help support the alveoli.
The lungs are covered by a thin tissue layer called the pleura. The same kind of thin
tissue lines the inside of the chest cavity -- also called pleura. A thin layer of fluid acts
as a lubricant allowing the lungs to slip smoothly as they expand and contract with each
breath.
COURSE IN THE WARD

DATE/TIME PROGRESS NOTE DOCTOR’S ORDER

07/30/2020 CXR-PTB  Please admit to medical ward isolation.
7:00 pm PLEURAL EFFUSION,  Secure consent.
RIGHT  TPR q shift and recorded
 Diet: DAT with aspiration precaution
 IVF: PNSS regulated at 20gtts/min
 LAB- stat ECG, CBC typing
-Sputum AFB GS for 3 consecutive days
 Urinalysis

 MEDS
o Cefuroxime 750mg IV q8 (-ANST)
o Salbutamol neb q8
o Hydrocortisone 100mg IV q8
o O2 inhalation via nasal cannula @4.5
L/min.
o for CTT insertion @ right
o secure consent
o prepare materials for procedures
o refer to SCOD stat
o refer to TB DOTS

Dr. Mirana

07/30/2020 (+) progressive DOB

 for CTT insertion @ right
9:00 pm (-) BS R lung Field
 inform IM for CP evaluation prior to procedure
(+)post/lateral
Chest pain  secure consent
 secure materials

Dr. Enesio

07/10/2020
10:00 pm  Stat RBS, BUN, Crea, Na, K, ECG

Dr. Tabanao

07/30/2020 RBS N
11:00 pm BUN Crea N  Transderm patch 5mg on
Na K N  O2 inhalation @4.5 L/min
 May proceed with contemplated procedure

Dr. Tabanao

DATE/TIME PROGRESS NOTE DOCTOR’S ORDER

08/01/2020 S/P  Tramadol 50mg IV q6
8:00 am Obtain initially 300 cc  O2 inhalation @ 4.5 L/min
purulent discharge  Deep breathing, coughing exercise
 Repeat CXR tomorrow

Dr. Enesio

9:00 am Hgb, Hct   Transfuse 1 unit PRBC type O+ after

properly type (matched)
 N-acetylcysteine 600mg to ½ glass of H20
OD
 Continue other meds
 Monitor CTT output
 Change CTT bottle when full

Dr. Tabanao

08/02/2020 CTT output 1000 total

CXR repeat-lung  For removal of CTT-done
expanded  Continue meds

Dr. Enesio
CHEST TUBE THORACOSTOMY

Background:

 The insertion and placement of a chest tube into the pleural cavity for the purpose of
removing air, blood, purulent drainage, or other bodily fluid foreign to this space and to
restore the mechanical function of the lung.
 If a patient with pneumothorax or other indication for tube thoracostomy requires
intubation and mechanical ventilation, the chest tube should be inserted first to avoid
creating an iatrogenic tension pneumothorax.
 The images and information provided below explain the process of preparing for and the
placement of the chest tube (tube thoracostomy).

Procedure:

Indications:

 Chylothorax
 Empyema
 Hemopneumothorax
 Hemothorax
 Pleural effusion with symptoms and signs of instability
 Pneumothorax (Symptomatic or simple but beyond 25%)
 Iatrogenic pneumothorax (e.g., post needle decompression for tension
pneumothorax)
Anatomical Placement

 5th intercostal space at the midaxillary line (note: in most patients this is lateral to
the nipple at the point of the midaxillary line)

Considerations & Special Circumstances:

 Avoid placement directly over an area of infected soft tissue (e.g., cellulitis or skin
abscess)
 Avoid going below or through the diaphragm, which can extend up as high as the nipple
during full expiration
 Consider going into the 4th intercoastal space at the midaxillary line in patients who are
pregnant, have ascites from cirrhosis, or large hemoperitenum where the increased
intraabdominal contents and pressure can further elevate the diaphragm

Supplies
 Chest tube tray (that includes Kelly clamps x 2 and forceps x 1)
 Sterile gloves, gown, hair covering, drapes and towels
 Chest tube (size is influenced by the reason for placement)
 Adults:
 36 - 38 F for large pneumothorax or hemothorax
 24 - 32 F for simple/nontraumatic pneumothorax
 Pediatrics:
 Based on Broselow tape but ranges 12 - 28 F for children and 12 -
18 F for infants
 Note: Consider having a back up chest tube available one size
smaller to avoid delays
 Pleurivac system (or alternative suction device with reservoir) and connection
tubing
 Betadine or chlorhexidine skin cleansing preparation
 Scalpel #10 blade and handle
 Nonabsorbable suture (e.g., 1-0 or 2-0 silk)
 Xeroform or Vaseline gauze dressing  
 Sterile 4" x 4" bandages with slits
 Elastoplast dressing roll
 Adhesive tape
 20-guage and 25-gauge needle with 10 ml syringe
 Local anesthetic (e.g., 1 - 2% lidocaine with or without epinephrine)
 Parenteral analgesia and/or sedative hypnotic

Pre-Procedure Preparation

 Explain the procedure to the patient and obtain informed consent if not emergent
 Place the patient on the cardiac monitor, pulse oximetry and supplemental oxygen
 Ensure 2 points of functioning intravenous (IV) access with 2 large bore (16 - 18 G)
catheters.
 Determine the right position for the patient:
 Lying in the supine position:
  Least preferred
 Used when the patient is hemodynamically unstable
 Sitting in the supine position:
 Preferred if stable. 
 Head of bed elevated to 30 degrees
 Regardless if the patient is sitting up or lying down, the patients arm on the side
of the chest tube placement should be abducted and flexed at the elbow with hand
up above the head to expose the area of insertion
 Identify the anatomical landmark to giving consideration to special circumstance
 Set up the Pleurivac system by injecting water to create the water seal (per
manufacturer), then attach to high-volume suction capable of creating at least 60 cm of
water pressure at a flow of at least 15 - 20 L/min
 Verify all supplies required for chest tube insertion are present at bedside and prepared
 Initiate procedural sedation and/or injection of local anesthetic for intercostal nerve block
(described in detail below)
 Set up the Pleurivac system by injecting water to create the water seal (per
manufacturer), then attach to high-volume suction capable of creating at least 60 cm of
water pressure at a flow of at least 15 - 20 L/min
 Verify all supplies required for chest tube insertion are present at bedside and prepared
 Initiate procedural sedation and/or injection of local anesthetic for intercostal nerve block
(described in detail below)

Procedure: Placement of Chest Tube

 Put on the hair covering, sterile gown and gloves

 Prepare chest tube by placing a Kelly clamp across the end of the chest tube that will
enter into the chest cavity and place forceps across the opposite end to prevent fluid from
the pleural cavity from escaping freely after the chest tube is in place.
 Note: Kelly clamp should be placed with the metal tip compressing the chest tube
but not extending beyond, as the free end of the Kelly clamp could result in tissue
damage to the lung on insertion into the chest cavity.
 Begin procedural sedation and parenteral analgesia based on clinical situation
 Clean the area of skin with topical antiseptic
 Drape the area using sterile technique
 At the 6th rib and intercostal space, anesthetize the skin at insertion point in an area of
about 4 cm going down to the periosteum of the rib under the incision.  Then anesthetize
the subcutaneous tissue along the tract to the 4th or 5th intercostal space.
 Note: Starting 1 rib and intercostal space below the entry into the chest cavity
(just above the 5th intercostal space) allows the tube to tunnel beneath
subcutaneous tissue and reduces the chance of air leak, especially at the time of
chest tube removal.
 Anesthetize the pleura in the area of the 4th or 5th intercostal space
 Note: It is important to anesthetize the pleura well due to the amount of pain in
this area when entering into the chest cavity.
 Make an incision over the 6th rib surface that is about 2 - 3 cm and extends down into the
subcutaneous tissue.
 With controlled effort, dissect bluntly with a Kelly clamp to the surface of the 5 th or 6th rib
and continue to dissect bluntly through the underlying subcutaneous tissue muscle,
creating a track the extends over the top of the 4 th or 5th rib (1 rib superior to your site of
 skin entry) and into the intercostal space.  Note: Going over the top of the rib avoids
injuring the neurovascular bundle that is present underneath the inner aspect of the rib.
 Once the intercostal muscles have been adequately dissected and the pleura reached
hold the closed Kelly clamp with a grip close to the end of the metal tips, and in a
controlled effort, puncture through the pleura.
 Note:  Avoid losing control of the Kelly clamp upon entering into the chest cavity
to avoid puncturing the lung and creating a hole.  Doing this could create an air
leak due to air moving into the lung alveoli but moving into the chest cavity and
then taken out by the chest tube.
 Once inside the chest cavity, with the tip of the Kelly clamp near the plane of the pleura,
open the Kelly clamp to stretch the tissue larger than the size of the chest tube.
 With the Kelly clamp still inside the chest cavity, insert your index finger into the hole to
keep the track open and take out the Kelly clamp.
 Using the index finger, sweep the inside of the chest cavity feeling for adhesions and to
make sure you are in the intrathoracic cavity and not in the intraperitoneal cavity.  Do not
take your index finger out if you are in the right location.
 Note: You should NOT feel the diaphragm in the cephalad direction, the liver (if
on the right side) or the spleen (if on the left side). If you have punctured through
the diaphragm, it will need to be repaired surgically.  If you feel a significant amount
of adhesions, then another location will be needed since it can be difficult to
appropriately insert the chest tube in a posterior - superior (apically) direction.
 While keeping your index finger in the chest cavity, take the chest tube with the Kelly
clamp and forceps still in place with your other hand and advance the tip of the chest
tube along your index finger to ensure you enter into the intrathoracic cavity.
 Once you have verified the chest tube in the right place, remove the Kelly clamp and
advance the tube further in a posterior direction and up towards the apex (superior
aspect) of the lung until all of the holes on the chest tube inside the chest cavity. 
 Note: It is important to ensure that the chest tube is advanced far enough that all
drain holes are within the thoracic cavity.
 Take out your index finger and now release the forceps attached the end of the chest
tube and immediately connect the end of the chest tube quickly to the Pleurovac that is
under water seal and set at negative 20 cm of H2O so that the lung can be re-expanded.
 Secure the chest tube with suture to the skin.
 Note: There are a number of techniques to suture the chest tube to the skin. 
However, the technique used should be able prevent inadvertent removal of the
chest tube or exposure of the holes in the chest tube, be so tight around the
chest tube as to clamp off the chest tube, or be too tight on the skin that the skin
around the chest tube insertion site does not start to have decreased blood flow. 
 Apply antibiotic ointment around the insertion point and then apply an occlusive dressing
(Xeroform or Vaseline gauze) over the chest tube insert site to create a seal.
 Apply two or four of the 4 x 4-inch dressings via the slits so that the chest tube is in the
center of the bandages and tape down the dressing and tube to the skin.
 Note:  Many clinicians will apply adhesive tape to the patient and then wrap the
tape in a spiral fashion or enveloped around the tube a few centimeters to create
another anchor of the chest tube to the patient. 
 Apply the Elastoplast dressing tape over the dressing and bandages to secure them to
the patient and help to maintain the seal around the insertion site.
 Note: Some clinicians will tape the connections to the suction tubing to help
ensure that the suction is not accidentally separated from the chest tube or
creates an air leak.
Post-Procedure Assessment

 Repeat vital signs including pulse oximetry

 Listen to bilateral lung sounds
 Obtain a portable chest radiograph to verify lung reexpansion and placement of the
chest tube
 Evaluate the activity of the Pleurovac to look for continued signs of an air leak and/or the
amount of blood or fluid being evacuated
 Reasons for persistent air leaks or failure of the ling re-expansion:
 A connection in the tubing is loose or not tight
 Hole in the tubing
 One of the holes in the chest tube is now exposed
 A bronchopleural fistula is present
 Esophageal rupture

Complications:

 Intraparenchyemal fistula from injury of the lung by the Kelly clamp or chest tube.
 Inserting the chest tube within a fissure of the lung
 Damage to the neurovascular bundle underneath the rib from using the wrong technique
 Pulmonary edema secondary to lung re-expansion
 Tension pneumothorax from an occluded or clamped tube
 Persistent pneumothorax
 Subcutaneous emphysema
 Injury to the diaphragm
 Placement into the peritoneum
 Infection (specially pneumonia)
 Bleeding from the chest wall (due to injury of the intercoastal artery).
 750mg
÷ 750mg x
6cc = 6cc

XXX, MR. X

CEFUROXIME 750mg IV
ANST (-) q8
6am-2pm-6pm

2.5mg ÷ 2.5mg = 1 nebule

XXX, MR. X

HYDROCORTISONE 100mg IV q8
6am-2pm-6pm

100mg ÷ 100mg = 1cc

 XXX, MR. X

SALBUTAMOL NEB q8
6am-2pm-6pm

50mg ÷ 100mg x 2ml = 1cc

XXX, MR. X

TRAMADOL 5Omg IV q6
6am-12pm-6pm-12am

600mg ÷ 600mg = 1 sachet to ½ glass of water

XXX, MR. X

N-ACETYLCYSTEIN 600mg
TO ½ GLASS OF WATER P.O OD
10am
5mg ÷ 5mg = 1 patch

XXX, MR. X

TRANSDERM PATCH 5mg ACW

NOW
NURSES
NOTES

DATE/TIME FOCUS DATA ACTION RESPONSE

07/30/2020 Ineffective D- Admitted a 50 years old male patient accompanied by

7:00 pm Breathing pattern his wife; with cc of difficulty of breathing; ambulatory,
conscious, restless and weak. Vital signs taken as follow;
BP-140/90mmHg, CR- 100bpm; RR- 30bpm;
temperature- 37.8c; O2 sat- 93%; cyanosis and
tachypnea noted; productive coughing
noted……………………………………………
A – Consent signed for admission; admitting orders
made by Dr. Mirana carried out; on NPO; established a
line for PNSS 1L regulated @20gtts/min. O2 inhalation
given via nasal cannula lpm; STAT ECG and CBC; for
sputum AFB GS and urinalysis; Informed Dr. Enesio for
CTT insertion; deep breathing exercise advised,
monitored respiratory pattern-rate depth and rhythm.
R – after 30 mins. of nursing intervention in ER, patient
demonstrates reduced difficulty of breathing on
moderate high back rest; still for monitoring; transferred
to medical ward isolation……………………………

Arianne Joy I. Balon, RN

Lic. No.1234567

07/30/2020 Ineffective Airway D- received patient from ER per wheelchair

7:30pm clearance accompanied by nurse on duty; with ongoing IVF of
PNSS 1L regulated @20 gtts/min @ full level infusing
well; with oxygen via nasal cannula @4-5 lpm;
productive cough with sputum secretions; decreased
chest expansion noted; ………………………………….
A – Placed the patient in moderate high back rest; vital
signs taken and recorded; initial meds started; Advised
DAT with SAP; deep breathing exercise advised; Sputum
collection for AFB GS tomorrow advised; as ordered by
Dr. Mirana;…………………
R – After 8 hours of nursing intervention, patient
maintained patent airway; able to expectorate
secretions………………………………………………..
Needs rendered; endorsed…………………………….
Jo-ann B. Barnuevo, RN.
Lic. No. 0500776
07/30/2020 Ineffective Tissue D – Received patient in bed with an IVF of PNSS 1L
10:00 pm Perfussion @600 cc level infusing well regulated @ 20gtts/min; still
with O2 via nasal cannula @4-5 lpm; cough and sputum
noted; chest pain reported with pain scale of 7/10;
………………………………………………………
A - vital signs taken and recorded as follows; BP-
130/90 mmHg, CR- 105; RR- 25; Temp- 36.8c, O2 sat-
94% S/E by Dr. Tabanao; with orders made and carried
out; STAT RBS, BUN, crea, Na, K,requested and
forwarded to laboratory; ECG done reading of Ischemia
lateral wall. Transderm patch attached to anterior chest
wall as per doctors order; monitored v/s frequently;
checked oxygen therapy and the patency of IVF; correct
positioning advised; instruct to cough or sneeze and
expectorate into tissue and to refrain from spitting;
proper disposal of tissue advised; good hand washing
techniques advised; adequate rest and sleep advised;
Due meds given…
R – After 8 hours of nursing intervention, patient rated
pain 3/10; able to expectorate secretions; v/s taken BP-
120/80; CR-99; RR- 20; Temp- 36.5c; O2sat- 98%;
advised to proceed for contemplated procedure;
Informed Dr. Enesio for CTT insertion tomorrow @ 8:00
am, 08/01/2020……………………

Charlyn Mhay Honrubia, RN

Lic. No. 7777777

08/02/2020 Risk for infection D – received pt on bed; with an IVF of PNSSL 1L @200
cc level regulated @20 gtts/min; infusing well; with CTT
on right, unclamped; Dressing is clean and dry; minimal
incision pain, 2/10 on pain scale…
A – V/S taken and recorder; CXR impression; lung
expanded; CTT removal done by AP aseptically;
advised good hygiene; kept dressing clean and dry;
monitor and note any untoward discharges; safety
measures advised; clean and safe environment
provided; due meds given…………………………….
R – After 8 hours of nursing intervention, pt was free
from pain; no signs and symptoms of infection; vital
signs are stable………………………………………

Gracia A. Nieves, RN
Lic. No. 0500776
NURSE’S NOTES

DATE/TIME FOCUS DATA ACTION RESPONSE

08/01/2020 Deficient D - Receive on bed; with an IVF of PNSS 1L @150 cc
6:00 am knowledge level, infusing well; conscious and coherent; expressed
related to misconceptions about health status; looks worried and
inaccurate restless………………………………
information A – v/s taken and recorded as follows; BP- 130/90, CR-
presented as 102; RR- 20; temp-36.8c, o2 sat 97%; Checked
evidenced by oxygen therapy and the patency of IVF; assess level of
express ability to learn; Note level of fear, concern and fatigue;
misconceptions provide accurate information about the situation;
about the health Encouraged patient to verbalize fears and concerns;
status Provide instruction and specific written information
about the disease; keep calm and provide patient with
emotional support; seen at all times; due meds given....
R- after giving enough information and emotional
support the patient was appeared comfortable and
relaxed; showed readiness to go to the procedure;
latest v/s taken as follows; BP- 120/80, CR-96, RR-22,
Temp- 36.8c, O2sat- 98%; wheeled to O.R. endorsed
to NOD………………………………………………………

Shermayne Hernandez
Lic. No. 5555555
08/01/2020 Risk for infection D- receive pt from ward per wheel chair accompanied
8:00 am by NOD; with an IVF of PNSS 1L @ full level regulated
at 20 ggts/min infusing well; conscious and coherent;
…………………………………
A – Placed pt @ OR table; vital signs taken and
recorder as follows; BP- 120/80, CR- 89, RR-20, Temp-
36.5c, O2 sat 97% given via FM @10 lpm; prepping of
the operative site done; sterile drapes placed;
anesthesia provided locally; Operative started @
8:45 am 8:45am; incision made; thoracic catheter inserted; initial
drainage of 300 cc; tube clamped ; closing of the
9:00am incision done; operation done @9:00 am; release 100
cc of pleural fluid every 1 hour then clamp; Keep CTT
open if less than 10 cc/hr. For CXR tomorrow with
request made; Post Op meds given; oral meds to start
@ ward; monitor vital signs every 30 mins;…………….
R- After 8 hours of giving nursing intervention; the
patient was appeared comfortable; (-) signs and
symptoms of complications; needs rendered and
endorsed…………………………………………………….

Melanie M. Cuba, RM, RN

Lic. No 1111111
08/01/2020 Pain D- Received patient from OR via stretcher; awake and
9:30 am conscious; with an IVF of PNSS 1L @ 800cc level
 regulated @ 20 gtts/min, infusing well; with CTT at right
side………………………………………………
A – Placed the patient on bed; v/s taken and recorded;
checked the oxygen and the patency of IVF; deep
breathing and coughing exercise advised; clean and
safe environment provided; check for drainage; wash
hands before and after clamping the drainage tube;
CTT output monitored; adequate rest and sleep
advised; due meds given; S/E by Dr. Tabanao; with
orders made and carried out; to transfuse 1 unit of
PRBC type O + after properly cross matched; change
CTT bottle when full; room kept well ventilated; safety
measures advised;………………..
R- After 8 hours of giving nursing interventions; the
patient was able to rest and sleep; (-) signs and
symptoms of any complications; vital signs are
stable………………………………………………………

Jhoan Melody Yanto RM, RN

Lic. No. 2222222

08/01/2020 Imbalanced D – Received pt on bed; with an IVF of PNSS 1L

2:00 pm nutrition less than @400cc level regulated @ 20gtts/min infusing well;
body cough and sputum noted; pt appeared weak;
requirements complaining of poor appetite;………………………….
related to A – vital signs taken and recorded; due meds given;
frequent blood transfusion of 1 unit of PRBC started @3pm to
cough/sputum run for 4 hours; WOF untoward s/sx; blood transfusion
production, ended @7pm; patient’s nutritional status on admission
reviewed; skin turgor, current weight and degree of
weight loss; ability or inability to swallow, presence of
bowel tones noted and monitored ; I&O and weight
monitored; Encourage and provide for frequent rest
periods; oral care before and after respiratory
treatments provided; small but frequent meal advised;..
R – After 8 hours of nursing interventions, pt was able
to intake food and regain energy; Reduced bad taste
left from sputum or medications; able to rest and sleep;
vital signs are stable……………………………………

Sherlyn P. Bibon RN
Lic. No. 3333333
NURSE’S NOTES

08/01/2020 Impaired Physical D – Received pt on bed; with an IVF of PNSS 1L

10:00 pm Mobility related to @700cc level regulated at 20gtts/min infusing well; with
CTT attached CTT on right; conscious and coherent……………………..
A – v/s taken and recorded as follows; BP- 120/80, CR-
85, RR-19, Temperature – 36.8c, O2sat 95%; safety
measure advised; assist the pt when changing position;
advise relatives to kept necessary utensils within reach
of pt, assist for elimination and urination; provide clean
and safe environment; due meds given; for CXR
tomorrow morning; released 1000 cc total output; still no
output draining so unclamped; needs rendered;…………
R – pt was able to move or do things within ROM; was
able to change position on bed safe and comfortable….

Arianne Joy I. Balon, RN

Lic. No. 4444444
 PLAN OF ACTION:
Pleural effusion occurs when fluid collects between the parietal and visceral pleura. Processes

causing a distortion in body fluid mechanics, such as in heart failure or nephrotic syndrome,

tend to cause transudative effusions, whereas localized inflammatory or malignant processes

are often associated with exudative effusions. Patients can be asymptomatic or can present with

cough, dyspnea, and pleuritic chest pain. Dullness to percussion on physical examination

suggests an effusion; chest radiography can confirm the diagnosis. Thoracentesis may be

indicated to diagnose effusion and relieve symptoms. Ultrasound guidance is preferred when

aspirating fluid. Routine assays for aspirated fluid include protein and lactate dehydrogenase

levels, Gram staining, cytology, and pH measurement. Light's criteria should be used to

differentiate exudative from transudative effusions. Additional laboratory assays, bronchoscopy,

percutaneous pleural biopsy, or thoracoscopy may be required for diagnosis if the initial test

results are inconclusive.

Patients with pleural effusion can be asymptomatic or can present with dyspnea, cough, or

pleuritic chest pain.  The history should focus on differentiating pulmonary etiologies from

cardiovascular and other causes of effusion. A thorough chest examination should be

performed, with particular attention to dullness to percussion because it is sensitive and specific

ROOM204 for diagnosing effusion

08/01/20
The tests most commonly used to diagnose and evaluate pleural effusion include:

 Chest x-ray

 Computed tomography (CT) scan of the chest

 Ultrasound of the chest

 Thoracentesis (a needle is inserted between the ribs to remove a biopsy, or sample of

fluid)
  Pleural fluid analysis (an examination of the fluid removed from the pleura space)

When the pleural effusion has remained undiagnosed despite previous, less-invasive tests,

thoracoscopy may be performed. Thoracoscopy is a minimally invasive technique, also known

as video-assisted thoracoscopic surgery, or VATS, performed under general anesthesia that

allows for a visual evaluation of the pleura). Often, treatment of the effusion is combined with

diagnosis in these cases

How is pleural effusion treated?

 Treatment of pleural effusion is based on the underlying condition and whether the

effusion is causing severe respiratory symptoms, such as shortness of breath or difficulty

breathing.

 A pleural effusion that is causing respiratory symptoms may be drained using

therapeutic thoracentesis or through a chest tube (called tube thoracostomy).

 For patients with pleural effusions that are uncontrollable or recur due to a malignancy

despite drainage, a sclerosing agent (a type of drug that deliberately induces scarring)

occasionally may be instilled into the pleural cavity through a tube thoracostomy to

create a fibrosis (excessive fibrous tissue) of the pleura (pleural sclerosis).

 Pleural sclerosis performed with sclerosing agents (such as talc, doxycycline, and

tetracycline) 

DISCHARGE INSTRUCTIONS:

Call your doctor if:

 You feel faint, or you cannot think clearly.

 Your lips or fingernails turn blue.

 You find it very hard to breathe.

 You have a fever.

  Your breathing problems do not go away or get worse.

 Your pain does not go away or gets worse.

 You cough up yellow, green, gray, or bloody mucus.

 You have questions or concerns about your condition or care.

Medicines:

 Diuretics may help decrease extra fluid caused by heart failure or other problems.

 Antibiotics help prevent or treat an infection caused by bacteria.

 NSAIDs help decrease swelling and pain or fever. This medicine is available with or

without a doctor's order. NSAIDs can cause stomach bleeding or kidney problems in

certain people. If you take blood thinner medicine, always ask your healthcare provider if

NSAIDs are safe for you. Always read the medicine label and follow directions.

 Prescription pain medicine may be given. Ask your healthcare provider how to take this

medicine safely. Some prescription pain medicines contain acetaminophen. Do not take

other medicines that contain acetaminophen without talking to your healthcare provider.

Too much acetaminophen may cause liver damage. Prescription pain medicine may

cause constipation. Ask your healthcare provider how to prevent or treat constipation.

 Steroids or other types of medicines may be given to decrease swelling.

 Take your medicine as directed. Contact your healthcare provider if you think your

medicine is not helping or if you have side effects. Tell him or her if you are allergic to

any medicine. Keep a list of the medicines, vitamins, and herbs you take. Include the

amounts, and when and why you take them. Bring the list or the pill bottles to follow-up

visits. Carry your medicine list with you in case of an emergency.

Self-care:

 Use pressure to decrease pain. Hold a pillow against your chest when you cough or take

a deep breath.
  Do not smoke, and do not allow others to smoke around you. If you smoke, it is never

too late to quit. Smoking increases your risk for lung infections such as pneumonia.

Smoking also makes it harder for you to get better after having a lung problem. Ask your

healthcare provider for information if you need help quitting.

 Drink liquids as directed and rest as needed. Liquids help to keep your air passages

moist and better able to get rid of germs and other irritants. Ask your healthcare provider

how much liquid to drink each day and which liquids are best for you. You may feel like

resting more. Slowly start to do more each day. Rest when you feel it is needed.

 Deep breathing and coughing will decrease your risk for a lung infection. Take a deep

breath and hold it for as long as you can. Let the air out and then cough strongly. Deep

breaths help open your airway. You may be given an incentive spirometer to help you

take deep breaths. Put the plastic piece in your mouth and take a slow, deep breath.

Then let the air out and cough. Repeat these steps 10 times every hour.

While pleural effusion is a common condition, it can quickly become serious. People living with

pleural effusion or pleurisy should see their doctor right away to begin treatment before infection

or other complications occur.

Always follow your treatment plan as prescribed and maintain a healthy lifestyle to prevent

recurrence. Here are some additional resources to help you.

Coping

If you have pleural effusion or pleurisy, there are steps you can take to manage unpleasant

symptoms and prevent the condition from recurring. Get plenty of rest, and avoid physical

activity that may intensify pain or breathing problems. If your pleural effusion is caused by an

underlying medical condition such as cancer, congestive heart failure or lung disease, speak

with your doctor to learn more about living with chronic disease. Be honest about your concerns,

and let your doctor know if you experience changes in your symptoms.
Eating

Eat a healthy, balanced diet with plenty of vegetables, fruit and lean protein. Limit sugar, fat and

alcohol, and maintain a healthy weight. Healthy eating is important during and after treatment.

Exercise

Your doctor may recommend avoiding physical activity while you have pleural effusion or

pleurisy. But after treatment, you’ll want to resume normal exercise. High blood pressure

increases your risk of pleural effusion. Exercise can help lower blood pressure, decrease stress

and anxiety and improve strength, mood and bone health. If you don’t regularly exercise, talk

with your doctor before you start. Your doctor can help recommend an exercise plan.

Lifestyle Changes

Smoking and high blood pressure put you at greater risk of getting pleural effusion. Avoid

smoking altogether, and seek help if you would like to quit. Find healthy ways to manage stress,

and aim for 7-8 hours of sleep a night. Get in the habit of washing your hands frequently to

avoid exposure to viruses or bacteria. If you feel like you have a cold or virus, get plenty of rest,

and seek medical attention if you experience chest pain, difficulty breathing or fever or if your

symptoms worsen.