Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

In Partial Fulfillment

Of the Requirement in

Related Learning Experience (RLE)

A Case Study on:

A Male Patient with Pleural Effusion

Submitted by:

JAZZLEY JONES C. BAÑEZ

BSN III-D
 I. INTRODUCTION

The patient to be mentioned in this paper will be given a pseudo name “Mr. X.” Mr. X

was one of the patients admitted to the Metro Vigan Cooperative Hospital, Male Medical

Ward last November 21, 2020 due to complaints of shortness of breath and was diagnosed

with Pleural Effusion.

A Pleural Effusion is the accumulation of fluid in the pleural space. The body

produces pleural fluid in small amounts to lubricate the surfaces of the pleura, the thin

membrane that lines the chest cavity and surrounds the lungs. Abnormalities with either

secretion or drainage of this fluid leads to pleural effusion. Clinical manifestations depend of

the amount of fluid present and the severity of lung compression. For larger effusions, lung

expansion may be restricted and the client may experience dyspnea primarily on exertion, and

a dry, non-productive cough caused by bronchial irritation or mediastinal shift.

Effusions also occur when the rate of fluid formation exceeds the rate of fluid

absorption. Pleural effusions are commonly classified as either exudative or transudative. An

exudative pleural effusion implies that there is a disease process that is affecting the pleura

directly, causing the pleura to be damaged. A transudative pleural effusion, the case of the

patient, results when the pleura itself is healthy and implies that a disease process is affecting

hydrostatic and/or oncotic factors that either increase the formation of pleural fluid or

decrease the absorption of pleural fluid. Deciding if the pleura is injured or intact helps in

formulating a concise differential diagnosis for potential causes.

Factors that increase the chance of developing pleural effusion include: pneumonia,

tuberculosis or other lung diseases, heart attack, heart failure, or infections such as

pericarditis, recent cardiac surgery, pleurisy, tumors, cancers, such as lung, breast, surgery,

especially involving the heart, lungs and the abdomen. Tests to diagnose pleural effusion

include chest x-ray, ultrasound, CT scan, thoracentesis, pulmonary function tests and biopsy.
General Objectives

It aims to analyze the problem and the cure about the patient’s condition and to provide

information with an overview of the patient’s condition process and nursing implication.

Specific Objectives

Student-centered Objectives

• To establish rapport to the patient and to be able to formulate nursing care plans for

the patient.

• To know the treatment about the patient’s condition.

• To gain knowledge on the anatomy and physiology of the organ involve, and the

pathophysiology of the patient’s case.

• To gain comprehensive knowledge about the patient’s condition/case.

• To know the medical management to the patient’s condition.

• To differentiate the actual and ideal medical management as well as the diagnostic

procedures related to the patient’s case.

• To improve our skills in assessing holistically.

• To formulate discharge plan for the patient and to identify the risk factor in acquiring

the patient’s case.

• To provide psychological support to the patient and to impart health teachings to

patient and family members to care of patient with congestive heart failure resulted by

difficulty of breathing.
Patient-centered Objectives

• The client will develop coping activities and will able to verbalize understanding of

need to carry emergency components for intervention, need to inform health care

providers about difficulty of breathing, and the importance of seeking emergency

care.

• Client will maintain an effective breathing pattern and will improve the nutritional

pattern.

Family-centered Objectives:

• The family or the significant others will be able to sustain psychological support for

the patient.

• The family of the patient will gain knowledge towards pleural effusion as resulted to

difficulty of breathing.
 II. DEMOGRAPHIC DATA

Name of Patient : “Mr. X”

Age : 57 Years Old

Sex : Male

Date of Birth : 02-26-1956

Place of Birth : Vigan City

Address : Barangay IX, Vigan City, Ilocos Sur

Religion : Roman Catholic

Nationality : Filipino

Civil Status : Married

Occupation : Market Vendor

Informant : Mrs. X and Client

Relationship to Patient : Wife (Mrs. X)

Date of Admission : November 21, 2020

Time of Admission : 4:11 PM

Attending Physician : Dra. Marie Alexis Divera

Admitting Vital Signs : Temp.: 37oC PR: 72 bpm

RR: 30 cpm BR: 100/80 mmHg

Food Allergy : No known food allergies

Drug Allergy : No known drug allergies

Educational Attainment : High School Level

Monthly Income : ₱ 8,000-10,000

Chief Complaint : Shortness of Breath

Diet : On diet as tolerated with strict aspiration precaution

Admitting Diagnosis : Right Pleural Effusion

III. HISTORY OF PAST AND PRESENT ILLNESS

HISTORY OF PAST ILLNESS

The patient experienced common illnesses during childhood such as fever, common colds,

coughs and abdominal pain. Have a family history of Hypertension and Diabetes Mellitus.

Patient denies having given vaccinations.

HISTORY OF PRESENT ILLNESS

Mr. X experienced dizziness and shortness of breath last March 2020. On April 2020,

which was his first BP measurement after many months, his blood pressure reading was

200/100 mmHg and decided to have his check-up at Ilocos Sur Provincial Hospital – Gabriela

Silang (ISPHGS). He was discharged after five days of admission. He was given prescription

medications for hypertension by his physician but has difficulty complying due to financial

difficulties. On June 12, 2020, Mr. X was again admitted at ISPHGS and was diagnosed with

Hypertensive Cardiovascular Disease (HCVD) and Cerebrovascular Accident (CVA), which

led to right residual weakness of his body. On September 6, 2020, He went back to ISPHGS

because he experienced shortness of breath and was admitted. Thoracentesis was done to the

patient on the same day. On November 13, 2020, his physician suggested a Chest Tube

Thoracostomy to be done at whichever hospital they prefer.

Mr. X, again experienced shortness of breath, was admitted at Metro Vigan Cooperative

Hospital on November 21, 2020 at 4:11PM. X-ray was done on the same day and revealed no

interval change in the right hemithorax. On November 22, 2020, chest ultrasound revealed a

right loculated pleural fluid of not less than 1000 cc. On November 23, 2020, a final

pathological report revealed a chronic inflammatory pattern negative for malignant cells. On
November 24, 2020, thoracentesis was done and two days after, CTT was done. Chest CT

scan, plain and contrast was done on November 25, 2020.

IV. PEARSON ASSESSMENT

HOSPITAL DATE: HOSPITAL DATE:

November 24, 2020 November 25, 2020
ASSESSMENT
PHYSIOLOGICAL Skin, hair and nails: Skin, hair and nails:

The Patient has a dark brown The Patient has a dark brown

complexion and skin is evenly complexion and skin is evenly

in color, Skin is intact and no in color, Skin is intact and no

reddened areas, Skin is dry and reddened areas, the skin is dry,

warm with poor skin turgor, no and no presence of any foul

presence of any foul odor odor especially on the skin

especially on the skin folds, has folds. has a body temperature of

a body temperature of 36.0° C. 36.0° C.

The hair color of the patient is a The hair color of the patient is a

little gray, has a thick hair, little gray, has a thick hair,

evenly distributed, scalp is clean evenly distributed, scalp is clean

and dry, no infection or and dry, no infection or

infestation present and the infestation present and the

amount of hair is variable. amount of hair is variable.

The client has a long brown The client has a long brown

nails, has the shape of convex nails, has the shape of convex

curve, nails are hard and curve, nails are hard and

immobile in texture, normal nail immobile in texture, normal nail

color and intact epidermis. No color and intact epidermis. No

presence of clubbing. presence of clubbing.

Head and Neck: Head and Neck:

The head of the client is hard The head of the client is hard

and smooth without lesions, and smooth without lesions,

symmetric facial features; symmetric facial features;

palpebral fissures equal in size palpebral fissures equal in size

and symmetric nasolabial folds. and symmetric nasolabial folds.

Symmetrical facial movements. No edema and symmetrical

The temporal artery is elastic facial movements. The temporal

and not tender. The neck is artery is elastic and not tender.

symmetric, with head centered The neck is symmetric, with

and without bulging masses. head centered and without

The client showed coordinated, bulging masses. The client

smooth head movement with no showed coordinated, smooth

discomfort. There is a head movement with no

displacement of the trachea and discomfort. There is a

mediastinum toward the side of displacement of the trachea and

the effusion mediastinum toward the side of

Eyes: the effusion

Black, equal in size with Eyes:

consensual and direct reaction, Black, equal in size with

pupils equally rounded and consensual and direct reaction,

reactive to light and pupils equally rounded and

accommodation. reactive to light and

Eyeballs are symmetrically accommodation.

aligned in socket with sunken Eyeballs are symmetrically

eyeballs. The eyelids close aligned in socket without

symmetrically and blinks protruding or shrinking. The

involuntary. No discharges and eyelids close symmetrically and

no discoloration. Eyebrows blinks involuntary. No

symmetrically aligned, hair is discharges and no discoloration.

evenly distributed and equal Eyebrows symmetrically

movement. The eyelashes are aligned, hair is evenly

equally distributed and curled distributed and equal

slightly outward. movement. The eyelashes are

There is absence of eye equally distributed and curled

infection or redness yet has a slightly outward.

little bit of white spots covering There is absence of eye

the pupil. infection or redness yet has a

Ears: little bit of white spots covering

The patient’s ears are the pupil.

symmetrical and have the same Ears:

color with his facial skin. Voice The patient’s ears are

sounds audible and has no symmetrical and have the same

drainage from the ears. color with his facial skin. Voice

sounds audible and has no

Mouth, throat, nose and sinus: drainage from the ears.

Patient’s nose is symmetric and Mouth, throat, nose and sinus:

straight, no discharge or flaring, Patient’s nose is symmetric and

no lesions and color is the same straight, no discharge or flaring,

as the rest of the face. Air no lesions and color is the same

moves freely as the patient as the rest of the face. Air

breaths through the nares. Nasal moves freely as the patient

septum intact and in midline. breaths through the nares. Nasal

Sinuses are not tender. septum intact and in midline.

The lips of the patient are dark Sinuses are not tender.

brown. There is yellowish The lips of the patient are dark

discoloration of the enamels. He brown. There is yellowish

is not suffering from gum discoloration of the enamels. He

bleeding or mouth lesions. The is not suffering from gum

uvula of the client is positioned bleeding or mouth lesions. The

in the midline of the soft palate. uvula of the client is positioned

The tongue of the client is in the midline of the soft palate.

centrally positioned. It is pink in The tongue of the client is

color, moist and moves freely. centrally positioned. It is pink in

Tonsils are pink, smooth and no color, moist and moves freely.

discharge. Tonsils are pink, smooth and no

discharge.

Thorax and lungs:

Dullness to percussion, Thorax and lungs:

decreased tactile fremitus, and Dullness to percussion,

asymmetrical chest expansion, decreased tactile fremitus, and

with diminished or delayed asymmetrical chest expansion,

expansion on the side of the with diminished or delayed

effusion. Spine is vertically expansion on the side of the

aligned. Skin intact and uniform effusion. Spine is vertically

in temperature. The patient is aligned. Skin intact and uniform

experiencing difficulty of in temperature. The patient is

breathing and chest pains. He experiencing difficulty of

also has persistent dry cough breathing and chest pains. He

and presence of diminished or also has persistent dry cough

inaudible breath sounds. and presence of diminished or

Heart and neck vessels: inaudible breath sounds.

The patient’s jugular vein is not Heart and neck vessels:

distended, bulging or The patient’s jugular vein is not

protruding. Pulses are equally distended, bulging or

strong with no variation in protruding. Pulses are equally

strength from beat to beat. The strong with no variation in

radial and apical pulse is strength from beat to beat. The

identical. Heart has irregular radial and apical pulse is

rhythm, murmur, and gallop. identical. Regular heart rhythm:

The patient has a blood pressure 80 beats per minute with

of 100/80 mmHg. rhythm, murmur, and gallop.

Peripheral vascular: The patient has a blood pressure

Arms are bilaterally symmetric of 100/70 mmHg.

with minimal variation in size Peripheral vascular:

and shape. The patient skin Arms are bilaterally symmetric

color is pinkish-brown, warm to with minimal variation in size

touch. regular apical pulse with and shape. The patient skin
a rate of 84 beats per minute, color is pinkish-brown, warm to

regular, strong radial pulse. Hair touch. Brachial pulses have

covers the skin on the legs, free unequal pulses strength

of lesions or ulcerations, bilaterally. Hair covers the skin

Presence of bipedal +2 pitting on the legs, free of lesions or

edema with inability to perform ulcerations, with the presence of

basic rom at right peripherals, +2 bipedal edema. Slight

redness color changes on the redness color changes on the

legs or feet. legs or feet.

Abdomen: Abdomen:

The patient experienced The patient experienced

abdominal pain. The patient has abdominal pain. The patient has

a symmetric big or enlarged a symmetric big or enlarged

abdomen. There were abdomen. There were

symmetric movements symmetric movements

associated with client’s associated with client’s

respiration and has no visible respiration and has no visible

vascular pattern. Free from vascular pattern. Free from

lesions or rashes. Umbilicus is lesions or rashes. Umbilicus is

midline at lateral line. midline at lateral line.

Musculoskeletal: Musculoskeletal:

Posture is erect and comfortable Posture is erect and comfortable

for age. Patient have average for age. Patient have decreased

weakness, and limited range of or limited ROM. No

motion at right peripherals. No contractures and no tremors.

 contractures and no tremors. Bones has no deformities and no

Bones has no deformities and tenderness. The patient needs to

no tenderness. The patient needs be accompanied when walking.

to be accompanied when He has stiffness of joints but can

walking. He has stiffness of still perform activities of daily

joints but can still perform living.

activities of daily living. Neurologic:

Neurologic: The patient has no changes in

The patient has no changes in general mood. He has no

general mood. He has no difficulty in speaking, The

difficulty in speaking, The patient is oriented to time place

patient is oriented to time place and person, has not been

and person, has not been suffering from memory

suffering from memory problems. The patient has a

problems. The patient has a right residual weakness of his

right residual weakness of his body

body
Gastrointestinal Gastrointestinal

The patient did not defecate in The patient did not defecate in

ELIMINATION the morning of Tuesday. No the morning of Tuesday. No

other significant findings other significant findings

determined. determined.

Renal Renal

The patient was in Indwelling The patient was in Indwelling

Folley Catheter. The client has Folley Catheter. The client has

normal urinary pattern with no normal urinary pattern with no

 urgency. On diet as tolerated urgency. On diet as tolerated

with strict aspiration precaution with strict aspiration precaution

as ordered. as ordered.
He works as a meat and He works as a meat and

vegetable vendor in a public vegetable vendor in a public

market. He states that he does market. He states that he does

ACTIVITY
not exercise but uses household not exercise but uses household
AND REST
chores and daily activities in the chores and daily activities in the

market as an exercise. He sleeps market as an exercise. He sleeps

at least 5-6 hours a day. at least 5-6 hours a day.

The patient stays at bed B2 on The patient stays at bed B2 on

Male Ward under Dra. Marie Male Ward under Dra. Marie

Alexis Divera. Walking with Alexis Divera. Walking with

slippers and wear additional slippers and wear additional

clothes if needed. His clothes if needed. His

significant other assists him in significant other assists him in

SAFETY AND activities. The environment is activities. The environment is

SECURITY quiet and calm. Hospital bed is quiet and calm. Hospital bed is

positioned high back with side positioned high back with side

rail raised and wheels are rail raised and wheels are

locked. The room is equipped locked. The room is equipped

with properly grounded with properly grounded

electrical equipment and electrical equipment and

nonconductive floor. nonconductive floor.

 The patient is experiencing The patient is experiencing

increased difficulty in breathing, increased difficulty in breathing,

or shallow breathing with use of or shallow breathing with fast

accessory muscle; fast breathing breathing rate at 30 cpm and has

OXYGENATION rate at 30 cpm with Fine cracles oxygen Saturation of 93%.

and hyporesonance at right lung

field and has oxygen Saturation

of 93%.

The patient consumed portion of The patient consumed portion of

vegetables, fruits and meat for vegetables, fruits and meat for

the past days prior to admission. the past days prior to admission.

Drinks clean water from refill Drinks clean water from refill
NUTRITION
filtration. Taking anti- filtration. Taking anti-

hypertensive daily. The hypertensive daily. The

patient’s diet decreases salt food patient’s diet decreases salt food

content as ordered. content as ordered.

V. DIAGNOSTIC PROCEDURE

A. Ideal

 Chest Radiograph (x-ray). A chest X-ray is a radiology test that involves exposing the

chest briefly to radiation to produce an image of the chest and the internal organs. Doctor

may order a chest x-ray if you have symptoms like persistent cough, chest injury, chest

pain, coughing up blood and difficulty in breathing.

 Thoracic Computed Tomography (CT). An imaging method that uses x-rays to create

cross-sectional pictures of the chest and upper abdomen. These cross-sectional images of
 the area being studied can then be examined on a computer monitor, printed or transferred

to a CD. It also provides greater clarity and reveals more details than regular x-ray

examination of the body. The test may be used to better view the structures inside the

chest.

 Chest Ultrasound. A chest ultrasound is a non-invasive procedure used to assess the

organs and structures within the chest, such as the lungs, mediastinum, and pleural space.

Ultrasound technology allows quick visualization of the chest organs and structures from

outside the body.

 Thoracentesis. A procedure is used to remove fluid from the space between the lungs

and the chest wall called the pleural space. The procedure is performed to to remove a

biopsy, or sample of fluid. Also to prevent the fluid from building up again and treating

the cause of the fluid build-up.

 Pleural Fluid Analysis. An examination of the fluid aspirated/collected from the pleural

space during thoracentesis and to look for cancerous or malignant cells, cellular makeup,

chemical content and tiny organisms that can cause the diseases.

 Complete Blood Count. This is used as a broad screening test to check for disorders

as anemia, infection, and many other diseases. It is actually a panel of tests that examines

different parts of the blood.

VI. ANATOMY AND PHYSIOLOGY

The pleural cavity is a fluid filled space that surrounds the lungs. It is found in the thorax,

separating the lungs from its surrounding structures such as the thoracic cage and intercostal

spaces, the mediastinum and the diaphragm. The pleural cavity is bounded by a double

layered serous membrane called pleura.

Pleura is formed by an inner visceral pleura and an outer parietal layer. Between these two

membranous layers is a small amount of serous fluid held within the pleural cavity. This

lubricated cavity allows the lungs to move freely during breathing.

 Pleural Cavity

The pleural cavity, with its associated pleurae, aids optimal functioning of the lungs

during breathing. The pleural cavity also contains pleural fluid, which acts as a
 lubricant and allows the pleurae to slide effortlessly against each other during

respiratory movements.

 Lungs

The lungs are the organ in which the exchange of gasses takes place. The lungs are

made up of extremely thin and delicate tissues. At the lungs, the bronchi subdivides,

becoming progressively smaller as they branch through the lung tissue, until they

reach the tiny air sacks of the lungs called the alveoli. It is at the alveoli that gasses

enter and leave the blood stream.

 Visceral Pleura

The visceral pleura is the serous membrane that is directly adhered to the outer

surface of each lung. It extends into the horizontal and oblique fissure of the lungs,

lining the opposing surfaces of these fissures. It is much thinner than the parietal

pleura, making it more delicate.

 Parietal Pleura

The parietal pleura covers the inside of the thorax, mediastinum, and diaphragm.

plays the major role in the formation and removal of pleural fluid. The parietal pleura

is the thicker and more durable outer layer that lines the inner aspect of the thoracic

cavity and the mediastinum.

 Diaphragm

The diaphragm, it is a large, dome-shaped muscle located below the lungs that

contracts rhythmically and continually, and plays a major muscle of respiration.

VII. PATHOPHYSIOLOGY
a. Algorithm
Precipitating Factors:
Stress from noisy environment with poor sanitation, P3000-P4000
Predisposing Factors: monthly family income, inability to maintain prescribed medications
Age: 57 for HPN, children, nature of work: Market vendor, diet: High in Na
Gender: M (Dried fish, “ginamos”, etc.), cardiovascular Disease (May 2020)

Increase peripheral vascular resistance

Hypertension (April 2020) 200/100

mmHg

Increased hydrostatic Cerebrovascular accident

pressure in arterial end with right residual
of capillary weakness (June 2020)

Fluid movement
into tissue

Presence of +2
bipedal edema
 Prevent forward flow of blood from left side of
Pleural Fluid Cytology: the heart
Final pathological report:
Chronic Inflammatory Pattern
WBC = 16.1/L
Negative for Malignant Cells.
Hb =11.4 g/dL
Gross/Microscopic Description: Backward pressure
Hct =34.4 vols%
Specimen consists of 1 liter
Platelets
blackish fluid for cytology
=329,000
Microscopy Description: Shortness of
Cell block shows lymphocytes breathing
and red cells
Pulmonary edema
tachypnea
Chest Ultrasound: Laboratory
Loculated fluid of and Impaired
Pleural effusion orthopnea
not less than 1,000 is Diagnostic gas
seen occupying the dyspnea
Examinations exchange
right hemithorax

Crackles, dullness
Chest xray: to upon percussion,
Shown progression of the density tactile fremitus is
in the right hemothorax with very attenuated
aerated lung seen at the outer
aspect of right upper lobe, left
lung is clear

CT Scan
1. There is 23 x 8.8 x 13.8 cms (1396.60 cc) thick walled loculated
pleural effusion which is slightly hyperdense in the right hemithorax
2. There is volume loss of the right lung with no definite mass lesion seen
and very minimal aerated lung at the upper lobe
3. There is minimal reticular and haze densities at the upper lobe
4. There is shift of mediastinal structure to left
5. The heart is not enlarged but there is minimal pericardial effuse
6. Aorta is normal in calibre with minimal calcification along the walls
7. No enlarged lymph nodes seen
8. There is minimal thoracic spondylosis
9. There is chest tube in place in the right side with tip at the medial
aspect, level of T8-9
b. Explanation

Pleural effusions develop when changes in fluid and solute homeostasis occur, and the

mechanism causing these changes determines whether it will be an exudative (high protein

content) or transudative (low protein content) effusion. Exudate is fluid that leaks around the

cells of the capillaries and is caused by inflammation, while transudate is fluid pushed

through the capillary due to high pressure within the capillary. An imbalance between the

hydrostatic and oncotic pressure within the capillaries causes a transudate effusion.

In the case of the patient, the precipitating factors plays a role in the increased of peripheral

vascular resistance that resulted to higher blood pressure with increased cardiac output.

Resulted to Cerebrovascular accident with right residual weakness, High blood pressure puts

an extra strain on all the blood vessels in your body. This can make a stroke due to a clot

more likely, because high blood pressure damages your blood vessels and makes them

become stiffer and more narrow. This can lead to clots forming and travelling to the brain,

causing a stroke. Failure on the left side of the heart will cause to have increased pressure on

the left side of the heart. The pressure will back up to the lungs that would Increased

hydrostatic pressure in arterial end of capillary that causes transudate. An increase in

pulmonary venous pressure that produces alveolar edema also increases the interstitial

pressure in subpleural regions; edema fluid leaks from the visceral pleural surface,

contributing to the rate of fluid accumulation. To the extent that the elevated left atrial

pressure is transmitted to the right heart, systemic venous pressure will also be increased. The

elevation of systemic venous pressure should increase the filtration of fluid from the parietal

capillaries and simultaneously decrease lymphatic flow from the pleural cavity by increasing

the outflow pressure in the thoracic duct. There will now a fluid movement into tissue, and

as a result, the fluid is going to be forced out in between the endothelial cells because the

pressure is too high. There is now presence of bipedal edema or the accumulation of fluid in
the feet and lower legs. Preventing forward flow of blood from left side of the heart that will

cause the blood can back up into the veins that take blood through the lungs. As the pressure

in these blood vessels increases, fluid is pushed into the air spaces in the lungs. That will

result into pulmonary edema. And The fluid leaking out is going to leak into the pleural space

that can cause pleural effusion or the accumulations of fluid within the pleural space.

The clinical presentation of patients with pleural effusions due to cardiac failure is usually

dominated by the classic symptoms and signs of congestive heart failure. The patient usually

complains of increasing dyspnea on exertion, peripheral edema, and orthopnea or paroxysmal

nocturnal dyspnea. Pleuritic chest pain is uncommon. Physical examination frequently

reveals signs of biventricular failure: distended neck veins, peripheral edema and

hepatojugular reflux are present, in combination with rales and a left-sided S3 gallop.

Dullness to percussion, decreased fremitus and diminished breath sounds at the bases indicate

the presence of pleural effusions.

VIII. MANAGEMENT

Medical Management

Ideal

Pharmacologic management of pleural effusion depends on the condition’s etiology. For

example, medical management includes nitrates and diuretics for congestive heart failure and

pulmonary edema, antibiotics for parapneumonic effusion and empyema, and anticoagulation

for pulmonary embolism.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens

in the context of the clinical setting.

 Ampicillin and sulbactam (Unasyn) This combination of ampicillin and a beta-

lactamase inhibitor interferes with bacterial cell wall synthesis during active replication,

causing bactericidal activity against susceptible organisms.

 Imipenem and cilastatin (Primaxin) This drug combination is used for the treatment of

multiple organism infections for which other agents do not have wide-spectrum coverage

or are contraindicated due to their potential toxicity.

 Piperacillin and tazobactam sodium (Zosyn) This consists of antipseudomonal

penicillin plus a beta-lactamase inhibitor. It inhibits biosynthesis of the cell wall

mucopeptide and is effective during the active multiplication stage.

 Clindamycin (Cleocin) Clindamycin is a lincosamide for the treatment of serious skin

and soft-tissue staphylococcal infections. It is also effective against aerobic and anaerobic

streptococci (except enterococci). Clindamycin inhibits bacterial growth, possibly by

blocking dissociation of peptidyl transfer ribonucleic acid (tRNA) from ribosomes,

arresting RNA-dependent protein synthesis.

 Piperacillin Piperacillin inhibits biosynthesis of cell-wall mucopeptides and the active

multiplication stage; it has antipseudomonal activity.

Vasodilators

Vasodilators are medications that open (dilate) blood vessels. They affect the muscles in the

walls of your arteries and veins, preventing the muscles from tightening and the walls from

narrowing. As a result, blood flows more easily through your vessels.

 Nitroglycerin (Nitrostat, Nitro-Bid, Nitro-Dur, Nitrolingual) It provides excellent and

reliable preload reduction. Higher doses provide mild afterload reduction.

Diuretics

Loop diuretics decrease plasma volume and edema by causing diuresis.

 Furosemide (Lasix) Furosemide increases the excretion of water by interfering with the

chloride-binding cotransport system, which, in turn, inhibits sodium and chloride

reabsorption in the ascending loop of Henle and distal renal tubule.

 Anticoagulants, Hematologic Anticoagulants prevent recurrent or ongoing

thromboembolic disorders by inhibiting thrombogenesis.

 Heparin Heparin augments the activity of antithrombin III and prevents the conversion of

fibrinogen to fibrin. Heparin prevents reaccumulation of a clot after spontaneous

fibrinolysis.

Surgical Management

Ideal

The management of Transudative effusions or of exudative effusions depends on the

underlying etiology of the effusion. However, regardless of whether transudative or

exudative, large, refractory pleural effusions causing severe respiratory symptoms can be

drained to provide symptomatic relief.

 Therapeutic Thoracentesis is used to remove larger amounts of pleural fluid to alleviate

dyspnea and to prevent ongoing inflammation and fibrosis in parapneumonic effusions.

 Tube thorascotomy is a minimally invasive procedure in which a thin plastic tube is

inserted into the pleural space and may be attached to a suction device to remove excess

fluid or air. A chest tube may also be used to deliver medications into the pleural space.

 Video-Assisted Thoracoscopic Surgery. For drainage of pleural effusions, it is sufficient

to use one small incision to accommodate the 10-mm offset scope, evacuate the effusion,

and use the talc poudrage and chest tube.

 Decortication is usually required for trapped lungs to remove the thick, inelastic pleural

peel that restricts ventilation and produces progressive or refractory dyspnea.

 Pleurodesis (also known as pleural sclerosis) involves instilling an irritant into the pleural

space to cause inflammatory changes that result in bridging fibrosis between the visceral

and parietal pleural surfaces, effectively obliterating the potential pleural space.

Pleurodesis is most often used for recurrent malignant effusions, such as in patients with

lung cancer or metastatic breast or ovarian cancer.

 Pleuroperitoneal shunts are another treatment option for recurrent, symptomatic

effusions, most often in the setting of malignancy, but they are also used for management

of chylous effusions.

 Indwelling Tunneled Pleural Catheters are a valid alternative for pleurodesis in

malignant and some benign effusions. TPC can be inserted as an outpatient procedure and

can be intermittently drained at home, minimizing the amount of time spent in the

hospital for patients with short prognoses.

IV. NURSING CARE PLANS
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS BACKGROUN S
D
Objective Data: Excess fluid Fluid Volume Short Term: Independent: Short Term:
 Bipedal volume related to Excess (FVE), or After 30 minutes  Reviewed  This can After nursing
edema +2 excessive sodium hypervolemia, patient will be dietary decrease intervention
 RR-30cpm intake refers to an able to verbalize restrictions and extracellular patient was able
 Crackles at isotonic understanding of safe substitutes fluid retention to verbalize
right lung expansion of the individual dietary for salt understanding of
upon ECF due to an restrictions  To reduce individual dietary
auscultation increase in total tissue restrictions.
 dyspnea body sodium Long Term:  Elevated pressure and Goal partially met
 right pleural content and an After 3 days of edematous risk of skin Long Term:
effusion as increase in total nursing extremities, breakdown After giving
evidenced by body water. This intervention change position nursing
an ultrasound fluid overload patient will be frequently  Pulmonary intervention
 pallor usually occurs able to stabilize fluid shifts patient was able
from fluid volume as  Encouraged potentiate to stabilize fluid
 poor skin
compromised evidenced by coughing/deep- respiratory volume as
turgor
regulatory vital signs within breathing complications evidenced by
mechanisms for client’s normal exercises. vital signs within
sodium and water limits and  Limited client;s normal
as seen reduced signs of cardiac limits and
commonly in edema  Encouraged reserves result reduced signs of
heart failure, bedrest. in edema.
kidney failure, Schedule care to fatigue/activit Goal partially met
and liver failure. provide frequent y intolerance.
Excessive intake rest periods. In addition,
of sodium from lying down
foods, favors
medications, IV diuresis and
solutions or reduction of
diagnostic dyes  Provided safety edema.
are also precautions as  Fluid shifts 
considered causes indicated, e.g., may cause
of FVE. use of side rails, cerebral edem
bed in low a or
position, changes in
frequent mentation,
observation, especially in
softrestraints (if the geriatric
required) population

 Placed in semi-
Fowler’s  To facilitate
position, as movement of
appropriate diaphragm,
thus
Dependent: improving
 Monitored respiratory
laboratory effort
studies as
indicated, e.g.,
electrolytes,  Extracellular
BUN. ABGs fluid shifts,
sodium
Collaborative: restriction
 Consult affect serum
dietitian, as sodium levels.
needed
 To address
ongoing
nutrition
 concerns or
dietary needs

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS BACKGROUN S
D
Subjective Cues: Ineffective Ineffective Short Term: Independent: Short Term:
“Nahihirapan breathing pattern breathing pattern After 30 minutes  Provided  To promote The patient shall
akong huminga ”, related to occurs when of nursing relaxing have
adequate rest
as verbalized by decreased lung inspiration and intervention, environment demonstrated
periods and to
the patient volume capacity expiration does patient will reveal appropriate
limit fatigue
as evidence by not provide no abnormal coping behaviors
Objective Cues: tachypnea and adequate breath sounds  To promote and method to
 Tachypnea presence of ventilation. upon  Elevated patient lung improve
 Presence of crackles on the Pleural auscultation; head expansion breathing pattern.
crackles at right side of the inflammation patient will Goal partially met
right lung lung fields causes sharp demonstrate  Assisted patient
field upon localized pain adequate in the use of  To maximize Long Term :
auscultation that increases breathing pattern, relaxation oxygen The patient shall
 Use of deep of breathing, with easy, techniques available for have applied
accessory coughing and unlabored cellular techniques that
muscle movement. This respirations;  Force Fluids uptake improved
 RR-30cpm can result to Patient will breathing pattern
 Orthopnea shallow and rapid demonstrate  To liquefy and be free from
 Diaphoresis breathing correct technique  Taught patient secretions signs and
pattern.. in pursed-lip on pursed-lip symptom of
 Dypnea
breathing, breathing,  These respiratory AEB
 Restlessness
abdominal abdominal activities respiratory rate
 Decreased breathing and
Tactile breathing and allow patient within normal
relaxation relaxation participate in range absence of
fremitus
 Dull techniques. techniques maintaining cyanosis,
resonance health status effective
Dependent: and breathing and
 Give oxygen as ventilation minimal used of
prescribed accessory
muscles during
 Supplemen breathing.
tation of Goal partially met
oxygen helps
to improve
 Chest breathing
thoracostomy pattern and
tube relieve
respiratory
Collaborative: distress
 Assist with
bronchoscopy  To remove
or chest tube excess fluid
insertion as from pleural
indicated. space.

 To provide
relief of
causative
agent
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS BACKGROUN S
D
Objective Cues: Risk for infection Infections occur Short Term: Independent Short Term:
 Presence of related to surgical when the natural After 30minutes  Stress and  Reduce cross The patient shall
chest procedure as defense of nursing model proper contamination identify behavior
thoracostomy evidenced by mechanisms of an intervention the hand washing and bacterial and practice in
tube at the presence of right individual are patient will be techniques to colonization preventing
right midaxillary chest inadequate to able to identify client and infection.
midaxilliary thoracostomy protect them. behavior and caregiver Goal partially met
area tube Organisms such practice to  Prevent entre
 Open as bacteria, prevent and  Maintained of bacteria
environment viruses, fungus, reduce the risk aseptic reducing risk Long Term :
 Over crowded and other for infection technique with nosocomial The patent shall
area parasites invade any procedures. infection achieve wound
susceptible hosts Long Term: Provide routine healing and free
through After 3 days of site care and from infection
inevitable injuries giving nursing wound care as  Early and
and exposures intervention the appropriate detection of inflammation.
like open wounds client will developing Goal partially met
such as presence achieved timely  Inspected infection
of chest wound healing dressing not provides
thoracostomy free of signs of characterized by opportunity
tube . Surgical infection and drainage for timely
site infection can inflammation intervention
range from purulent drainage and
cellulitis to and fever prevention
necrotizing soft and more
tissue infection. serious
Tube  Encouraged complication
thoracostomy frequent
drainage for position  Limit stasis of
empyema changes and body fluids
thoracis has a being out of bed promotes
higher probability or early optimal
of giving rise to ambulation as functional
necrotizing soft tolerated organ system
tissue infection. and
 Monitored vital gastrointestin
signs al tract

 To have base
Dependent: line data
 Administered specially
antibiotics as increase
indicated temperature

Collaborative:  Antibiotic
 Refer to therapy may
physician for be geared
Administering toward
antibiotics specific
organism

 To promote
wellness
ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS S
Subjective Cues: Ineffective Due to limited Short Term Independent Short Term:
“Nahihirapan airway clearance lung expansion Goal:  Anterior and At the end of 4 hours
akong huminga ”, related to during At the end of 4 hours posterior chest  To determine in giving nursing
as verbalized by weakness and ventilation, in giving nursing intervention
auscultated the decrease
intervention patient’s lung sounds
the patient poor cough effort. pleural effusion or absence of will be clear to
patient’s lung sounds
causes will be clear to ventilation auscultate; Patient
Objective Cues: impairment in the auscultate; Patient and the will be free of
 Slight gas exchange that will be free of  Maintained presence of dyspnea; Patient will
weakness leads to dyspnea; Patient will adequate sound demonstrate correct
 Crackles at inadequate demonstrate correct hydration. barriers. coughing and deep
oxygen supply in coughing and deep breathing techniques
the right lung
field upon the body that breathing techniques
 To reduce the Goal partially met
results to easy Long term Goal:
auscultation  Instructed viscosity of
Long term:
fatigability At the end of 1
 Tachypnea patients about secretions.
At the end of 1
day of giving
 RR: 30 cpm cough and deep day of giving
nursing
 Dyspnea breathing  To facilitate nursing
intervention
 Used if techniques. the release of intervention
patient will
accessory secretion. patient will
maintain a patent  Encouraged
muscle airway maintain a patent
physical
 Pallor airway
activity.  To improve Goal partially met
the movement
of secretions.
 If the patient is
unable to  To avoid
perform pneumonia
ambulation, the and pressure
location of the ulcers.
 patient sleeping
position
changed every 2  To reduce
hours. anxiety and
 Informed increase self-
patients before control.
starting the
procedure.
 Controlled
couching is
accomplished
 Encouraged to by closure of
take a deep the glottis and
breath hold for the explosive
two second, and expulsion of
cough two or air from the
three times in lungs by the
succession. work by the
abdominal
and chest
muscle.

 Promotes better
lung expansion
 Elevated the head and improved
of the patient in gas exchange.
semi high fowler’s
position.  Early
supplemental
Dependent oxygen is
essential since
early mortality is
 associated with
 Administer inadequate
supplemental delivery of
oxygen. oxygenated
blood to the
brain and vital
organs.

Collaborative:  To medically
 Refer for any manage any
changes in the complications
body

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS S
Subjective Cues: Acute pain Pain may be Short Term:  Performed  These Short Term:
“ Ramdam na related to considered as comfort measures
ramdam niya ang placement of Pleuritic chest After 3 hours of measures to reduce muscle The patient shall
sakit dahil sa chest pain. Pleuritic nursing promote tension or have reported
lugar kung saan thoracostomy chest pain derives intervention, the relaxation such spasm, and pain is relieved
nakalagay ang tube from patient will be as repositioning help patient from a pain scale
tubo, hindi mo inflammation of able to report a and relaxation focus on non- of 6/10 to 3/10
siya gagalawin ” the parietal decrease of pain. techniques. pain related Goal partially met
as verbalized by pleura,the site of subjects.
the significant pleural pain Long Term:  Provided patient
others fibers. After 2 days of with  This educates Long Term :
Patient verbalized Occasionally, this nursing information to patient and The patient shall
pain scale of 6 symptom is interventions, the help increase encourages be free from pain
out of 10. accompanied by patient will be pain tolerance; compliance in as evidenced by
Objective Cues: an audible or free from pain for example trying demonstration of
 Facial palpable pleural and demonstrate reasons for pain alternative relaxation skills
grimace rub,reflecting the relaxation skills. and length of pain relief and diversional
 Guarded movement of time it will last. measures activities with the
behaviour on abnormal pleural help of the SO.
the CTT site tissues.  Manipulated the  This promotes Goal partially met
 Tachypnea environment to health, well-
 RR: 30 cpm promote periods being, and
 Dyspnea of uninterrupted increased
 Use of rest energy level
accessory important to
muscle pain relief.

 Encouraged and  Deep

assist client to breathing
do deep exercises
breathing contribute to
exercises
 Encouraged relief of pain.
verbalization
and feelings of  Only the
pain client can
judge the
level and
degree of
pain; pain
Dependent: management
 Administered should be a
medications, team
particularly approach that
analgesics, as includes the
prescribed client
Collaborative:
 Refer to
physician for
Administering  To relieve
analgesics pain

 To medically
manage any
complications
b. Promotive and Preventive

 Eat in heart-healthy ways. The foods that help you are those that contain little

saturated fat, trans fat, sugar or sodium. Think fruits and vegetables, low-fat dairy, lean

protein such as chicken without the skin, and “good” fats such as those found in olive

oil, fish and avocadoes.

 Stop smoking—better yet, don’t start. It’s a major factor in the arterial damage that

can cause heart failure. Also, avoid secondhand smoke.

 Reduce stress. When you are anxious or upset, your heartbeats faster, you breathe more

heavily and your blood pressure often goes up.

 Lose pounds if you are overweight. Along with diet, being physically active helps

achieve this goal and is great for your heart.

 If you have another type of heart disease or related condition, closely follow your

treatment program. Ongoing care and adherence to prescribed medications, such as

statin drugs to treat high cholesterol, can make a big difference.

 Check your legs, ankles and feet for swelling daily. Check for any changes in

swelling in your legs, ankles or feet daily. Check with your doctor if the swelling

worsens.

 Eat a healthy diet. Aim to eat a diet that includes fruits and vegetables, whole grains,

fat-free or low-fat dairy products, and lean proteins.

 Restrict sodium in your diet. Too much sodium contributes to water retention, which

makes your heart work harder and causes shortness of breath and swollen legs, ankles

and feet.

 Maintain a healthy weight. If you are overweight, your dietitian will help you work

toward your ideal weight. Even losing a small amount of weight can help.
 Consider getting vaccinations. If you have heart failure, you may want to get influenza

and pneumonia vaccinations. Ask your doctor about these vaccinations.

 Limit saturated or 'trans' fats in your diet. In addition to avoiding high-sodium

foods, limit the amount of saturated fat and trans fat — also called trans-fatty acids — in

your diet. These potentially harmful dietary fats increase your risk of heart disease.

 Keep track of the medications you take. Make a list and share it with any new doctors

treating you. Carry the list with you all the time. Don't stop taking any medications

without talking to your doctor. If you experience side effects to medications, discuss

them with your doctor.

 Avoid certain over-the-counter medications. Some over-the-counter medications,

such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) and diet pills,

may worsen heart failure and lead to fluid buildup.

 Be careful about supplements. Some dietary supplements may interfere with heart

failure medications or could worsen your condition. Talk to your doctor about any

supplements you are taking.

 Keep track of your weight and bring the record to visits with your doctor. An

increase in weight can be a sign you are building up fluids. Your doctor may tell you to

take extra diuretics if your weight has increased by a certain amount in a day.

 Keep track of your blood pressure. Consider purchasing a home blood pressure

monitor. Keep track of your blood pressure between doctor appointments and bring the

record with you to visits.

X. DISCHARGE PLANS

 Instruct patient to comply on the following medication regimen:

1. Moriamin Forte 1 cap twice a day for vitamins and minerals

supplementation, which is essential to the body.

2. Atorvastatin 40 mg tab once a day, bedtime or before time of sleep (9PM)

– this drug is used to lower cholesterol

Medications
: 3. Tramadol + Paracetamol 50 mg/tab 1 tab every 6-8 hours as needed for

pain - to relieve pain discomfort.

4. Clonidine 75 mg/tab 1 tab SL taken in the morning and at bedtime to treat

high blood pressure/hypertension

5. Acetylcystein (Mucomyst) 30mg before bedtime to liquefy or dissolve

mucus so that it maybe coughed up easily.

6. Multivitamins + Iron 1 tab at once daily to supplement vitamin and

mineral deficiency and iron to aid in the formation of hemoglobin.

 Take medications on time.

 Instruct patient to perform deep breathing exercise to help strengthen the

lungs, build lung capacity and prevent further accumulation of fluid

Exercise:
between the pleural cavities.

 Advice patient to perform simple coughing exercise to allow chest wall

contraction and may help prevent excess fluid from accumulating and

help prevent condition such as pneumonia. To decrease pain when

coughing, hold a pillow over the chest where the pain is located and take

pain medications as directed.

 Perform passive active exercise (e.g. bending, and moving) to help joints
 and muscle become stable. It keeps the joint areas flexible. Exercise also

helps calf pump which promotes venous return and thus presents further

formation of edema. Without these exercises, blood flow and flexibility of

the joints can decrease.

 Position the patient to high fowlers’ position or elevate the head of patient
Treatment:
to promote optimal lung expansion.

 Provide relaxing environment to promote adequate rest periods and to

limit fatigue.

 Frequent position changes every two hours to prevent pressure ulcers.

 Maximize respiratory effort with good posture and effective use of

accessory muscle to promote wellness.

 Stop smoking or avoid second hand smoke, because it can exacerbate the

condition.

 Instruct routine and reminders to facilitate adherence

Health Teaching  Educate the patient and significant other about the symptoms, and

treatment of Pleural effusion and Hypertension

 Practice deep breathing exercise

 Increase oral fluid intake

 Maintain balance periods of activity and rest

 Instruct patient and significant others about the risk of noncompliance to

medications

 Providing a calm environment to avoid stressors and for her to take

enough rest periods

 Contact immediately the healthcare workers if there’s any

  unnecessary signs & symptoms observed

 Instruct patient to return to the hospital 1 week after discharge or as set by

Outpatient
the doctor for updates of the patient’s condition. Or when the following
(Check-up):
situations occur: Accidental expulsion of Chest tube thoracostomy or

Inability to breathe

 Instruct patient if fever, increasing trouble breathing or rapid breathing,

coughing up blood, and worsening or continued chest pain occur, she

must seek medical attention immediately.

 Limit foods rich in sodium (e.g. dried fish, junk foods, etc.). Because it
Diet:
can exacerbate the condition and it retains fluid on the body adding more

complication to the patient.

 Eat a healthy diet (e.g. fruits, vegetables, and protein like meat); good

nutrition can help body fight illness and protein helps in oncotic

pressure/absorption mechanism of fluid.

 Drink plenty of fluids at least 8 glasses per day or more within patients

tolerance to keep the air passage moist and better able to get rid of germs

and other irritants, and liquefy secretions.

XI. UPDATES

This case study revolved on the situation happened to Patient “X”, a 57 years old male

from Barangay IX, Vigan City, Ilocos Sur. He was admitted at Metro Vigan Cooperative

Hospital, Male Medical Ward last November 21, 2020 due to complaints of shortness of

breath and was diagnosed with Pleural Effusion.

 Due to pandemic, the student nurse is unable to conduct a home visit. It is to maintain

safety and follow the health protocols. However through the use of social media and a phone

call, student nurse was able to communicate with the patient and asked him regarding his

condition. The patient replied, “ Okay nak metten nakkong, haan met unay agsaksakit detoy

barukong kon ken mayat met ti pinaganges ko detoy napalabas nga al-aldaw, awan met dagiti

umbal na ditoy saka kon. Kaasi ni Apo haan nak met unay ag high-high blood’n, ta

kontrolado gamin ti kankanekon ken adda met bassit exercise. Mayat met toy marikrikna

kon.” as verbalized by the patient.

The student nurse therefore implied that the patient feels much better that before,

Further assessments and medical interventions are about to be done in the future to fully

achieved patient’s optimal health.

Pleural diseases remain a common and challenging clinical problem. With an

estimated 5 million new pleural effusions diagnosed annually in the World, Yet in spite of

pleural diseases' high prevalence and standardized diagnostic approaches, the etiology of up

to one-quarter of effusions remains unknown even after an exhaustive investigation. Almost

75 percent of effusions are ultimately due to congestive heart failure, malignancy or

infection, and with an aging population, the incidence of all three continues to rise

worldwide. This update addresses some of the latest understanding and approaches to

management of malignant pleural disease and pleural space infection.

XII. BIBLIOGRAPHY

BOOKS/EBOOKS

Balita, Octaviano (2008). Theoretical Foundations of Nursing: The Philippine Perspective. Ultimate
Learning Service
Black, J., Hawk, J. (2008). Medical Surgical Nursing: Clinical Management for Positive
Outcomes, 8th Ed. Management of Clients with Digestive Disorders. Singapore: Elsevier Pte
Ltd.

Bouros, D., (2004). Pleural Disease. Boca Raton, FL: CRC Press

Khan, Daw (2011). Do the right thing:how to judge a good ward: ten standards for adult in-
patientmental healthcare. London

King, C., & Henretig F. (2008). Textbook of Pediatric Emergency Procedures. Baltimore, MD:
Lippincott Williams & Wilkins

Kollef, M., & Isakow, W. (2012). The Washington Manual of Critical Care. Baltimore, MD:
Lippincott Williams & Wilkins

Rinzler, C. A., (2011). Nutrition for Dummies (5th edition). Hoboken, NJ: Wiley Publishing, Inc.

Slatter, D. (2003). Textbook of Small Animal Surgery. Philadelphia, PA: Elsevier Health Sciences.

INTERNET

Ambekar, A. (2008). Hypertensive Cardiovascular Disease. Jellons. Retrieved from

http://www.articleswave.com/articles/hypertensive-cardiovascular-disease.html

American Thoracic Society. (2013). Chest Tube Thoracostomy. American Thoracic Society.
Retrieved fromhttp://www.thoracic.org/clinical/critical-care/patient-information/icu-devices-and-
procedures/chest-tube-thoracostomy.php

ArcMesa Educators. (2013). Neurological System. Nursing Link. Retrieved from

http://nursinglink.monster.com/training/articles/240-physical-assessment---chapter-8-neurological-
system

Enchanted Learning. (2010). Human Digestive System. Retrieved from

http://www.enchantedlearning.com/subjects/anatomy/digestive/

Mitrouska I, Klimathianaki M, Siafakas NM. (2004). Effects of pleural effusion on respiratory

function. National Center for Biotechnology Information. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/15505703.
Storm, J. (2011). Loss of Appetite It's No Good. The Nation’s Health. Retrieved from http://nation-
health.blogspot.com/2011/05/reasons-of-loss-of-appetite.html

The Cleveland Clinic Foundation. (2009). Normal Structure and Function of the Musculoskeletal
System. Cleveland Clinic. Retrieved from
http://my.clevelandclinic.org/anatomy/musculoskeletal_system/hic_normal_structure_and_function_o
f_the_musculoskeletal_system.aspx

Waldstein, S. (2001). The Relation of Hypertension to Cognitive Function. Psychological Science.

Retrieved from http://www.psychologicalscience.org/journals/cd/12_1/Waldstein.cfm
Wikipedia (2013). Retrieved from http://en.wikipedia.org/wiki/Integumentary_system

XIII. CONSENT FORM

Republic of the Philippines

University of Northern Philippines
 Tamag, Vigan City
College of Nursing

CONSENT FORM FOR STUDENTS CASE STUDY

Activity: ________________________________________________________

Student’s Name: _________________________________________________

Name of Clinical Instructor: _______________________________________

Name of Patient: _________________________________________________

I, ___________________________ of _______________________________ at legal

age and presently confined at ___________________________________________________

have willingly agreed to participate in this case study. Additionally, any questions asked

pertaining to this scholastic endeavor have been answered to my utmost satisfaction. I agree

to participate in this study, realizing that I may withdraw my consent at any time. I agree that

the data and information gathered for this study maybe published and utilized for learning

purposes and that the actual name of the patient may be used in the presentation of this study.

________________________________
(Signature Over Printed Name)

XIV. GRADING SYSTEM

Republic of the Philippines

University of Northern Philippines
Tamag, Vigan City
 College of Nursing

Parameter Percentage (%) Actual Grade

Introduction and Objectives 5%
Personal Data 2.5%
Nursing History of Past and Present Health Illness 2.5%
PEARSON Assessment 15%
Diagnostic Procedures 5%
a. Ideal
b. Actual
Anatomy and Physiology 5%
Pathophysiology 15%
a. Algorithm
b. Explanation
Management
a. Medical and Surgical (Ideal and Actual) 5%
b. Promotive and Preventive 5%
Nursing Care Plan 20%
Drug Study 5%
Discharge Plan 5%
Updates 5%
Organization 2.5%
Bibliography 2.5%
TOTAL: 100 %

Remarks:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________