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Clinical Case Presentation

On
Pleural Effusion

Presented By
Fatema Akhter
MSN ID:07
Major:Cardio-thoracic Nursing
1st Batch BSMMU
 Patient’s Profile
Name: Asia Bed No: 01
Age: 40 years Ward: 17-B
Reg. No- 2451/8 Unit: 01
Date of Admission: Block: D, Level: 17
10/10/2022

Diagnosis : Right Sided plural effusion

Prof. Dr. A.K.M Mosarraf Hossain
Hospital Name: Bangabandhu Sheikh Mujib
Medical University (BSMMU)
 PHYSICAL ASSESSMENT
The patient was fully conscious, well alert .
 Appearance: Ill Looking.
 Anemia : (+)
 Jaundice: (-)
 Cyanosis: (-)
 Oedema : (+)
 Color of skin: Pale
 Nutritional status:
 Temperature:1010F
 Chief Complain
 Face Swelling
 Haemoptysis
 Fever
 Shortness of Breath (SOB) for last one month
 Non Hypertensive
 Non DM

History of Present Illness

 Cough
 Chest Pain
 Fever
 Difficulty in Breathing
 Shortness of Breath (SOB)
 Past Medical History
No History of -
 Childhood Illness
 Adulthood illness
 Accident and injuries
 Hospitalizations due to LUCS
 Transfusion
 Psychiatric illness

Gynecological History
History of LUCS at the age of 20 years
 Family History
No History of -
 HTN
 DM
 IHD
 Stroke
 Kidney disease
 Arthritis
 Asthma
 Allergies
 Epilepsy
 Dyslipidaemia
 Socio-economic History
 Education level: S.S.C
 Occupation: Housewife
 Smoking / Tobacco : No
 Alcohol: No
 Socioeconomic status : Middle class
 Sleep disturbance: Present
 PHYSICAL ASSESSMENT
The patient was fully conscious, well alert .

 Appearance: Ill Looking.

 Anemia : (+)
 Jaundice: (-)
 Cyanosis: (-)
 Oedema : (+)
 Color of skin:Pale
 Clinical Examination
Book Profile Patient’s Profile

Auscultation: Pleural rub, Diminished breath sound

reduced breath sound.
Percussion note: Stony dull Dull

Heart sounds: Third heart Normal

sound can be heard
 Definition
An abnormal collection of fluid between the
thin layers of tissue (pleura) lining the lung
and the wall of the chest cavity
 Causes and Risk Factors of
Pleural Effusion
 Pneumonia
 Leak from other organs
 Cancer
 Pulmonary embolism
 Kidney disease
 Inflammatory disease
 Tuberculosis
 Sign/Symptoms
Patient’s Profile Book Profile

Difficulty in Breathing Breathlessness

Chest Pain Chest Pain

Fever May or may not have fever

Cough May have cough

Sleep disturbance Sleep disturbance

 Pathophysiology
• Pleural effusion is the accumulation of fluid in
between the parietal and visceral pleura, called the
pleural cavity.

• It can occur by itself or can be the result of

surrounding parenchymal disease like infection,
malignancy, or inflammatory conditions
 Pleural Fluid Aspiration on
-12/10/2022
Time: 1.10 pm
Amount : 800 ml
Colour: Straw
Pleural fluid for cytology : No Malignant cell
is found
 Medical Management

Patient Profile Book Profile

Effusion depends on the condition’s etiology.

• Inj: Ceftron 1gm For example, medical management includes
1 vial IV Stat and BD nitrates and diuretics for congestive heart
failure and pulmonary edema. Antibiotics
• Tab: Montair 10 mg should be administered early when these
conditions are suspected.
0+0+1
• Tab: Doxiva 200 mg
1+0+0
• Inh: Pulmicort F
2 puff-BD (gurgle after use)
Patient Profile Book Profile

• Inh: Asmasol HFA

2 puff-TDS
• Tab: Fenadin 120 mg
0+0+1
• Tab: Famomax 20 mg

1+0+1 (B/M)
• Cap: Traxyl (500mg)
1+1+1
 Nursing Care plan
Assessment Nursing Objectives Planning Intervention Rationales Evaluation
Diagnosis

Subjective: Increase To Taped Taped Minimize Patient

Patient body normalize sponging sponging shivering & temperature
complaints temperature the body provided, decrease has been
that she related to temperature Administe body gradually
has fever disease . ring Administered temperatur normalize.
Objective: condition as antipyretic antipyretic & e by means
Temperatur evidence by & antibiotic as through
e:101oF measuring antibiotic prescribed by evaporation
Temperatur as doctor and
e. prescribed conduction.
by doctor. Removed
heavy
Removing clothing's
heavy
clothing's Provided
healthy diet to
Providing the patient
healthy
diet to the
patient
Assessment Nursing Objectives Planning Nursing Rationales Evaluation
Diagnosis Intervention

Subjective: Ineffective To Positioning Propped up Prevention Patients

breathing improve the patient. positioning of breathing
Breathlessn pattern breathing provided. suffocation pattern
ess, related to pattern Providing & improve was
verbalized bronchoco and aid in O2 8LO2 maintained by airflow, improved
by the nstriction respiratio mask.
as
patient. n Providing Promotes evidenced
CPT- well ventilated airway by normal
Objective: Breathing environment clearance breath
SpO2:88% & coughing provided. and sound &
exercise, promotes decreased
Giving CPT- breathing effort for
Inhaler Breathing & breathing.
coughing SpO2:97%
exercise done.

Inhaler
therapy given
as prescribed
Assessment Nursing Objectives Planning Nursing Rationales Evaluation
Diagnosis Intervention

Subjectiv Pain in the To Reduce Administer Administered To alleviate After 4 hours

thoracic pain prescribed analgesics as the pain & to of nursing
e:
cavity pain prescribed. monitor the intervention
related to medications.. efficacy of patient feels
Feeling
Comfortable pain relief. better than
discomfort. disease
condition Provide position before.
nonpharmaco provided.
Objective:
logic
methods of Deep
Pain in the
pain relief. breathing
chest
exercises
Provide rest done.
and simplify
ADLs.

Educate the
patient on
deep
breathing
exercises.
 Health Education
 Take adequate rest and avoid physical
activity that may intensify pain or
breathing problems.
 Regular follow up
 Taking inhaler accurately
 Maintain personal hygiene
 Taking healthy diet
 Regular breathing exercise
 Rehabilitation
 Chest physiotherapy
 References
•Pleural effusion: Symptoms, causes, treatments (no date) Cleveland Clinic. Available at:
https://my.clevelandclinic.org/health/diseases/17373-pleural-effusion-causes-signs- (Accessed:
November 1, 2022).

•Hopkins, J. (2019, August 19). Johns Hopkins Medicine, based in Baltimore, Maryland. Hopkinsm
edicine.org. https://www.hopkinsmedicine.org
•Mayo Clinic. (2019). Mayo Clinic - Mayo Clinic. Mayoclinic.org. https://www.mayoclinic.org
•Pleural effusion: Symptoms, causes, treatments (no date) Cleveland Clinic. Available at:
https://my.clevelandclinic.org/health/diseases/17373-pleural-effusion-causes-signs- (Accessed:
November 1, 2022).
•List of 11 pleural effusion medications compared (no date) Drugs.com. Available at:
https://www.drugs.com/condition/pleural-effusion.html (Accessed: December 02.11. 2022).
• 
•Pleural effusion treatment (no date) ucsfhealth.org. Available at:
https://www.ucsfhealth.org/conditions/pleural-effusion/treatment (Accessed: December 16, 2022).
Any Questions??
THANK YOU