Pleural Effusion-Individual CP

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Capitol University

Corrales Extension, Cagayan de Oro City

College of Nursing

PLEURAL EFFUSION

SUBMITTED TO:

MR. RICK WILSON BUNAO, RN MN

(Clinical Instructor)

SUBMITTED BY:

KRISTINE MAE U. SUGAROL

RLE 7 GROUP 21

January 19, 2010

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TABLE OF CONTENTS

I. Introduction………………………………………………..…………….…3

A. General objective…………………………………………………6B. Specific objectives………………………………………………..6C. Scope and limitations……………………………………………6

II. Assessment

A. Patient demographic data………………………………………7B. Assessment tool…………………………………………………8C. Laboratory results……………………………………………….13

III. Anatomy and physiology…………………………………………….…17

IV. Pathophysiology

A. Narrative form…………………………………………………….24B. Schematic Diagram………………………………………………26

V. Medical management

A. Nursing Care Plan……………………………………………….28B. Drug study………………………………………………..………34

VI. Health Teaching ……………….…………………………..……………37

VII. Learning Experience ……………………………………….…….…...38

VIII. Discharge Planning….…………………………………….….………39

IX. Doctor’s Order …………………….……………………………………41

X. References ……………………….………………………………...……42

I. INTRODUCTION

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Approximately 1 million pleural effusions are diagnosed in the United

States each year. The clinical importance of pleural effusions ranges from incidental

manifestations of cardiopulmonary diseases to symptomatic inflammatory or malignant

diseases (as shown in the image below) requiring urgent evaluation and treatment.

Pleural effusion is excess fluid that accumulates in the pleural cavity, the

fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair

breathing by limiting the expansion of the lungs during inhalation.

Pleural fluid normally seeps continually into the pleural space from the

capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries

and lymphatic system. Any condition that interferes with either secretion or drainage of

this fluid leads to pleural effusion.

Causes of pleural effusion can be grouped into four major categories:

Increased systemic hydrostatic pressure (e.g., heart failure)

Reduced capillary oncotic pressure (e.g., liver or renal failure)

Increased capillary permeability (e.g., infections or trauma)

Impaired lymphatic function (e.g., lymphatic obstruction caused by tumor)

Anteroposterior upright chest radiograph shows a massive left-sided pleural effusion with contralateral mediastinal shift.

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A pleural effusion is an abnormal collection of

fluid in the pleural space resulting from excess fluid

production or decreased absorption. It is the most

common manifestation of pleural disease. The pleural

space is bordered by the parietal and visceral pleurae.

The parietal pleura covers the inner surface of the

thoracic cavity, including the mediastinum, diaphragm,

and ribs. The visceral pleura envelops all lung

surfaces, including the interlobar fissures. The right

and left pleural spaces are separated by the

mediastinum.

The pleural space plays an important role in

respiration by coupling the movement of the chest wall

with that of the lungs in two ways. First, a relative

vacuum in the space keeps the visceral and parietal

pleurae in close proximity. Second, the small volume

of pleural fluid, which has been calculated at 0.13

mL/kg of body weight under normal circumstances, serves as a lubricant to facilitate

movement of the pleural surfaces against each other in the course of respirations. This

small volume of fluid is maintained through the balance of hydrostatic and oncotic

pressure and lymphatic drainage, a disturbance of which may lead to pathology.

Clinical manifestations depend on the amount of fluid present and the

severity of lung compression. If the effusion is small (i.e., 250ml), its presence may be

discovered only on a chest radiograph. With larger effusions, lung expansion may be

restricted, and the client may experience dyspnea, primarily on exertion, and a dry,

nonproductive cough caused by bronchial irritation or mediastinal shift. Tactile fremitus

may be decreased or absent, and percussion notes dull or flat.

Dyspnea is the most common symptom associated with pleural effusion

and is related more to distortion of the diaphragm and chest wall during respiration

than to hypoxemia. In many patients, drainage of pleural fluid alleviates symptoms

despite limited improvement in gas exchange.

Underlying intrinsic lung or heart disease, obstructing endobronchial

lesions or diaphragmatic paralysis can also cause dyspnea, especially after coronary

artery bypass surgery. Drainage of pleural fluid may partially relieve symptoms but also

may allow the underlying disease to be recognized on repeat chest radiographs.

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Less common symptoms of pleural effusions include mild, nonproductive

cough or chest pain. Other symptoms may suggest the etiology of the pleural effusion.

More severe cough or production of purulent or bloody sputum suggests an underlying

pneumonia or endobronchial lesion. Constant chest wall pain may reflect chest wall

invasion by bronchogenic carcinoma or malignant mesothelioma. Pleuritic chest pain

suggests either pulmonary embolism or an inflammatory pleural process. Systemic

toxicity evidenced by fever, weight loss, and inanition suggests empyema.

Thoracentesis is used to remove excess pleural fluid. The removed fluid is

analyzed to determine whether it is transudate or exudate. Transudates are

substances that have passed through a membrane or tissue surface. They occur

primarily in conditions in which there are protein loss and low protein content (e.g.,

hypoalbuminemia, criihosis, nephrosis) or increased hydrostatic pressure (e.g., heart

failure). Exudates are substances that have escaped from blood vessels. They contain

an accumulation of cells, have a high specific gravity and a high lactate dehydrogenase

(LDH) level, and occur in response to malignancies, infections or inflammatory

processes. Exudates occur when there is an increase in capillary permeability.

Differentiating between transudates and exudates helps establish a specific diagnosis.

Diagnosis may also require analysis of the fluid for white and red blood cells, malignant

cells, bacteria, glucose content, pH, and LDH.

Pleural fluid may be (1) hemorrhagic (or bloody), such as when a tumor is

present or after trauma or pulmonary embolus with infarction; (2) chylous (or thick and

white), such as after lymphatic obstruction or trauma to the thoracic duct; or (3) rich in

cholesterol, such as in chronic, recurrent effusions caused by tuberculosis or

rheumatoid arthritis. If there is a high in WBC count and the pleural fluid is purulent, the

effusion is called emphysema. Emphysema of any volume requires drainage and

treatment of the infection.

If the pus is not drained, it may become thick and almost solidified or

loculated (containing cavities), a condition called fibrothorax.

After the thoracentesis, closed-chest drainage with suction is used to re-

expand the lung rapidly and fill the pleural space. If the fibrous material has restricted

the lung for some time, the lung may not re-expand effectively and further intervention

(usually thoracoplasty) may be needed.

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A. GENERAL OBJECTIVE

At the end of this case presentation, I will be able to improve knowledge in

various concepts related to my patient’s condition, and skills in careful assessment and

rendering of nursing interventions involved in the management of the client’s case; and

develop positive attitudes as I accomplish my case study using concepts that I have

acquired from our RLE, theory classes and previous related subjects in the BSN

curriculum.

B. SPECIFIC OBJECTIVES

1. Perform a thorough assessment and careful gathering of data that are clinically

significant and will be utilized as reliable cues for our care plans.

2. Further completion of data that will supplement our assessment.

3. Trace and familiarize the pathophysiology of our patient’s disease process.

4. Design individualized nursing care plans based on nursing diagnoses that are

suitable and feasible to carry out.

5. Carry out nursing interventions that are effective, reality based, time-bounded,

achievable and beneficial for our client.

6. Develop a sense of positive thinking in coming up with the case study.

C. SCOPE AND LIMITATION

The study focuses on the assessment, anatomy, and pathophysiology and

its diagram, nursing care plans, discharge plan, prognosis, recommendation and

conclusion revolving around the diagnosis of the patient which is Pleural Effusion

probably secondary to pneumonia.

This study is limited only to the available records found on the patient’s

chart and the information being provided for by the family members present at the

patient’s room during the time of assessment. Other factors that will also be considered

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as limitations to this study would include the short-duration of time given for ICU

rotation.

II. ASSESSMENT

A. PATIENT DEMOGRAPHIC PROFILE

Patient Demographic Profile

Name of patient: Panugaling, Jonathan Castro

Age: 27 years old

Birthday: July 2, 1982

Sex: Male

Address: Purok 3-C Baloy, Tablon, Cagayan de Oro City, Misamis Oriental

Civil status: Single

Height: NA

Weight: NA

Language spoken: Visayan

Educational Attainment: Elementary Graduate

Religion: Roman Catholic

Nationality: Filipino

Name of Father: Felipe Panugaling

Name of Mother: Saturnina Monte Castro

Occupation: barber

Income: P1700/month

Chief complaint: cough and fever

Name of Hospital: Northern Mindanao Medical Center

Date of Admission: January 7, 2010 (11:00pm)

Name of Attending Physician: Dr. Sarmiento

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Admitting Diagnosis:

Pleural Effusion probably secondary to Pneumonia

B. ASSESSMENT TOOL

VITAL SIGNS:

Temperature: 36.7°c

Pulse Rate: 64 BPM

Respiratory Rate: 24 CPM

Blood Pressure: 120/190 mmHg

Weight: NA

Height: NA

GENERAL DATA:

A case of 27 y.o., male, single, Roman Catholic from Tablon, Cagayan de

Oro City, admitted for the 1st time due to cough

Source of information:

Patient: 90% reliability

HISTORY OF PRESENT ILLNESS:

5 days PTA, noted to have cough, productive of whitish phlegm

associated with fever, on and off, low to moderate grade and back pains on the left.

Consult done at the Family Medicine OPD. Work up done with CXR which revealed

pleural effusion L. Patient refused in our institution for further evaluation and

management. Hence this admission,

( + ) occasional SOB ( + ) easy fatigue ability

( - ) chest pain

PAST MEDICAL HISTORY:

Previous admission due to vehicular accident 2007 Head injury sutured

( - ) operation

Non asthmatic

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Non diabetic

Non hypertensive

( - ) food/drug allergy

( - ) illness

FAMILY HISTORY:

( + ) HPN (paternal)

PERSONAL / SOCIAL HISTORY:

Non smoker but occasional alcoholic beverage drinks

Single, barber

FUNCTION HEALTH PATTERNS

ACTIVITY-EXERCISE PATTERN

Pt.X pericordial area is flat; PMI is best heard at 5th ICS midclavicular line with

apical rate of 142bpm. Her peripheral pulse is symmetrical, palpable, and regular & her

capillary refill is 2sec. No pacemaker attached & hemodynamic monitoring but Chest

Thoracostomy Tube (CTT) is attached at the left mid-axillary line of the patient’s body.

Has O2 inhalation attached to patient’s nose upon assessment.

Pt. X is in irregular breathing pattern of 33cpm upon assessment. The lung

expansion is asymmetrical, with diminished or delayed expansion on the side of effusion

which is at the left.

Pt. X ADL is in total dependence and mobility status is limited because of fear of

injury to the site of the CTT. Pt. X back & extremities has no deformities but ROM is

also limited. The spine is in the midline.

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NUTRITION & METABOLIC PATTERN

Prior to admission pt. X has no special diet. Does not have any supplement

rather than Ferrous sulfate.

Pt. X mouth & mucosa are pinkish; tongue is in the midline. Uvula is in the

midline & pinkish, tonsils are not inflamed. The trachea is in the midline with non-

palpable thyroids & minimal ROM on bed.

Pt. X skin general color is pallor, rough, firm, warm to touch. Patient has an

ongoing IVF of PNSS 940cc regulated at 30gtts/min. Patient has also a surgical wound

(suture) in the left mid-axillary line where Chest Thoracostomy Tube is attached with

drainage of 590 level in bloody color.

ELIMINATION PATTERN

During admission pt. X defecates 1 time with yellow, slightly firm stool at medium

amount. Last bowel movement on January 13, 2010; and the day of assessment was

January 14, 2010. No incontinence & any method use to manage bowel movement

noted.

The abdomen is symmetrical but flat and normoactive without any abnormal

findings upon palpation. Pt. X usually urinates 1-2 times a day, appeared in yellow color

and has no problem in urinating. Patient also sweats minimally during afternoon but no

noted excessive perspiration.

SLEEP-REST PATTERN

Pt. X sleeps 7-8 hours at night. There were no histories of sleep disturbances of

the patient. Pt. X is always at the bed and easily drops to sleep.

COGNITIVE-PERCEPTION PATTERN

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Pt. X is conscious and calm upon assessment and disoriented to time. The head

is normocephalic with symmetrical facial movements & sunken fontanels. Hair is dry

with dandruff seen in the scalp. Pt. X eyelids are asymmetrical, with pink conjunctiva.

No lesions in the cornea & lens & anecteric sclera. Pupils are at equal size with 4mm in

diameter.

Pt. X external pinnae of ears is normoset with cerumen discharge & intact

tympanic membrane. The nasal septum is in the midline with pinkish mucosa & both

patent.

SELF-PERCEPTION & SELF CONCEPT PATTERN

Pt. X feels fine about himself but I observed that he is not. Pt. X is depressed

about himself for being sick and hospitalized.

ROLE-RELATIONSHIP PATTERN

Pt. X lives with his mother, father and younger siblings. When it comes to the

feelings of his family members regarding her illness, pt. X mother felt so sad about her

son’s condition but she tries to understand the nature of the problem and accepts the

fact about the condition of her son. The mother also verbalized that her son needs

support about his present condition.

DAY 1: PHYSICAL ASSESSMENT (Jan. 14, 2010)

SKIN - General color is pallor, rough, firm, and warm to touch.

NAILS

- His nails were pallor but it is firm and convex-shape.

HAIR - Her hair is dry and black, with dandruff.

HEAD - Normocephalic head and facial movements are symmetrical in size- Sunken fontanels.

EYES - He has no edema. Both eyes are coordinated with parallel alignment.- Anicteric sclera and conjunctiva and no abnormal tears noted.

EARS - Normal voice tones audible.

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- Her ears were symmetrical - There was cerumen noted

NOSE AND SINUSES - There is nasal flaring upon assessment due to SOB- No tender sinuses noted- Gross smell is symmetrical

MOUTH AND THROAT - He has pallor lips, pinkish mucosa - Tongue is in midline with missing teeth- Has pinkish gums

NECK - Trachea is placed midline. Lymph nodes are not palpable.

LUNGS-CHEST WALL - Asymmetric chest expansion, with diminished or delayed expansion on the side

of the effusion- Breaths per minute is 33cpm (abnormal).

Drainage Color: (according to 3-11 shift)

1. Bloody about 320 cc level Jan. 14, 2010

2. Yellowish about 10cc level + 110 water from bottle Jan. 15, 2010

3. Clear yellow about 190 cc level from previous bottle Jan. 16, 2010

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C. LABORATORY RESULTS:

Hematology Report: Jan. 12, 2010 7:24pm

Test Result Unit Reference Interpretation WBC 5.7 10^3/uL 5.0-10.0 NORMALRBC 4.22 10^6/uL 4.2-5.4 NORMAL

Hemoglobin 11.7 y/dL 12.0-16.0 LOW Hematocrit 35.2 % 37.0-47.0 ANEMIA

MCV 83.4 fL 82.0-98.0 NORMALMCH 27.7 fL 27.0-31.0 NORMAL

MCHC 33.2 g/dL 31.5-35.0 NORMALRDW-CV 12.8 % 12.0-17.0 NORMAL

PDW 9.3 fL 9.0-16.0 NORMALMPV 8.1 fL 8.0-12.0 NORMAL

Differential Count

Lymphocyte (%) 20.8 % 17.4-48.2 NORMALNeutrophil 57.3 % 43.4-76.2 NORMALMonocyte 21.9 % 4.5-10.5 HIGHEosinophil % 1.0-3.0Basophils % 0.0-2.0

Bands/Stabs % 1.0-2.0Platelets 513 10^3/uL 150-400 HIGH

Hematology Result: Jan. 10, 2010 5:11pm

Test Result Unit Reference InterpretationWBC 5.8 10^3/uL 5.0-10.0 NORMALRBC 4.34 10^6/uL 4.2-5.4 NORMAL

Hemoglobin 12.2 y/dL 12.0-16.0 NORMALHematocrit 36.2 % 37.0-47.0 LOW


MCHC 33.7 g/dL 31.5-35.0 NORMALRDW-CV - % 12.0-17.0

PDW - fL 9.0-16.0MPV - fL 8.0-12.0

Differential Count

Lymphocyte (%) 18.3 % 17.4-48.2 NORMAL

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Neutrophil 21.7 % 43.4-76.2 LOWMonocyte 30.0 % 4.5-10.5 HIGHEosinophil - % 1.0-3.0Basophils - % 0.0-2.0

Bands/Stabs - % 1.0-2.0Platelets 452 10^3/uL 150-400 HIGH

Hematology Result: Jan. 7, 2010 3:33pm

Test Result Unit Reference InterpretationWBC 7.2 10^3/uL 5.0-10.0 NORMALRBC 4.71 10^6/uL 4.2-5.4 NORMAL

Hemoglobin 13.0 y/dL 12.0-16.0 NORMALHematocrit 38.4 % 37.0-47.0 NORMAL


MCHC 33.9 g/dL 31.5-35.0 NORMALRDW-CV 12.6 % 12.0-17.0 NORMAL

PDW 9.9 fL 9.0-16.0 NORMALMPV 8.8 fL 8.0-12.0 NORMAL

Differential Count

Lymphocyte (%) 18.2 % 17.4-48.2 NORMALNeutrophil 56.3 % 43.4-76.2 NORMALMonocyte 24.5 % 4.5-10.5 HIGHEosinophil 0.7 % 1.0-3.0Basophils 0.3 % 0.0-2.0 NORMAL

Bands/Stabs - % 1.0-2.0Platelets 406 10^3/uL 150-400 HIGH

January 10, 2010

Serous Effusions & Synovial Fluid Analysis

Gross Examination:

Volume: 10 mlColor: yellowClarity: hazy

Microscopic Examination:

RBC count: 3697/mm3

WBC count: 1238/mm3

Differential count (%):

Segmenters: 15%Lymphocytes: 85%

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Mononuclear cells: - Other types: -

Others:Specific gravity: 1.005Rivaltas Test: positiveGlucose: trace

January 7, 2010

BLOOD CHEMISTRY SIGNIFICANCE

Blood sugar (Rbs): 103.2 (60-110) mgs%Blood Urea Nitrogen: (4.6-23.4)Creatinine: 6.75 (0.6-1.2)Electrolyte: 3.93 (3.5-5.3)mmol/LPotassium: 139.55 (135-148)mmol/L

NORMAL-

NORMALNORMALNORMAL

EXAM: CHEST, PA Jan. 7, 2010

Radiographic Report:Chest in PA projections shows homogenous density occupying the lower 2/3 of the left hemithorax eccentric upper border. Heart shadow is slightly deviated to the right. No right parenchymal infiltrate. Right hemidiaphragm and its corresponding sinuses are intact.

Impression:Consider Pneumonia, Left w/ Pleural Effusion.

Suggest: UTS of the left hemithorax to determine the amount of fluid within the pleural activity.

SONOGRAPHIC REPORT: Jan. 7, 2010

There is fluid collection in the left lower hemithorax measuring 11.6cm x 11.9cm x 5.5cm, approximately 395cc. No sepatations, no debris noted within the fluid. At the marked area, skin to parietal pleural is 2.2cm & interpleural distance is 4.7cm.

Impression:

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Pleural Effusion, left, as described

January 11, 2010

Panugaling, Jonathan C.27/M

NMMC Specimen #: pf 0008Date of Birth: July, 2, 1982 Specimen Date: Jan. 11, 2010Date of Admission: Jan. 7, 2010 Specimen Type: Pleural Fluid

Organism: No GrowthComment: No growth after 72 hours incubation

January 15, 2010MICROBIOLOGY EXAMINATION

Specimen SputumAcid-Fast Stain: First Taking (Negative)

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III. ANATOMY AND PHYSIOLOGY

Anatomy and Physiology

Anatomy of the lower respiratory tract: Lungs

Lungs

The lungs are paired elastic structures enclosed in the thoracic cage, which is an

airtight chamber with distensible walls. Ventilation requires movement of the walls of the

thoracic cage and of its floor, the diaphragm. The effect of these movements is

alternately to increase and decrease the capacity of the chest. When the capacity of the

chest is increased, air enters through the trachea (inspiration) because of the lowered

pressure within and inflates the lungs. When the chest wall and diaphragm return to

their previous positions (expiration), the lungs recoil and force the air out through the

bronchi and trachea. The inspiratory phase of respiration normally requires energy; the

expiratory phase is normally passive. Inspiration occurs during the first third of the

respiratory cycle, expiration during the latter two thirds.

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Pleura

The lungs and wall of the thorax are lined with a serous membrane called the

pleura. The visceral pleura cover the lungs; the parietal pleura lines the thorax. The

visceral and parietal pleura and the small amount of pleural fluid between these two

membranes serve to lubricate the thorax and lungs and permit smooth motion of the

lungs within the thoracic cavity with each breath.

Mediastinum

The mediastinum is in the middle of the thorax, between the pleural sacs that

contain the two lungs. It extends from the sternum to the vertebral column and contains

all the thoracic tissue outside the lungs.

Lobes

Each lung is divided into lobes. The left lung consists of an upper and lower lobe,

whereas the right lung has an upper, middle, and lower lobe. Each lobe is further

subdivided into two to five segments separated by fissures, which are extensions of the

pleura.

Bronchi and Bronchioles

These are several divisions of the bronchi within each lobe of the lung. First are

the lobar bronchi (three in the right lung and two in the left lung). Lobar bronchi divide

into segmental bronchi (10 on the right and 8 on the left), which are the structures

identified when choosing the most effective postural drainage position for a given

patient. Segmental bronchi then divide into subsegmental bronchi. These bronchi are

surrounded by connective tissue that contains arteries, lymphatics and nerves. The

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subsegmental bronchi then branch into bronchioles, which have no cartilage in their

walls. Their patency depends entirely on the elastic recoil of the surrounding smooth

muscle and on the alveolar pressure. The bronchioles contain submucosal glands,

which produce mucus that covers the inside lining of the airways. The bronchi and

bronchioles are lined also with cells that have surfaces covered with cilia. These cilia

create a constant whipping motion that propels mucus and foreign substances away

from the lung toward the larynx. The bronchioles then branch into terminal bronchioles

then become respiratory bronchioles, which are considered to be the transitional

passageways between the conducting airways and the gas exchange airways. Up to

this point, the conducting airways contain about 150 ml of air in the tracheobronchial

tree that does not participate in gas exchange. This is known as physiologic dead

space. The respiratory bronchioles then lead into alveolar ducts and alveolar sacs and

then alveoli. Oxygen and carbon dioxide exchange takes place on the alveoli.

Alveoli

The lung is made up of about 300 million alveoli, which are arranged in clusters

of 15 to 20. These alveoli are so numerous that if their surfaces were united to form one

sheet, it would cover 70 square meters- the size of a tennis court. There are three types

of alveolar cells. Type I alveolar cells are epithelial cells that form the alveolar walls.

Type II alveolar cells are metabolically active. These cells secrete surfactant, a

phospholipid that lines the inner surface and prevents alveolar collapse. Type III

alveolar cell macrophages are large phagocytic cells that ingest foreign matter (eg.

mucus, bacteria) and act as an important defense mechanism).

Function of the Respiratory System

The cells of the body derive the energy they need from the oxidation of

carbohydrates, fats, and proteins. As with any type of combustion, this process requires

oxygen. Certain vital tissues, such as those of the brain and the heart, cannot survive

for long without a continuing supply of oxygen. However, as a result of oxidation in the

body tissues, carbon dioxide is produce and must be remove from the cell to prevent

the build of acid waste products. The respiratory system performs this functions by

facilitating life sustaining processes such oxygen transport, respiration and ventilation,

and gas exchange.

Oxygen transport

Oxygen is supplied to and carbon dioxide is remove from cell by way of

circulating blood cells are enclosed contact with capillaries, and oxygen diffuses from

the capillary through the capillary wall to the interstitial fluid.

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Respiration

After this, tissue capillary exchanges blood enters systemic veins and travels to

pulmonary circulation. The oxygen diffuses from the alveoli from the blood. Carbon

dioxide diffuses from the blood to alveoli movement of air in and out of the airways

continually replenishes the oxygen and removes the carbon dioxide from the airways in

the lungs this whole process of gas exchange is called respiration.

Ventilation

During inspiration, air flows from the environment into the trachea, bronchi,

bronchioles and alveoli. During expiration, alveolar gas travels the same route in

reverse.

Anatomy of the Pancreas

In humans, the pancreas is a 15-25 cm (6-10 inch) elongated organ in the

abdomen. One of the organs behind the abdominal cavity, it is located posterior to the

stomach and in close association with the duodenum.

It is often described as having three regions: a head, body and tail.

• The pancreatic head abuts the second part of the duodenum.

• The body of the pancreas lies at the level of L2 on the spine.

• The tail of the pancreas extends towards the spleen.

The pancreatic duct (also called the duct of Wirsung) runs the length of the

pancreas and empties into the second part of the duodenum at the ampulla of Vater.

The common bile duct usually joins the pancreatic duct at or near this point. Many

people also have a small accessory duct, the duct of Santorini, which extends from the

main duct more upstream (towards the tail) to the duodenum, joining it more proximal

than the ampulla of Vater.

Arteries and veins

The pancreas is supplied arterially by the Pancreaticoduodenal arteries and the

splenic artery:

• the splenic artery supplies the neck, body, and tail of the pancreas.

• the superior mesenteric artery provides the inferior pancreaticoduodenal artery

• the gastroduodenal artery provides the superior pancreaticoduodenal artery

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Venous drainage is via the pancreaticoduodenal veins which end up in the portal

vein. The splenic vein passes posterior to the pancreas but is said to not drain the

pancreas itself. The portal vein is formed by the union of the superior mesenteric vein

and splenic vein posterior to the neck of the pancreas. In some people (some books say

40% of people), the inferior mesenteric vein also joins with the splenic vein behind the

pancreas (in others it simply joins with the superior mesenteric vein instead).

Nerves

The pancreas is innervated by the pancreatic plexus; a subdivision of the celiac

plexus that accompanies pancreatic arteries.

Physiology of the Pancreas

Under a microscope, when properly stained, it is easy to distinguish two different

tissue types in the pancreas. These regions correspond to the main pancreatic

functions:

Appearance Region Function

light staining circles (islets of Langerhans)

endocrine pancreas

secretes hormones that regulate blood glucose levels

Darker surrounding tissue exocrine pancreas

produces enzymes that break down digestible foods

Endocrine

There are four main types of cells in the islets of Langerhans. They are relatively

difficult to distinguish using standard staining techniques, but they can be classified by

their secretion:

Name of cells

Endocrine product

% of islet cells

Representative function

beta cells Insulin and Amylin 50-80% lower blood sugar

alpha cells Glucagon 15-20% raise blood sugar

delta cells Somatostatin 3-10% inhibit endocrine pancreas

PP cells Pancreatic polypeptide 1% inhibit exocrine pancreas

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The islets are a compact collection of endocrine cells arranged in clusters and

cords and are crisscrossed by a dense network of capillaries. The capillaries of the

islets are lined by layers of endocrine cells in direct contact with vessels, and most

endocrine cells are in direct contact with blood vessels, by either cytoplasmic processes

or by direct apposition. According to the volume The Body, by Alan E. Nourse, in the

Time-Life Science Library Series, the islets are "busily manufacturing their hormone and

generally disregarding the pancreatic cells all around them, as though they were located

in some completely different part of the body.

Anatomy of the Heart

Position

The heart is a hallow organ positioned left of the center in the chest cavity within

the pericardial cavity. The base of the heart is located superiorly in and the apex is

directed downward and leftward and formed by the lateral tip of the left ventricle

Physiology of the Heart

The essential function of the heart is to pump blood to various parts of the body.

The mammalian heart has four chambers: right and left atria and right and left

ventricles. The two atria act as collecting reservoirs for blood returning to the heart while

the two ventricles act as pumps to eject the blood to the body. As in any pumping

system, the heart comes complete with valves to prevent the back flow of blood.

Deoxygenated blood returns to the heart via the major veins (superior and inferior vena

cava), enters the right atrium, passes into the right ventricle, and from there is ejected to

the pulmonary artery on the way to the lungs. Oxygenated blood returning from the

lungs enters the left atrium via the pulmonary veins, passes into the left ventricle, and is

then ejected to the aorta. In the frontal view of the heart shown below, the right atrium is

in blue, the left atrium in yellow, the right ventricle in purple, and the left ventricle in red.

The chambers are semi-transparent so that the valves, drawn in white, can be seen.

The large valve in the foreground is the tricuspid valve that prevents backflow

from the right ventricle to the right atrium. The small round valve you see near the top is

the pulmonary valve, where the pulmonary artery comes out of the right ventricle.

The inner edge of the tricuspid and the mitral valves end in filamentous

connective tissue (chordae tendineae). These are attached to small columns of muscle

(papillary muscles) arising out of the inner surface of the ventricles. As the pressure

builds in the ventricles, the valves snap shut, and the papillary muscles prevent the

valves from blowing into the atrium and opening.

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Pumping Action of the Heart

The pumping action starts with the simultaneous contraction of the two atria. This

contraction serves to give an added push to get the blood into the ventricles at the end

of the slow-filling portion of the pumping cycle called "diastole." Shortly after that, the

ventricles contract, marking the beginning of "systole." The aortic and pulmonary valves

open and blood is forcibly ejected from the ventricles, while the mitral and tricuspid

valves close to prevent backflow. At the same time, the atria start to fill with blood again.

After a while, the ventricles relax, the aortic and pulmonary valves close, and the mitral

and tricuspid valves open and the ventricles start to fill with blood again, marking the

end of systole and the beginning of diastole. It should be noted that even though equal

volumes are ejected from the right and the left heart, the left ventricle generates a much

higher pressure than does the right ventricle.

Electrical Activity of the Heart

When vertebrate muscles are excited, an electrical signal (called an "action

potential") is produced and spreads to the rest of the muscle cell, causing an increase in

the level of calcium ions inside the cell. The calcium ions bind and interact with

molecules associated with the cell's contractile machinery, the end result being a

mechanical contraction. Even though the heart is a specialized muscle, this

fundamental principle still applies.

One thing that distinguishes the heart from other muscles is that the heart muscle

is a "syncytium," meaning a meshwork of muscle cells interconnected by contiguous

cytoplasmic bridges. Thus, an electrical excitation occurring in one cell can spread to

neighboring cells. Another defining characteristic is the presence of pacemaker cells.

These are specialized muscle cells that can generate action potentials rhythmically.

Under normal circumstances, a wave of electrical excitation originates in the

pacemaker cells in the sinoatrial (S-A) node, located on top of the right atrium.

Specialized muscle fibers transmit this excitation throughout the atria and initiate a

coordinated contraction of the atrial walls. Meanwhile, some of these fibers excite a

group of cells located at the border of the left atrium and ventricle known as the

atrioventricular (A-V) node. The A-V node is responsible for spreading the excitation

throughout the two ventricles and causing a coordinated ventricular contraction.

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IV. PATHOPHYSIOLOGY

A. NARRATIVE FORM

Microorganisms that produce pneumonia can end up in air sacs in several ways.

In some cases, people inhale microorganisms (which are present in tiny droplets) when

they are near someone already infected. Spread in hospitals and nursing homes often

occurs this way. More common among older people, however, is the presence of

bacteria in their throat (colonization). These bacteria may remain there harmlessly or

suddenly cause pneumonia if mucus or food is inhaled into the airway (aspiration)

instead of passed into the esophagus. When aspiration occurs, the food or mucus can

make its way into the lungs, carrying the bacteria from the throat along for the ride.

Rarely, microorganisms from elsewhere in the body reach the lungs by traveling through

the bloodstream. These are usually blood borne microorganisms that enter the

pulmonary circulation and are trapped in the capillary bed, becoming a potential source

of pneumonia.

Pneumonia often affects both ventilation and diffusion. An inflammatory reaction

can occur in the alveoli, producing an exudate that interferes with the diffusion of

oxygen and carbon dioxide. White blood cells, mostly neutrophils, also migrate into the

alveoli and fill the normally air-containing spaces. Areas of the lung are not adequately

ventilated because of secretions and mucosal edema that cause partial occlusion of the

bronchi or alveoli, with a resultant decrease in the alveolar oxygen tension. Because of

hypoventilation, a ventilation-perfusion mismatch occurs in the affected area of the lung.

Venous blood entering the pulmonary circulation passes through the underventilated

area and exits to the left side of the heart poorly oxygenated. The mixture of oxygenated

and unoxygenated blood eventually results in arterial hypoxemia.

Pleural effusion is an indicator of an underlying disease process that may be

pulmonary or nonpulmonary in origin, acute or chronic.

Normal pleural fluid has the following characteristics:

o Clear ultrafiltrate of plasma that originates from the parietal pleura

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o pH 7.60-7.64

o Protein content less than 2% (1-2 g/dL)

o Fewer than 1000 WBCs per cubic millimeter

o Glucose content similar to that of plasma

o Lactate dehydrogenase (LDH) less than 50% of plasma

o Sodium, potassium, and calcium concentration similar to that of the

interstitial fluid

The following mechanisms play a role in the formation of pleural effusion:

o Altered permeability of the pleural membranes (eg, inflammation,

malignancy, pulmonary embolus)

o Reduction in intravascular oncotic pressure (e.g., hypoalbuminemia,

cirrhosis)

o Increased capillary permeability or vascular disruption (e.g., trauma,

malignancy, inflammation, infection, pulmonary infarction, drug

hypersensitivity, uremia, pancreatitis)

o Increased capillary hydrostatic pressure in the systemic and/or pulmonary

circulation (eg, congestive heart failure, superior vena cava syndrome)

o Reduction of pressure in the pleural space, preventing full lung expansion

(eg, extensive atelectasis, mesothelioma)

o Decreased lymphatic drainage or complete blockage, including thoracic

duct obstruction or rupture (eg, malignancy, trauma)

o Increased peritoneal fluid, with migration across the diaphragm via the

lymphatics or structural defect (eg, cirrhosis, peritoneal dialysis)

o Movement of fluid from pulmonary edema across the visceral pleura

o Persistent increase in pleural fluid oncotic pressure from an existing

pleural effusion, causing further fluid accumulation

The net result of effusion formation is a flattening or inversion of the diaphragm,

mechanical dissociation of the visceral and parietal pleura, and a restrictive ventilatory

defect.

Inflammation

Precipitating factor:>prolonged back rest>aspiration>inhaled microorganism (Bacteria)

Predisposing factor:>stress>exposure to polluted air>depressed cough reflex

Inhaled in the alveolus

Inhalation of causative agents (CA):Streptococcus pneumoniae

Reproduction of CA in the lungs

Activation of first line of defenseS/sx: cough, mucus production

Partial occlusion of bronchus alveoli

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B. SCHEMATIC DIAGRAM

Increased capillary permeability or vascular disruption

Exudates

Pleural Effusion

Complication:AtelectasisInfection

hypoxemia

SIGNS AND SYMPTOMS:Dyspnea

chest paindecreased tactile fremitus

diminished or absent breath soundspleural friction rub during both inspiration and expiration

dry nonproductive coughshortness of breath

Treated Not treated

Prevents serious Complications

Metastasis of Complications

Recovery Danger to health (serious)

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NURSING CARE PLAN

NURSING DIAGNOSIS

Ineffective Breathing Pattern related to difficulty of breathing secondary to pneumonia

ASSESSMENT DATA (SUBJECTIVE AND OJECTIVE CUES)

Subjective Cue:

“Maglisod ko ug ginhawa usahay, murag dili ko kaginhawa”, as verbalized by the patient.

Objective Cue:

- Nonproductive cough noted

- Dyspnea on exertion

- Pursed-lip breathing

- Nasal flaring

- Chest pain, scale of 6/10

GOALS AND OBJECTIVE

Short Term Goal:

After 1 hour of Nursing Intervention, the patient will:

- Deep breathing exercises

- Use of relaxation techniques

- Verbalize understanding of technique in doing deep breathing exercise

- maintain adequate ventilation and oxygenation

- maintain a patent airway

Long Term Goal:

After 4-5 days of Nursing Care, the patient will be able to establish a normal/effective respiratory pattern.

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NURSING INTERVENTION

Independent:

Instruct the patient to do deep breathing exercises

R> to assist the patient in “taking control” of the situation/inspiration

Assist for discomfort and place patient in a high back position

R> This would limit/restrict respiratory effort.

Monitor pulse oximetry as indicated.

R> To verify maintenance of O2 saturation

Dependent:

Medicate with analgesics as appropriate to promote deeper respiration and cough.

R> Tramadol 50mg IVTT q8h is given

Collaborative:

Assist with Chest Thoracentesis Tube insertion as indicated

R> To drain fluid in the pleural space.

EVALUATION

Short Term Goal = Goals met

The patient was able to participate and perform deep breathing exercises and verbalizes understanding about the relaxation techniques when the patient has dyspnea.

Long Term Goals = Goals not met

The goal in not yet met since the patient still has pneumonia and needs for further evaluation.

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NURSING DIAGNOSIS

Acute Pain related to inflammatory process of the Pleural Effusion due to infectious

process from pneumonia.


Subjective Cue:

“Sakit akong dughan duol sa bangag didto sa nay tubo”, as verbalized by the patient.

Objective Cue:

- Chest pain, scale of 6/10

- Guarding behavior noted

- Positioning to avoid injury near CTT observed

- Reduced interaction to people observed

- Flaccid muscle tone of the left arm near CTT noted

- Localized pain identified by the patient

GOALS AND OBJECTIVE

Short Term Goal:

After 8 hours of Nursing Intervention, the patient will:

- Report relief of pain or controlled

- report reduced levels of concern to attached tubing

Long Term Goal:

After 3-4 days of Nursing Care, the patient will experience controlled pain regarding the draining of the pleural fluid.


Independent:

Assess the client’s description of pain

R> Pain is a subjective experience & cannot be felt by others but can be objective when assessed in scale of 0-10

Observe non verbal cues/pain behaviors

R> To determine the congruency of pain reactions to client’s verbalization of pain.

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Instructed to do relaxation techniques, such as focused breathing.

R> To distract attention & reduce tension from pain.

Monitor the skin color/temperature & vital signs.

R> These are usually altered in severe pain.

Dependent:

Administer analgesics, as indicated to maximum dosage, as needed.

R> To maintain acceptable level of pain. Given with Tramadol every 8 hours 50mg via IVTT route.

EVALUATION


The patient reported relief or controlled pain from pain scale of 6/10 to 4/10 after given with the medication in given intervals. Also used relaxation techniques and followed treatment regimens.


The goal is not met as it has to be evaluated yet.

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NURSING DIAGNOSIS

Risk for Infection related to, damaged tissue integrity due to insertion of CTT.


Objective Cue:

- Has attached Chest Thoracostomy Tube on the left mid-axillary line noted

GOALS AND OBJECTIVE

Short Term Goal:

After 8 hours of Nursing Intervention, the patient will:

- Be free of purulent drainage

- Prevent or decrease the risk of infection

- Be placed with a new dressing to the wound

- Provide clean environment for the patient’s safety to infection

Long Term Goal:

After 2-3 days of Nursing Care, the will maintain an infection free environment from harmful pathogens.


Independent:

Note the risk factors of occurrence of infection like skin/tissue wounds

R> to assess causative or contributing factors of infection

Observe for localized signs of infection at insertion site of invasive lines, surgical incision or wound.

R> to determine the portal of entry causing infection

Change surgical wound dressing as indicated using proper technique for changing or disposing the contaminated materials.

R> to reduce the risk for infection

Dependent:

Discuss importance of not taking antibiotic or using left over drugs unless specifically instructed by the health care provider.

R> inappropriate use can lead to drug-resistant strains.

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EVALUATION


Providing a clean environment for the patient was given in order to prevent infection from the damaged tissue due to CTT draining of pleural fluid. The surgical dressing was not advised to be replaced since the chest was totally covered or no openings were noted for risk of infection.

Provision of clean clothes was given in order to prevent infection of the CTT site.


The goal is not met as it has to be evaluated yet.

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DRUG STUDY

DRUG ORDERMECHANISM OF

ACTIONINDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS

OF THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

Generic name:Cefuroxime

Brand name:Ceftin

Classification:Antibiotic

Dosage:750 mg

Route:IVTT

Frequency:q8h

A second – generation cephalosporin that binds to bacterial cell membranes and inhibits cell wall synthesis

Therapeutic Effect: Bactericidal

Treatment of susceptible infections due to group B streptococci, pneumococci, staphylococci, H. Influinzae, E.coli.

History of anaphylactic reaction to penicillins or hypersensitivity to cephalosporins.

Cautions: renal impairment, history of GI disease (especially ulcerative colitis, antibiotic – associated colitis), concurrent use of nephrotoxic medications.

Antibiotic – associated colitis and other supr infections may result from altered bacterial balance.

Question for history of allergies, particularly cephalosporins, penicillins. Assess oral cavity for white patches on mucous membranes, tongue, monitor bowel activity and stool consistency carefully; mild GI effects ,may be tolerable, but increasing severity may indicate onset of antibiotic associated colitis. Monitor I&O, renal function reports for nephrotoxicity. Be alert for superinfection: severe genital/anal pruritus, severe mouth soreness, moderate to severe diarrhea.

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OF THE DRUG


PRECAUTIONS

Generic name:Tramadol hydrochloride

Brand name:Ultram

Classification:Analgesic

Dosage:50mg

Route:IVTT

Frequency:q8h

An analgesic that binds to mu-opioid receptors and inhibits reuptake of norepinephrine and serotonin reduces the intensity of pain stimuli reaching sensory nerve endings.

Therapeutic Effect:Alters the perception of and emotional response to pain.

Management of moderate to moderately severe pain.

Acute alcohol intoxication, concurrent use of centrally acting analgesics, hypnotics, opioids, or psychotropic drugs, hypersensitivity to opioids.

Seizures have been reported in patients receiving tramadol within the recommended dosage range. Overdose results in respiratory depression and seizures. Tramadol may not have prolonged duration of action and cumulative effect in patients with hepatic or renal impairment.

Check the prescribed medication for 3 time on the first encounter, before and after withdrawing the medR> so that the medicine is properly checked according to the doctor’s prescription.

Give first health teaching before giving the patient.R> to make the patient prepare and know what to expect

The med should be given in IVTT route according to the doctorR> Follow the doctor’s order as prescribed to the patient.

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OF THE DRUG


PRECAUTIONS

Generic name:Paracetamol

Brand name:-

Classification: Analgesics and Antipyretics

Dosage:300mg

Route:IVTT

Frequency:PRN

Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces antipyresis by inhibiting the hypothalamic heat – regulating center. Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.

For treatment of mild to moderate pain and fever.

No known contraindications.

Nausea, allergic reaction, skin rashes, acute renal tubular necrosis.

Potentially Fatal: Very rare, blood dyscrasias (e.g., thrombocytopenia, leukopenia, neutropenia, agranulocytosis); liver damage.

The medication should be given in IVTT.R> this is according to the doctor’s order.

Assess patient for any drug allergy to the medicine.R> to determine if the patient is allergic to drug

Intruct the patient/ give first health teaching before giving the patient.R> to make the patient prepare and know what to expect

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HEALTH TEACHING

The patient with Pleural Effusion needs to be given attention especially if the

patient has experienced pain in the site if CTT, had dyspnea, chest pain, nonproductive

cough.

The following are some Nursing Management on Pleural Effusion:

Management:

1. Assess for associated problems.

2. Administer medications which may be prescribed for associated problems such

like Tramadol 50mg IVTT for management of pain.

3. Implement a plan of care that is teaching the client to do deep breathing exercise

since the client has shortness of breath.

4. Encourage the patient and the significant others to do counseling.

5. Explain to the significant others the limitation of the patient’s mobility due to

attached chest thoracostomy tube.

6. Explain tests and procedures to the patient, including thoracentesis, and answer

questions he has.

7. Before thoracentesis, tell the patient to expect a stinging sensation from the local

anesthetic and a feeling of pressure when the needle is inserted. Instruct him to tell you

immediately if he feels uncomfortable or has trouble breathing during the procedure.

8. If the patient developed pleural effusion because of pneumonia or influenza, tell him to

seek medical attention promptly whenever he gets a chest cold.

9. Teach the patient the signs and symptoms of respiratory distress. If any of these

develop, tell him to notify his physician.

10. Fully explain the drug regimen, including adverse effects. Emphasize the importance of

completing the prescribed drug regimen.

11. If the patient smokes, urge him to stop.

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LEARNING EXPERIENCE

As part of the learning process, there are things that you need to discover

yourself and need to explore in order to fulfill the things that you are curious about. And

I have learned something from this. Although there are hard times and mistakes that we

may encounter, there is only one thing that you can appreciate more which is the

experience. I have learned that through this individual case study, I was able cope

myself in doing the requirement alone without the assistance of anybody, which makes

me feel joyous since this is a tough thing to make a case study. I have learned from this

case the hardship and the joy of fulfilling the requirement and it is a one way step of

developing my skills in doing the case study.

I realized that one should work hard amidst of your limits and accomplish

the things that you are ought to do. Not by just passing a requirement but also learning

from it as part of you dream to become an effective nurse in the future. One must have

focus and not to left the things unappreciated for nurses deals with the lives of many

individuals and thus must be accountable for the patient’s life in alleviating the pain,

restoring the health, etc as possible it may be.

Lastly, as a student nurse, I have learned and kept in mind the most

important thing to do for our patient and that is not to get mistakes in rendering care for

our patient for one slip could end up the life of your patient and that could be your

hardest thing that could happen for you and the patient’s family of losing one’s life in just

a minor mistake. So I guess that I should practice myself to seek for perfection in giving

care to patients and diminish the faulty errors in the clinical area when you are on duty.

At a short period stay at NMMC Medical Ward, I am a student nurses on

action. It is where I put all of what I am in extreme preparation. You should not waste

time doing senseless distractions, rather gain from your opportunities, reading, handling

cases and interactions are just a few that we have mastered. Although change does not

happen overnight, it is a good feeling to know that you have controlled yourself and

leading it to make a difference. As our duty progresses, we have established a great

bond among our group mates. We learn together, we work together and care for each

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other and that is the beauty in our group. We never fail to be concerned towards each

other as it is just more than a group but a family.

DISCHARGE PLAN

M-MEDICATION

Explain the purpose, dosage, schedule, and route of administration of any prescribed

drugs, as well as side effects to report to the physician or nurse.

Instruct the watcher to refer any abnormalities about the pt. to the nurse or physician to

prevent complications. (The patient is not yet discharged and there were no PO meds

given in the hospital except for IVTT meds).

Outpatient medication therapy is directed at the underlying etiology of the effusion.

A social services professional should be consulted when a patient cannot afford

prescribed medications.

E-EXERCISE

The patient is advised to take rest after discharge in order to prevent injury and to

regain strength. The site of effusion needs proper attention and careful not to be

strained. The patient is not advised to do hard and stressful work yet he can still take

walking exercise that he is capable of doing.

T-TREATMENT

Patient is advised to consult his physician if he cannot afford the treatment. It is best

that the health care provider is aware so that he can make adjustments. Instruct

significant others to monitor patients condition.

H-HEALTH TEACHINGS

Teach the significant others on the simple pathology and physiology of the disease to

help them understand and to clarify misconceptions of the disease. Discuss the possible

causes of the disease, prognosis, and describe the disorder. Demonstrate to significant

others the proper wound care, administration of medicines and how to care for the

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patient. Explain the effects of the treatment of the patient and what to do when side

effects occur. Aware the patient and significant others the importance of knowing the

Do’s and Don’ts while the effusion is still present. Determine the patient’s expectations

to alleviate fear and anxiety.

OUT-PATIENT CHECK-UP

Follow-up with the patient's primary care physician or a pulmonary specialist within 2-3

days is advisable, especially if thoracentesis is deferred.

If early follow-up seems unlikely, the patient should be given clear instructions to return

to the ED in 2-3 days for reevaluation.

Patient is instructed to have a regular check up in the hospital if there are any signs of

complications of risks and if there is also improvement or progress regarding his case.

DIET

Instruct patient’s family, significant other to follow recommended diet provided by her

dietician if any.

SPIRITUAL

Patient’s family is very religious that is why we always continue to encourage him to

remain that faithful and strong to God. Continue praying and reading the bible and never

forget that during times of difficulties, God carries our burden. It is about putting our trust

in him and never giving up.

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DOCTOR’S ORDER

January 7, 2010 Thursday11pm

Please admit pt at P1F2 (male charity ward) Secure consent to care DAT Venolysis with PNSS 1L @ 30gtts/min IVFTT PNSS 1L @ 30gtts/min Nursing

1. VS q4h & recordRefer if BP ≥ 130/90 < 90/60mmHg

HR > 100 < 60 beats/minRR > 24 < 12 beats/min

2. I&O q shift3. Refer for signs of respiratory distress

Chest pain, SOB and cyanosis

CXR: Consider, Pneumonia

PA w/ Pleural eff. Diagnostics

1. CBC with pH ct2. URA3. CXR – PA view (attached)

Therapeutics1. Cefuroxime 750mg IVTT q8h ANST2. Paracetamol 300mg IVTT q4h for fever 38.50C

o For thoracenthesis w/ local anesthesiao Refer for unsualities

January 14, 2010 Thursday11:40 am> anemia > CTT drainage monitoring of output > asthmatic > continue meds> SOB > repeat CBC with pH today

> refer> IVF with PNSS 1L @ 30gtts/min x 3

January 15, 2010 Friday11:45am> - SOB > for Sputum AFB 3x> C/L: ECE, CBR > encourage breathing exercise> DTB – murmur > continue present meds> good posture > may D/C O2 inhalation, standby PRN

> IVF w/ PNSS 1L @ 30gtts/min x3 cycle

L

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> continue CTT bottle draining monitoring

January 16, 2010 Saturday10:00am> - SOB > for Sputum AFB> - chest pain > continue present meds> C/L: ECE, CBR > continue CTT bottle drainage monitoring> DTB, - murmur > refer> good posture, > IVF w/ PNSS 1L @ 30gtts/min x3 cycle - edema

CTT drainagereading

REFERENCE:

www.wisegeek.com

www.wikipedia.com

www.emedicine.medscape.com

Black & Hawks. Medical – Surgical Nursing Clinical Management for Positive

Outcomes. Saunders Elsevier 8th edition.

Pleural Effusion-Individual CP

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