World Citi Colleges

960 Aurora Blvd. Quezon City

Case Presentation

In

NCM 103

Pleural Effusion

Submitted by:

Alenzuela, Dianne Reyes, Ella Sherman, Myrna

Aloy, Marlyn Salazar, James Solatre, Carlo

Bacera, Arfel Sañosa, Jasmine Tabieros, Kristine Joy

Boncato, Ronnie jay Saquitan, RJ Taclas, Josid

Reyes, Daniel Saring, Marie Tobari, Diane

Ungos, Abby

Submitted to:

Mr. Dominic Bautista

Ms. Myla Lim

Mr. Sherwin Villegas

Date of Submission:

Aug. 7, 2010
 I. Introduction

This is the case of C.J 17 y/o male patient who was admitted at WCMC on
July 26, 2010 at 12:15am due to chief complain of DOB. His final diagnosis
is Pleural Effusion probable secondary to PTB stage 3.

Pleural Effusion, a collection of fluid in the pleural space, rarely a primary

disease process; it is usually secondary to other disease. Normally, the
pleural space contains a small amount of fluid (5-15mL), which acts as a
lubricant that follows the pleural surfaces to move without friction. Pleural
effusion maybe complication of heart failure, tuberculosis, pneumonia,
pulmonary infections (particularly viral infections), nephrotic syndrome,
connective tissue disease, pulmonary embolus, and neoplastic tumors.
The most common malignancy associated with a pleural effusion is
bronchogenic carcinoma. Usually the patient is acutely ill and has signs
and symptoms similar to those of an acute respiratory infection or
pneumonia (fever, night sweats, pleural pain, cough, dyspnea, anorexia,
weight loss). If the patient is immunocompromise, the symptoms may be
vague. If the patient has received anti-microbial therapy, the clinical
manifestations maybe less obvious. The severity of symptoms is
determined by the size of the effusion the speed of its formation, and the
underlying lung disease. A large pleural effusion causes dyspnea (SOB)
.The diagnosis is established by chest CT. Usually a diagnostic
thoracentesis is performed, often under ultrasound guidance.

Anatomy of Pleura

• Pleural fluid

•Normally present between the

parietal and the visceral pleura.

• Acts as a lubricant and

• Allows the visceral pleura covering

the lung to slide along the parietal
pleura lining the thoracic cavity
during respiratory movements.

Physiology of Pleural Fluid

• It is believed that the fluid that normally enters the pleural space originates
in the capillaries in the parietal pleura

•Human beings
•Amount of pleural fluid formed daily
in a 50-kg individual =
approximately 15 mL

• The mean lymphatic flow from one

pleural space = 0.40 mL/kg/hour

• Pleural fluid accumulates when the rate of pleural fluid formation exceeds
the rate of pleural fluid absorption.

•Normally, there should be a small amount

(0.01 mL/kg/hour) of fluid constantly
enters the pleural space from the
capillaries in the parietal pleura.

Almost all of this fluid is removed by the

lymphatics in the parietal pleura, which
have a capacity to remove at least 0.20
mL/kg/hour.

• Note that the capacity of the lymphatics to remove fluid exceeds the
normal rate of fluid formation by a factor of 20.

In 2000, tuberculosis was the sixth leading cause of morbidity and mortality
in the Philippines. The burden of the disease is made more serious by the fact
that the country has the 8th highest TB incidence in the world and the 3rd in
the Western Pacific Region in 2003. The control of TB, an airborne infection,
is achieved mainly by rendering infectious smear-positive cases noninfectious
soon after diagnosis is made and by curing as many TB cases identified.
These measures reduce disease transmission and minimize the physiological
and socio-economic impact of TB on the patient, his family and community.
Only Vietnam, among the countries with high TB prevalence, has attained the
global target of 85 percent cure rate and 70 percent case detection rate(WHO
2002). The Philippines has already achieved the 85 percent cure rate target
but the case detection rate is still at 61 percent. This means that the country
is on the verge of achieving the 70/85 global target for tuberculosis.
II. Objectives

General:

After the completion of the case presentation, the student will be

able to:

Further their knowledge about respiratory system and pleural

effusion.

Specific:

After the completion of the case presentation, the student will be

able to:

• Determine the health profile of the patient using the nursing

assessment guide.

• Discuss the anatomy and physiology of the respiratory disease system

that is directly affected in a Pleural Effusion and relates the concept to
the actual situation of the patient.

• Discuss comprehensively the pathophysiology of Pleural Effusion.

• Relate the diagnostic findings to the pathophysiology of the disease

process.

• Discuss the effect of the therapeutic regimen used.

• Relate the nursing care plan to the needs and problem of the patient.

• Discuss comprehensively the nursing care plan.

• Determine the prognosis of the patient.

III. Theoretical Framework

Virginia Henderson

Nursing

Virginia Henderson viewed the patient as an individual requiring help toward

achieving independence. She states that “The unique function of the nurse is
to assist individual, sick or well, in the performance of those activities
contributing to health or its recovery (or peaceful death) that he would
perform unaided if he had the necessary strength, will, or knowledge and to
do this in such a way to help him gain independence as rapidly as possible.”

Health
Virginia Henderson did not state her own definition of health. But in her
writing, she equated health with independence.

Environment

Again, Henderson did not give her own definition of environment. Instead,
she used Webster’s New Collegiate Dictionary, 1961, which defined
environment as “the aggregate of all the external conditions and influences
affecting the life and development of organism.”

Person

Henderson viewed the patient as an individual who requires assistance to

achieve health and independence or peaceful death. The mind and body are
inseparable. The patient and his or her family are viewed as a unit.

The 14 Basic Human Needs

1. Breathe normally.- In our patient’s case there is presence of difficulty

of breathing due to plural effusion the main goal is to secure patient’s
breathing.
2. Eat and drink adequately. – There is presence of malnutrition because
of sudden weight loss due to having PTB. Our concern is to regain
patient’s desirable body weight.
3. Eliminate body wastes. – There is presence or impaired gas exchange
in the patient. The nurse’s responsibility is to correct this problem to
provide comfort to the patient.
4. Move and maintain desirable postures. – The patient is now bed ridden
due to his illness and can’t even go to the bathroom by him self. The
health care provider’s responsibility is to take care and give as much
care as possible to the patient to give the best care while in recovery.
5. Sleep and rest. – The patient is usually sleeping during his
hospitalization period the goal of the health care provider is to give as
much comfort as possible to the patient while sick.
6. Select suitable clothes--dress and undress. – Give proper clothing to
help in breathing and comfort. Health care provider should advise
patient to wear the suitable clothing as needed.
7. Maintain body temperature within normal range by adjusting clothing
and modifying the environment. – The health care provider’s
responsibility is to constantly check the VS of the patient to check if
there are abnormalities or significant changes noted and to give proper
action as soon as possible.
8. Keep the body clean and well groomed and protect the integument. –
It is important to maintain the hygiene of the patient to avoid any
complication such as infection and to give comfort while sick,
recovering or well.
9. Avoid dangers in the environment and avoid injuring others. – Make
sure that the patient as well as the people surrounding him is safe the
health care provider’s job is to ensure the safety of the patient and the
people around him such as advising relatives or visitors to wear mask
for precaution and as for the patient putting side rails to avoid falling in
from bed.
10. Communicate with others in expressing emotions, needs, fears or
opinions.- Proper communication is a good way to show care,
Establishing rapport is a good way of better relationship as patient
nurse interaction.
11. Worship according to one's faith. – Respecting the patient’s spirituality
is an important factor in good relationship between health care
provider and patient.
12. Work in such a way that there is a sense of accomplishment. – Make
sure to finish what you start.
13. Play or participate in various forms of recreation.
14. Learn - Discover, or satisfy the curiosity that leads to normal
development and health and use the available health facilities.

IV. Nursing Assessment

A. Personal Data
Name: C.J.

Age: 17 years old

Birthday: February 12, 1993

Nationality: Filipino

Gender: Male

Civil Status: Single

Address: Marikina City

 Occupation: HRM 2nd year Student

Adm. Date: July 26, 2010

Adm. Time: 12:15 am

Chief complaint: DOB – Difficulty of Breathing

Clinical Impression:Pleural effusion probable secondary to PTB stage 3.

B. History of Present illness:

2 days prior to admission the patient complains chest pain and
difficulty of breathing especially at night. When he takes a rest, it
lessens the pain. He also complains stomach ache. Then few hours
prior to admission the patient DOB, fever and accompanying pain in his
right lower quadrant. He was then immediately rushed to WCMC on
June 27, 2010

C. Past Health history:

June 17, 2010 he was admitted to St.Victoria Hospital in Marikina
City and was confined for 1 week. Chief Complaint is fever. The doctor
gave medication of Myrin P forte & Iberet ordered to take for a month,
because the doctor’s finding was pleural effusion.

D. Family history:
Both of the patient’s parents have no history of illness. But
the grandfather on his father side died due to Cardiac Arrest. His
grandmother on his father side has a history of Hypertension. Also, his
grandfather and grandmother on his mother side has a history of
Hypertension

E. Social History:
The patient is 17 years old. He’s taking up Hotel Restaurant
Management 2nd year student. His usual daily activity is playing
basketball 3 times a day. During high school he was a varsity in
basketball on his school. He also spends a lot of time in front of the
computer. The earliest time he finish his stuff is 12 midnight & most
late is 2am. He also wants to hang out with his friends.

PHYSICAL ASSESSMENT
Day 1

HAIR

Black, thin, straight, shiny and short

SCALP

White, oily w/ presence of dandruff

FACE

Symmetrical facial movement, he is exhausted due to lack of sleep and pain

EYES

The outer cantus of the patient eyes were symmetrical to the pinna of his
ears. The eyebrows were thin but evenly distributed and have short
eyelashes. Patient’s was observed to have white sclera, pale conjunctivas,
and black equally rounded pupils. Constriction were observed when light
stimulation done at varying distance.

NOSE

The patient has pointed nose, with dry mucus membranes.

EARS

Tip of the ear is aligned with the outer canthus of the eye. Ear wax observed
when exposed to pen light. He is able to hear from both ears because he was
able to respond to the questions that was asked to him.

MOUTH

He is able to open and close with ease.

TEETH

He has a complete white tooth w/ no dentures and any dental carries.

TONGUE

The patient has moist with white patches over the tongue.

LIPS

Dry and pale in color.

NECK
The patient’s neck has fair skin complexion and muscle tone was fairly good
and able to move his head. No masses palpated along lymph nodes. But
there’s a presence of wounds & lesions. The carotid pulse is palpable.

CHEST

Chest is symmetrical during respiration, fair skin in color and smooth with
respiratory rate of 28 bpm. The patient has test tube drainage for his pleural
effusion.

ABDOMEN

The patient has undergone appendectomy on his RLQ. He is wearing a

binder.

UPPER EXTREMETIES

The patient is having difficulty in lifting his left arm due to the presence of
edema. Has fair complexion but pale. Patient’s both arms are edematous and
palms were dry and warm to touch. Capillary refill was within 3 seconds. The
patient has an IV fluid of 5% Dextrose in water 250 ml on his right hand.

LOWER EXTREMETIES

The patient’s right and left lower extremities are fair in complexion. Patient’s
legs and feet is edematous were dry and warm to touch. Capillary refill was
within 3 seconds.

Day 2

HAIR

Black, thin, straight, shiny and short

SCALP

White, smooth scalp, oily w/ presence of dandruff

FACE

Symmetrical facial movement, he is more exhausted. He is sleeping during

assessment because of Demerol administration to ease his pain on his RLQ.
EYES

The outer cantus of the patient eyes were symmetrical to the pinna of his
ears. The eyebrows were thin but evenly distributed and have short
eyelashes. Patient’s was observed to have white sclera, pale conjunctivas,
and black equally rounded pupils. Constriction and dilation were observed
when light stimulation done at varying distance.

NOSE

The patient has pointed nose, with dry mucus membranes

EARS

Tip of the ear is aligned with the outer canthus of the eye. Ear wax observed
when exposed to pen light. He is able to hear from both ears.

MOUTH

The patient is able to open and close with ease.

TEETH

He has a complete white tooth w/ no dentures and any dental carries.

TONGUE

The patient has moist with white patches over the tongue.

LIPS

Dry and pale in color.

NECK

The patient’s neck has fair skin complexion and muscle tone was fairly good
and able to move his head. No masses palpated along lymph nodes. But
there’s a presence of wounds & lesions. The carotid pulse is palpable.

CHEST

Chest is symmetrical during respiration, fair skin in color and smooth with
respiratory rate of 28 bpm. The patient has test tube drainage for his pleural
effusion.

ABDOMEN

Undergo appendectomy on his RLQ. He is wearing a binder.

UPPER EXTREMETIES

The patient is having difficulty in lifting his left arm due to the edema. Has
fair complexion but pale. Patient’s both arms are edematous and palms were
dry, warm to touch with dry. Capillary refill was within 3 seconds. The patient
has an IV fluid of 5% Dextrose in water 250 ml on his right hand.

LOWER EXTREMETIES

The patient’s right and left lower extremities fair complexion. Patient’s legs
and feet is edematous were dry and warm to touch. Capillary refill was within
3 seconds.

Vital Signs

Day 1, 4pm (August 05, 10): T: 36'C, P: 70bpm, R: 28bpm, BP: 110/80

Day 1, 8pm: 37.1'C, P: 100bpm, R: 28bpm, BP: 110/80 U: 2, S: 1

Day 2, 4pm (August 06, 10): T: 37.6'C, P: 98bpm, R: 25bpm, BP: 120/80

Day 2, 8pm: 37.9'C, P: 90bpm, R: 28bpm, BP: 110/80 U: 2 S: 1

V. Usual pattern of ADL (GORDON’S)

AREA BEFORE DURING DURING

HOSPITALIZATION HOSPITALIZATIO HOSPITALIZA
N (DAY1) TION (DAY2)

1. Social The pt had an active He socializes with The patient

history lifestyle when he the nurses and the was asleep
was still well. He doctors. He was throughout the
plays basketball as accompanied by day.
his form of exercise. one of his parents.
 He socializes with His classmates
his friends at from FEU also
school. At home, he visited him.
was playing
computer games
such as dota from
7:00 pm until dawn

2. Mental Conscious and Conscious and The patient

aware of time, date aware of time, date was asleep
and reality. Able to and reality. Able to throughout the
do his task as a answer the day.
student. questions when
asked to.

3. Emotional He was contented He was sad when The patient

with his life as a he was alone but was asleep
student. he cheers up when throughout the
his relatives, day.
classmates and
friends visited him.

4. Sensory His sensory were all The patient was The patient
perception working, able to able to perceive was asleep
perceive stimuli. stimuli. throughout the
day but wakes
up when feels
the pain on his
RLQ.

5. Motor Able to move his The patient is in The patient is

Capabilitie body with ease. strict bed rest. in strict bed
s rest.

6. Respirator RR: 4pm: 28 bpm RR: 4pm: 25

y bpm
8pm: 27 bpm
8pm: 28 bpm

7. Circulatory PR: 4pm: 70bpm PR: 4pm:

98bpm
8pm: 100bpm
 BP: 4pm: 8pm: 90bpm
110/80mmHg
BP: 4pm:
8pm: 110/80mmHg 120/80
8pm:110/80
mmHg

8. Body Temp: 4pm: 36’C Temp:4pm:

temperatu 37.6’C
re 8pm: 37.1’C
8pm: 37.9’C

9. Nutritional He eats all the foods He is in soft diet. He is in soft

he likes especially He only eats diet. He only
fried chicken. He “lugaw” eats “lugaw”
just eats vegetables
when his mother
forced him to.

10. Elimi He urinates and Urine: 2 Urine: 2

nation defecates regularly.
Stool: 1 Stool: 1

11. Stat He usually sleeps He sleeps anytime He sleeps

e of around 10 in the of the day. throughout the
physical evening when day.
rest &
there’s a class on
comfort
the ff morning.

12. Stat Good skin turgor Incision on the Incision on the

e of skin and warm feeling. RLQ. Wounds and RLQ. Wounds
and lesions on the and lesions on
appendice
neck. the neck.
s

VI. ANATOMY AND

PHYSIOLOGY
 The respiratory system is an intricate arrangement of spaces and
passageways that conduct air from outside the body into the lungs and
finally into the blood as well as expelling waste gasses. This system is
responsible for the mechanical process called breathing.

When engaged in strenuous activities, the rate and depth of breathing

increases in order to handle the increased concentrations of carbon
dioxide in the blood. Breathing is typically an involuntary process, but can
be consciously stimulated or inhibited as in holding your breath.

Upper Respiratory System

Nostrils/Nasal Cavities
During inhalation, air enters the nostrils and passes into the nasal
cavities where foreign bodies are removed, the air is heated and
moisturized before it is brought further into the body. It is this part of the
body that houses our sense of smell.

Pharynx
The pharynx, or throat carries foods and liquids into the digestive tract
and also carries air into the respiratory tract.

Larynx
The larynx or voice box is located between the pharynx and trachea. It
is the location of the Adam's apple, which in reality is the thyroid gland
and houses the vocal cords.

Trachea
The trachea or windpipe is a tube that extends from the lower edge of
the larynx to the upper part of the chest and conducts air between the
larynx and the lungs.

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.

Lower Respiratory System

Bronchi
The trachea divides into two parts called the bronchi, which enter the
lungs.

Bronchioles
The bronchi subdivide creating a network of smaller branches, with the
smallest one being the bronchioles. There are more than one million
bronchioles in each lung.

Avleoli
The alveoli are tiny air sacks that are enveloped in a network of
capillaries. It is here that the air we breathe is diffused into the blood, and
waste gasses are returned for elimination.

Gas Exchange

The major function of the respiratory system is gas exchange. As gas

exchange occurs, the acid-base balance of the body is maintained as part
of homeostasis. If proper ventilation is not maintained two opposing
conditions could occur: 1) respiratory acidosis, a life threatening condition,
and 2) respiratory alkalosis.
 VII. Pathophysiology
Risk factors:
Presence of Pulmonary
Tuberculosis

Organ Affected:
LUNGS

Disease Process:
An exudative effusion results from
increased capillary permeability
characteristic of the inflammatory
reaction. This type of effusion occurs
secondary to other conditions.

BOO ent
K Pati

Clinical Manifestations: Clinical Manifestations:

Some symptoms are caused by the
underlying disease. Size of effusion & DOB
the time course of development
determine the severity. Tachypnea
- Large effusion: SOB to acute
respiratory distress Chest pain
- Small – Moderate: Dyspnea may not
be present
- Dullness/Flatness to percussion over

Diagnostic Evaluation:
- CXR (lateral decubitis) Diagnostic Evaluation:
- Chest CT scan
- Ultrasound - CXR – pleural effusion in left
-Thoracentesis hemithorax
- Pleural Biopsy
- Pleural fluid analysis - Thoracentesis

Medical Management:
- Thoracentesis Medical Management:
- Chest tube and water-seal drainage - Thoracentesis
- Chemical pleurodesis - Chest tube and water-seal drainage;
- Surgical pleurectomy left side
- Educate pt and family about - Meds: ethambutol, corticosteroid
management of drainage system with (Prednisone), levofloxacin
outpatient therapy
Laboratory Exam Results:

ARTERIAL BLOOD GAS

Date Laboratory Results Normal Significance

ordered exams values

July 27, pH 7.388 7.35-7.45 Increase:

2010 • Hyperventilation
• Anxiety, pain
• Anemia
• Shock
• Some degrees of
Pulmonary
disease
• Some degrees of
Congestive heart
failure
• Myocardial
infarction
• Hypokalemia
(decreased
potassium)
• Gastric
suctioning or
vomiting
• Antacid
administration
• Aspirin
intoxication
Decrease:
• Strenuous
physical exercise
• Obesity
• Starvation
• Diarrhea
• Ventilatory
failure
• More severe
degrees of
Pulmonary
Disease
• More severe
degrees of
Congestive Heart
Failure
• Pulmonary
edema
 • Cardiac arrest
• Renal failure
• Lactic acidosis
• Ketoacidosis in
diabetes
PCO2 40.1 35-45mmHg Increase:
• Pulmonary
edema
• Obstructive lung
disease
Decrease:
• Hyperventilation
• Hypoxia
• Anxiety
• Pregnancy
• Pulmonary
Embolism

PO2 94.3 80-100mmHg Increase:

• Increased
oxygen levels in
the inhaled air
• Polycythemia
Decreased
• Decreased
oxygen levels in
the inhaled air
• Anemia
• Heart
decompensation
• Chronic
obstructive
pulmonary
disease
• Restrictive
pulmonary
disease
• Hypoventilation

HCO3 23.6 22-26 mEq/L Decreased HCO3

• Metabolic
Acidosis

Increased HCO3

• Metabolic
 Alkalosis

BE 1.3 +/- 2 mEq/L More Negative Values

of Base Excess may
Indicate:
• Lactic Acidosis
• Ketoacidosis
• Ingestion of
acids
• Cardiopulmonary
collapse
• Shock
More Positive Values of
Base Excess may
Indicate:
• Loss of buffer
base
• Hemorrhage
• Diarrhea
• Ingestion of
alkali

O2 saturation 97.1% 95-100% Oxygen Saturation will

fall if:
• Inspired oxygen
levels are
diminished, such
as at increased
altitudes.
• Upper or middle
airway
obstruction
exists (such as
during an acute
asthmatic
attack)
• Significant
alveolar lung
disease exists,
interfering with
the free flow of
oxygen across
the alveolar
membrane.
Oxygen Saturation will
rise if:
• Deep or rapid
breathing occurs
• Inspired oxygen
 levels are
increased, such
as breathing
from a 100%
oxygen source

PO2 (A-a) 55.1 It is an important factor

affecting the amount of
oxygen that is bound to
hemoglobin.

BLOOD CHEMISTRY

Date ordered Laboratory Results Normal values Significance

exams

July 27, 2010 AST(SGOT) 25.3 0.00-35.00 U/L Increased-

myocardial
infarction,
skeletal muscle
disease, and
liver disease.

ALT(SGPT) 17.9 0.00-45 U/L Same

conditions as
AST(SGOT), but
increased is
more marked in
liver disease
than
AST(SGOT)

Creatinine 64.4 ↓ 72.00-127.00 Increase-

umol/L mascular
dystrophy,
fever,
carcinoma of
liver,
 Potassium 3.58 3.50-5.50 Increased-
mmol/L hemolysis,
chronic renal
failure,
acidosis,
cushing’s
diease, corpus
luteum cysts.

Decrease –
diarrhea,
adrenocortical
insuffiency.

Sodium 132.7 ↓ 135.00-148.00 Increased-

mmol/L useful in
detecting gross
changes in
water and salt
balanced

COMPLETE BLOOD COUNT

Date Laboratory results Normal values Significant

ordered exams

August 5, WBC 11.7 ↑ 4.00-10.00 Increased-

2010 10^9/L neurosyphilis,
anterior
poliomyelitis,
encephalitis
lethargic.

RBC 4.01↓ 4.50-6.50 Decreased-

10^12/L iron deficiency,
vit. B6, b12 or/
and folic acid
deficiency,
chronic
 disease,
hereditary
anemia, free
radical
pathology,
toxic metals,
catabolic
methabolism.

HGB 109↓ 130.00-170.00 Decreased in

g/L various
anemias,
pregnancy,
severe of
prolonged
hemorrhage,
and with
excessive fluid
intake.

HCT 0.36↓ 0.40-0.54 Decrease in

severe
anemias,
anemia in
pregnancy,
acute massive
blood loss.

MCV 89 80.00-100.00 fl Increase in

macrocytic
anemias;

decrease in
microcytic
anemia

MCH 27.2 27.00-32.00 pg Increase in

macrocytic
anemias;

decrease in
microcytic
anemia

MCHC 306↓ 320.00-360.00 Decreased in

g/L severe
 hypocromic
anemia.

Increased and
decreased is
same with MCV
two exceptions
in
spherocytosis,
the MCHC is
elevated but
not in
pernicious
anemia

PLT Increased 150.00-350.00 Increased in

10^9/L malignancy,
myeloproliferat
ive disease,
rheumatoid
arthritis, and
postoperativerl
y; about 50%
of patients
with
unexpected
increase of
platelet count
will be found to
have a
malignancy;

Lymphocytes 0.19↓ 0.25-0.50 Increase with

infectious
mononucleosis
, viral and
some bacterial
infections,
hepatitis;
decreased with
aplastic
anemia, SLE,
immunodeficie
ncy including
 AIDS.

Monocytes 0.01↓ 0.02-0.10 Increase with

viral infections,
parasitic
disease,
collagen and
hemolytic
disorder;
decreased with
use of
corticosteroids,
RA, HIV
infection.

Neutrophils 0.80 0.50-0.80 Increase with

acute
infection,
trauma or
surgery,
leukemia,
malignant
disease,
necrosis;
decrease with
viral infections,
bone marrow
suppression,
primary bone
marrow
disease.

Eosinophils 0.00-0.05 Increase in

allergy,
parasitic
disease,
collagen
disease,
subacute
infections;
decrease with
stress, use of
some
medications(A
CTH,
 epinephrine,
thyroxin

COMPLETE BLOOD COUNT

Date Laboratory results Normal values Significance

ordered exams

August 1, WBC 18.3↑ 4.00-10.00 Increased-

2010 10^9/L neurosyphilis,
anterior
poliomyelitis,
encephalitis
lethargic.

RBC 3.58↓ 4.50-6.50 Decreased-

10^12/L iron deficiency,
vit. B6, b12 or/
and folic acid
deficiency,
chronic
disease,
hereditary
anemia, free
radical
pathology,
toxic metals,
catabolic
methabolism.

HGB 103↓ 130.00-170.00 Decreased in

g/L various
anemias,
pregnancy,
severe of
prolonged
hemorrhage,
and with
excessive fluid
intake.

HCT 0.32↓ 0.40-0.54 Decrease in

severe
anemias,
 anemia in
pregnancy,
acute massive
blood loss.

MCV 80.00-100.00 fl Increase in

macrocytic
anemias;

decrease in
microcytic
anemia

MCH 27.00-32.00 pg Increase in

macrocytic
anemias;

decrease in
microcytic
anemia

MCHC 320.00-360.00 Decreased in

g/L severe
hypocromic
anemia.

Increased and
decreased is
same with MCV
two exceptions
in
spherocytosis,
the MCHC is
elevated but
not in
pernicious
anemia

PLT Increased 150.00-350.00 Increased in

10^9/L malignancy,
myeloproliferat
ive disease,
rheumatoid
arthritis, and
postoperativerl
y; about 50%
 of patients
with
unexpected
increase of
platelet count
will be found to
have a
malignancy;

Lymphocytes 0.06↓ 0.25-0.50 Increase with

infectious
mononucleosis
, viral and
some bacterial
infections,
hepatitis;
decreased with
aplastic
anemia, SLE,
immunodeficie
ncy including
AIDS.

Monocytes 0.02-0.10 Increase with

viral infections,
parasitic
disease,
collagen and
hemolytic
disorder;
decreased with
use of
corticosteroids,
RA, HIV
infection.

Neutrophils 0.94 ↑ 0.50-0.80 Increase with

acute
infection,
trauma or
surgery,
leukemia,
malignant
disease,
necrosis;
 decrease with
viral infections,
bone marrow
suppression,
primary bone
marrow
disease.

Eosinophils 0.00-0.05 Increase in

allergy,
parasitic
disease,
collagen
disease,
subacute
infections;
decrease with
stress, use of
some
medications(A
CTH,
epinephrine,
thyroxin

COMPLETE BLOOD COUNT

Date Laboratory results Normal values Significant

ordered exams

July 27, WBC 15.2↑ 4.00-10.00 Increased-

2010 10^9/L neurosyphilis,
anterior
poliomyelitis,
encephalitis
lethargic.

RBC 3.58↓ 4.50-6.50 Decreased-

10^12/L iron deficiency,
vit. B6, b12 or/
and folic acid
deficiency,
chronic
disease,
hereditary
 anemia, free
radical
pathology,
toxic metals,
catabolic
methabolism.

HGB 108↓ 130.00-170.00 Decreased in

g/L various
anemias,
pregnancy,
severe of
prolonged
hemorrhage,
and with
excessive fluid
intake.

HCT 0.37↓ 0.40-0.54 Decrease in

severe
anemias,
anemia in
pregnancy,
acute massive
blood loss.

MCV 80.00-100.00 fl Increase in

macrocytic
anemias;

decrease in
microcytic
anemia

MCH 27.00-32.00 pg Increase in

macrocytic
anemias;

decrease in
microcytic
anemia

MCHC 320.00-360.00 Decreased in

g/L severe
hypocromic
anemia.
 Increased and
decreased is
same with MCV
two exceptions
in
spherocytosis,
the MCHC is
elevated but
not in
pernicious
anemia

PLT 502 150.00-350.00 Increased in

10^9/L malignancy,
myeloproliferat
ive disease,
rheumatoid
arthritis, and
postoperativerl
y; about 50%
of patients
with
unexpected
increase of
platelet count
will be found to
have a
malignancy;

Lymphocytes 0.05↓ 0.25-0.50 Increase with

infectious
mononucleosis
, viral and
some bacterial
infections,
hepatitis;
decreased with
aplastic
anemia, SLE,
immunodeficie
ncy including
AIDS.

Monocytes 0.02-0.10 Increase with

viral infections,
 parasitic
disease,
collagen and
hemolytic
disorder;
decreased with
use of
corticosteroids,
RA, HIV
infection.

Neutrophils 0.92 ↑ 0.50-0.80 Increase with

acute
infection,
trauma or
surgery,
leukemia,
malignant
disease,
necrosis;
decrease with
viral infections,
bone marrow
suppression,
primary bone
marrow
disease.

Eosinophils 0.00-0.05 Increase in

allergy,
parasitic
disease,
collagen
disease,
subacute
infections;
decrease with
stress, use of
some
medications(A
CTH,
epinephrine,
thyroxin
 Total Protein and A/G

Date Laboratory Results Normal Significance

ordered exams values

July 27, Total 65.5 66.00- DECREASE

2010 Protein 83.00 G/L
Low total protein levels
can suggest a liver
disorder, a kidney
disorder, or a disorder
in which protein is not
digested or absorbed
properly. Low levels
may be seen in
severe malnutrition an
d with conditions that
cause malabsorption,
such as Celiac
disease or inflammator
y bowel disease (IBD).

INCREASE

High total protein

levels may be seen
with chronic inflammati
on or infections such
as viral
hepatitis or HIV. They
may be caused
by bone marrow
disorders such
as multiple myeloma.

Albumin 24.6 ↓ 35.00- Albumin's role in the

52.00 G/L body is to maintain
osmotic pressures and
to also transport
hydrophobic
substances

Globulin 40.9 ↑ 15.00-

30.00 G/L

A/G ratio 0.60 ↓ 1.50-2.50 A high A/G ratio

suggests
underproduction
of immunoglobulins as
may be seen in some
genetic deficiencies
and in some leukemias

A low A/G ratio may

reflect overproduction
of globulins, such as
seen in multiple
Body Fluid Cell Count (July 27, 2010)

Appearance before centrifugation- yellow/turbid

Appearance after centrifugation- yellow/ clear

Total Volume: 3mL

RBC Count: 1950 cells/ cu.mm

WBC Count: 2250 cells/ cu.mm

Total Cell Count: 4,200

Differential Count:

Neutrophils- 0.49

Lymphocytes: 0.51

RBC Morphology:

Creanated RBC- 100%

Non-creanated-

Gram Stain Result (July 27, 2010)

Polymorphonuclear cells= Few

No microorganisms seen

Chest X-ray(July 30, 2010)

Recheck chest x-ray after 2 days show diminution in the pleural effusion in
the left hemithorax

A T-Tube is seen in situ

 VIII. Drug Study

Date Medication Action Indication Nursing

Intervention
Ordere
d

July GN: To treat several As part of a class of Monitor patients

28,201 conditions related drugs known as hypersensitivity to
0 to the esophagus, proton pump omeprazole and
BN: stomach, and inhibitors (PPIs), it its components
Omeprazole intestines. works by
decreasing the
amount of acid that
is produced in your
Dosage: stomach.
40mg

Frequency:
 OD

Route: IV

July GN: TAZOCIN is for TAZOCIN is Monitor bleeding

28, Piperacillin treatment of the indicated for the manifestations or
2010 following treatment of significant
systemic and/or polymicrobic leukopenia
local bacterial infections including following
BN:Tazocin
infections in those where gram- prolonged
which susceptible positive and gram- administration
organisms have negative aerobic have occurred in
Dosage: been detected or and/or anaerobic some patients
2.2g are suspected: organisms are receiving b-
suspected (intra- lactam antibiotics,
Children
abdominal, skin including
Frequency: and skin structure, piperacillin
Appendicitis
Q8 lower respiratory
complicated by
rupture with tract)
peritonitis and/or
Route: IV abscess
formation in
children aged 2
12 years.

Bacterial
infections in
neutropenic
children in
combination with
an
aminoglycoside.

July GN: Digoxin Lanoxin is used to Lanoxin is also used Before giving the
28, treat congestive to slow the heart drug ask the
2010 heart failure rate in patients with patient about
chronic atrial allergic reactions
BN:Lanoxin fibrillation, a heart to digoxin
rhythm disorder of
the atria (the upper
Dosage: chambers of the
25mg heart that allow
blood to flow into
the heart).
Frequency:
OD

Route:

August Maalox Maalox is a Gastritis & Make sure patient

06,201 Suspenscio balanced mixture duodenitis has food intake 20
0 n of 2 antacids: accompanied by minutes – 1 hour
Aluminum flatulence, post-op before taking
hydroxide is a gas pain. maalox
slow-acting
Dosage:
antacid and
30cc magnesium
hydroxide is fast
acting.
Frequency:
Stat Antacid therapy
in gastric and
duodenal ulcer,
gastritis,
heartburn and
gastric
hyperacidity.

August GN: Demerol is used for The principal Monitor patient

06,201 Meperidine the relief of actions of include
0 moderate to severe therapeutic value in hyperexcitability,
pain, most Demerol are convulsions,
BN:Demerol commonly in analgesia and tachycardia,
obstetrics and sedation. Demerol hyperpyrexia, and
post-operative is a narcotic hypertension
conditions. analgesic with
Dosage: effects similar to
 25mg morphine.

Reassess
patient’s level of
Route: IV pain.

Frequency:
Now

August GN: Metronidazole is an Metronidazole is Safety and

04,201 Metronidaz antibiotic effective used alone or in effectiveness in
0 ole against anaerobic combination with pediatric patients
bacteria and other antibiotics in have not been
certain parasites treating abscesses established,
BN: Flagyl in the liver, pelvis, except for the
abdomen and brain treatment of
caused by amoebiasis.
susceptible
Dosage: anaerobic bacteria.
1gm/ tab

Frequency:
Q12

Medication Action Indication Nursing

Consideration
Generic Name: Inhibits the Active - Mycobacterial
ethambutol growth or other tuberculosis or studies and
myobacteria. other susceptibility
Brand Name: THERAPEUTIC mycobacterial tests should be
Myrin P Forte EFFECTS: disease (with at performed before
Tuberculostatic least one other and periodically
3tab effects against drug) during therapy to
AC breakfast susceptible detect possible
OD organisms. resistance.
- - Assess lung
PHARMACOLOGIC sounds and
 ACTION: character and the
antituberculars amount of sputum
periodically during
therapy.

Generic Name: Inhibits the Edema due to - Monitor blood

furosemide reabsorption of heart failure, pressure and
sodium and hepatic pulse before and
Brand Name: chloride from the impairment or during
N/A loop of Henle and renal disease. administration.
distal renal Hypertension. Monitor frequency
40mg/IV tubule. Increases of prescription
STAT renal excretion of refills to
water, sodium, determine
chloride, compliance in
magnesium, patient treated for
potassium, and hypertension.
calcium. - Assess patients
Effectiveness receiving digoxin
persists in for anorexia,
impaired renal nausea, vomiting,
function. muscle cramps,
THERAPEUTIC paresthesia, and
EFFECTS: Diuresis confusion.
and subsequent Patients taking
mobilization of digoxin are at risk
excess fluid of digoxin toxicity
(edema, pleural because of the
effusion). potassium-
Decrease blood depleting effect
pressure. of diuretics.
PHARMACOLOGIC
ACTION: loop
diuretics.
Generic Name: Inhibits Short-term - Assess pain (note
ketorolac prostaglandin management of type, location,
synthesis, pain (no to and intensity)
Brand Name: producing exceed 5 days prior to and 1-2 hr
Ketoradol peripherally total for all routes following
mediated combined) administration.
30mg/IV analgesia. Also - May cause
q6 has antipyretic prolonged
and anti- bleeding time that
inflammatory may persist for
properties. 24-48 hr following
THERAPEUTIC discontinuation of
EFFECTS: therapy.
Decreased pain. - May cause
 PHARMACOLOGIC increased BUN,
EFFECT: serum creatinine,
pyrroziline or potassium
carboxylic acid. concentrations.
Generic Name: Binds action to Moderate to - Assess type,
tramadol mu-opioid moderately location, and
receptors. Inhibits severe pain. intensity of pain
Brand Name: reuptake of before and 2-3hr
Tramadin serotonin and (peak) after
nonepinephrine in administration.
100mg/IV the CNS. - Assess blood
q8 THERAPEUTIC pressure and
EFFECTS: respiratory rate
Decreased pain. before and
PHARMACOLOGIC periodically during
ACTION: administration.
analgesics Respiratory
(centrally acting) depression has
not occurred with
recommended
doses.
Generic Name: Decreases It is prescribed in - Assess patient for
corticosteroids inflammation by the treatment of signs of adrenal
reversing severe insufficiency
Brand Name: increased cell inflammation and (hypotension,
Prednisone capillary for weight loss,
permeability and immunosuppressi weakness,
20mg/tab inhibiting on. nausea, vomiting,
1tab BID migration of anorexia,
polymorphonucle lethargy,
ar leukocytes. confusion,
Suppresses restlessness).
immune system - Monitor intake
by reducing and output ratios
lymphatic and daily weights.
activity. Observes patient
THERAPEUTIC for peripheral
EFFECT: edem, steady
Suppression of weight gain,
inflammation and rales/crackles, or
modification of dyspnea. Notify
the normal health care
immune professional if
response. these occur.
PHARMACOLOGIC
EFFECT:
corticosteroids
(systemic)

Generic Name: Inhibits the Management of - Assess ROM,

celocoxib enzyme COX-2. acute pain degree swelling,
This enzyme is including primary and pain in
Brand Name: required for the dysmenorrhea. affected joints
Celebrex synthesis of before and
prostaglandins. periodically
400mg/tab Has analgesic, throughout
1tab OD anti- therapy.
inflammatory, - Assess patient for
and antipyretic allergy to
properties. sulfonamides,
THERAPEUTIC aspirins, or
EFFECTS: NSAIDs. Patients
Decreased pain with these
and inflammation allergies should
caused by not receive
arthritis or celecobix.
spondylitis.

Generic Name: Inhibits the Preoperatively to - Assess patient for

scopolamine muscarine produce amnesia sign of urinary
activity of and to decrease retention
Brand Name: acetylcholine. salivation and periodically during
Buscopan Corrects the excessive therapy.
imbalance of respiratory - Monitor heart rate
1amp acetylcholine and secretion. periodically during
STAT norepinephrine in parenteral
the CNS, which therapy.
may be - Assess patient for
responsible for pain prior to
motion sickness. administration.
THERAPEUTIC Scopolamine may
EFFECT: act as a stimulant
Reduction of in the presence of
nausea and pain, producing
vomiting. delirium if used
Preoperative without morphine
amnesia and and meperidine.
decreased
secretions.
PHARMACOLOGIC
ACTION:
anticholinergics
Generic Name: Inhibit the Treatment of - Assess for
levofloxacin bacterial DNA bacterial infection (vital
synthesis by infections such as signs; appearance
Brand Name: inhibiting DNA respiratory tract of wounds,
Levox gyrase. infection. sputum, urine,
THERAPEUTIC and stool; WBC;
750mg/tab EFFECTS: Death urinalysis;
1tab OD of susceptible frequency and
bacteria. urgency of
PHARMACOLOGIC urination; cloudy
ACTION: or foul-smelling
fluoroquinolones urine) prior to and
during therapy.
- Obtaining
specimens for
culture and
sensitivity before
initiating therapy.
First dose may be
given before
receiving results.
Generic Name: Reduces the
trimetazidine metabolic
damage caused
Brand Name:
during ischemia,
Vastarel Mr
by acting on a
35mg /tab critical step in
1tab BID cardiac
metabolism: fatty
acid β-oxidation.
IX. Nursing Management

Assessment Planning Nursing Intervention Evaluation

Subjective: After 1-2 hours of
nursing • Monitor and record After 1- 2 hours of
• Dyspnea interventions the vital signs nursing
patient will intervention the
Objectives: demonstrate R. To obtain patient has
appropriate baseline data demonstrate
The patient coping behaviors improve breathing
manifested the and methods to • Provide relaxing pattern because
following: improve environment he was able to
breathing pattern. answer the
• Tachypnea R. To promote questions that
• RR of 28 adequate rest was being asked
periods to limit to him.
The patient may fatigue
manifest the
following: • Assist client in
the use of
• Pallor skin relaxation
• Orthopnea technique

R. To provide relief
of causative factors
Nursing Diagnosis:
• Administer
prescribed
Ineffective Breathing
medications as
Pattern RT Decreased
ordered
Lung Volume Capacity
as evidenced by
R. For the
tachypnea, and
pharmacological
dyspnea
management of the
patient’s condition

• Encourage
adequate rest
periods between
activities

R. to limit fatigue
Acute Pain

Assessment Planning Intervention Evalutaion

Subjective: After 1-2 hours of Independent After 1-2 hours of
“Masakit na nursing Nursing Action: nursing
masakit po iyong intervention the interventions,
inoperahan, lalo patient will Note location of patient verbalized
na pagumuubo verbalize that surgical that pain scale of
ako.” as pain scale of 9/10 procedures. 9/10 was reduced
verbalized by the will reduce to to 5/10.
patient. 5/10. R: Presence of
Pain Scale: 9/10 known/unknown
complication/s
Objective: may make the
(+) abdominal pain more severe
guarding than anticipated.
(+) facial
grimace Provide comfort
(+) crying during measures such as
onset of pain touch therapy,
Restlessness repositioning,
RR- 28 providing a quite
PR- 98 environment

Nursing R: to promote non

Diagnoses: pharmacological
Acute pain pain
related to management.
surgical
procedure. Encourage use of
relaxation
techniques such
as focused
breathing,
imaging and
listening to music.

R: To distract
attention and
reduce tension.

Collaborative:
Administer
analgesics as
prescribed to
 maximum dosage
as needed.

R: To maintain
acceptable level
of pain.

Imbalanced Nutrition: Less than body requirements

Assessment Planning Intervention Evaluation

Subjective After 1-2 hours of Record the After 1-2 hours of
nursing the patient’s weight nursing the
patient and his and height on patient and his
Objective: relatives will be intake. Weigh relatives has able
Weight before able to verbalize regularly, to verbalize and
hospitalization: and demonstrate maintaining demonstrate
50 kg ways of standard ways of
Height: 165 cm nutritional status, conditions nutritional
BMI: 18.4 food and fluid status,food and
intake and R: This ensures fluid intake and
Weight: 45 kg weight control accurate record weight control
Height: 165 cm of weight
BMI= 16.5 changes.
Underweight:
<18.5 Conduct a
nutritional
Diagnosis: assessment
Imbalanced
Nutrition: Less R: It is critical
than body that the health
requirements care provider
related to openly discuss
absence of and have an
physical understanding of
conditions that the complex food
would explain and weight-
weight loss or related behaviors
prevent weight of the patient so
gain. that appropriate
supports can be
integrated into
the treatment
plan.

Assess
cardiovascular,
metabolic, renal,
gastric,
hematological,
and endocrine
system
functioning.

R: Assessment
provides data on
the severity of
malnutrition.

Monitor intake
(i.e., daily food
plans that track
eating trends
along with
emotional states
and triggering
events). Record
intake and output
for the
hospitalized
patient.

R: These data
help determine
the patient’s
actual caloric
intake and eating
behaviors.
Activity Intolerance

Assessment Planning Intervention Evaluation

 After 1-2 hours of Independent: The patient shall
Subjective: nursing have used
“nahihirapan ako interventions, the *Note client identified
gumalaw dahil patient will use reports of techniques to
masakit ang identified weakness, improve activity
tagiliran ko”as techniques to fatigue, pain. intolerance
verbalized by the improve activity
patient. intolerance R: Symptoms
may be result
Objectives:
- Body of/or contribute
weakness to intolerance of
activity.
- Limited
range of Provide the
motion. patient with a
calm and quiet
- Unable to environment
get up to go
to the R: To provide
bathroom relaxation
Nursing Diagnosis: *Promote comfort
measures and
Activity
intolerance provide for relief
related to of pain.
insufficient
oxygen, R: to enhance
generalized ability to
weakness and participate in
complete bed rest. activities.

*Plan for maximal

activity within
the client’s
activity.

R: to determine
current status
and needs
associated with
participation in
needed or
desired activities

Risk for Infection

 Assessment Planning Intervention Evaluation
Subjective After 2-3 hours Independent After 2-3 hours
none of nursing Monitor vital signs of nursing
intervention the and records intervention the
Objective patient and his patient and his
*T- 36.5 relatives will be R: To provide relatives has
*P- 73bpm able to verbalize baseline data for able to verbalize
*R- 27bpm and comparison. and
*BP- 90/70 mmHg demonstrate Elevation in rates demonstrate
ways in may signal infection ways in
preventing preventing
*S/P CTT Insertion infection Assess insertion infection
specifically site for signs of specifically
*With CTT proper hand infection proper hand
connected to one washing, proper washing, proper
way water sealed wound care and R: To check for skin wound care and
bottle water-sealed integrity and water-sealed
drainage bottle identify need for drainage bottle
*With dry and further
intact dressing on management
operative/insertio
n site Assess patency and
intactness of water
Diagnosis: sealed bottle
Risk for infection
related to tissue R: Any obstructions
trauma and kink may delay
secondary to flow. Absence of
surgical fluctuations and
procedure ( CTT excessive bubbling
and may indicate leaks
appendectomy)
Monitor and record
amount and
characteristics of
drainage

R: Increase amount
s of drainage may
signal worsening
condition

Provide regular
wound dressing and
tube care

R: To promote
comfort and
hygiene. To prevent
growth of
microorganisms in
dressings, tube

Change linens and

pt’s robes

R: To promote
comfort and
hygiene. To prevent
growth of
microorganisms in
linens and robes
X. Evaluation

I. Evaluation

Medication: Continue prescribed medications for PULMONARY

TUBERCULOSOS, and be aware of their complications.

These include:

- Omeprazol
- Tazocin
- Lanoxin
- Maalox Suspension
- Demerol
- Flagyl
-Myrin
-Vastarel
-Furosemide
-Ketoradol
-Tramadin
-Prednisone
-Celebrex
-Buscopan

Exercise: Avoid strenuous activities, such as heavy lifting and any other
extreme sports or activities that may trigger an increase in heart rate. After
recovery if the patient discharged the patient should start with short slow
walks for about 10-15 minutes and with time gradually increase the duration
and intensity of the walk. Patient should also be advised to “take it easy” to
do activates that their body can handle.

Treatment: Educate the patient how to properly take the medications and
explain the action of it and the considerations to be taken during medication
intake.
Hygiene: Educate patient on the proper self hygiene techniques to prevent
any further complications. Like brushing teeth to avoid any further
infections.

Out Patient: Remind patient about upcoming check ups needed to increase
the patients health. Also advice patient about any further appointments that
need to be made. Educate the patient about physical limitations and the time
needed to make a full recovery before resuming normal activates before
hospitalization.

Diet: low sodium and low fat diet. Avoid foods that will cause constipation
and strain during bowel movements. Stick to a soft diet to ease the digestion
process. To avoid any further complications with the patient’s condition.

Spiritualism – joining to some activities like bible studies and attending

events to further develop the client’s condition after being discharged from
the hospital.

Prognosis

The client’s prognosis is not that good though he is showing some

progress like being able to communicate well to the relatives and nurses,
able to move on his own and even smiling while talking even though he is
suffering from pain.

After having been admitted at WCMC, the patient is more comfortable

and showed an increase in sense of energy and communication.