Case Study Pleural Effusion

CAPITOL UNIVERSITYCollege of Nursing

Cagayan de Oro City

A Case Study On

Pleural EffusionIn Partial Fulfillment

Of the course RLE 7

Submitted to:

Clinical InstructorMrs. Maria Rica Adane, RN

Submitted by:

Caralde, Maricar

Cardoza, Roxanne

Carlos, Mary Rose

Carpo, Jennifer

Carreon, Rizza Mae

Castillejos, Maryjes

Castillo, Bryan

Cervantes, Bryle Gil

Chavez, Eren Son

Chavez, Kirk Don

Cimacio, Hannah Lee

Cirera, Marlon

RLE 7 Group 7

THFS 3:00 pm – 11:00 pm

TABLE OF CONTENTS

I. Introduction

II. Client’s Profile

III. Anatomy and Physiology

IV. Pathophysiology

V. Diagnostic Procedures and Lab Results

VI. Drug Study

VII. Nursing Care Plans

VIII. Discharge Plan

IX. Learning Insights

X. Reference

I. INTRODUCTION

Our group chose this case as interesting to us because it is a common disease

entity that is usually underestimated as a cause of mortality and morbidity to patients.

We would like to make an outlook of what this case is and gather information that can

help us learn how it occurs, manifest, develop and cause a disease.

It is our goal to identify the risk factors that affects people making them at risk for

the disease. How is the disease being treated. And by learning from the inputs we gather

from out patient.

We discuss pleural effusion as its definition as the collection of at least 10-20 mL

of fluid in the pleural space. Pleural effusion develops because of excessive filtration or

defective absorption of accumulated fluid. Pleural effusion may be a primary

manifestation or a secondary complication of many disorders. Pleural effusions are

usually classified as transudates and exudates. Diseases that affect the filtration of

pleural fluid result in transudate formation, such as in congestive heart failure and

nephritis. Transudates usually occur bilaterally because of the systemic nature of the

causative disorders. Inflammation or injury increases pleural membrane permeability to

proteins and various types of cells and leads to the formation of exudative effusion

Infectious effusions are usually unilateral. However, a recent large Turkish study

revealed bilateral effusion in 5% of 515 children.

Its frequency occurs, as in the US: American and international frequencies

are similar. The prevalence of pleural infections appears to be increasing in some

developed countries; this could be partly due to increased referral of patients with

these conditions to tertiary-care pediatric hospitals.

Nonbacterial infectious agents, such as viruses and Mycoplasma pneumoniae,

cause more pleural effusion in children than do bacterial organisms. Although

bacteria are more likely than viruses to cause effusion, viral infections in children occur

more frequently than bacterial infections, explaining the observation above. As

many as 20% of the viral infections can cause small and transient effusions that

resolve spontaneously, affects internationally and more frequently on developed nations.

Several decades ago, pleural effusion was a complication of 70% of all cases of

Staphylococcus aureus pneumonia, with positive cultures resulting from 80% of pleural-

fluid specimens. In the late 1970s, pleural effusion occurred in 75% of cases of

pneumonia secondary to Haemophilus influenzae type b. In a report by Murphy et al,

empyema complicated the course of pneumonia in 9 of 21 patients with Streptococcus

pneumoniae pneumonia. Chartrand and McCracken indicated that empyema

complicated the course of pneumonia in 57 of 79 patients with S aureus infections.

Pleural effusion occurs in 6-12% of all cases of pulmonary tuberculosis (TB) in

children. Of 175 Spanish children with pulmonary TB, 39 (22.1%) had pleural effusion.

Congenital effusions, including chylothorax, occur in 1 per 10,000-15,000 live

births annually. In a review of 74 patients with intrathoracic lymphomas, Chaignaud et al

found pleural effusions in 10 (71%) of 14 children with lymphoblastic lymphoma and in 7

(12%) of 60 children with non-Hodgkin lymphoma.

The outcome of this condition affects the morbidity and mortality of patients. Most

effusions caused by viral and mycoplasmal infections resolve spontaneously.

Empyema has a complicated course if not treated early, especially in children

younger than 2 years. Thirty years ago, the mortality rate from empyema was 100%. At

present, the mortality rate from empyema is 6-12% in infants younger than 1 year.

Malignant effusion worsens the patient's prognosis depending on the underlying

tumor. With regards to its ratio. Pleural effusions may be more common in boys than in

girls.

II. CLIENT’s PROFILES

Patient Ω is 52 years-old female, Filipino, Roman Catholic from the

province of Jasaan, Misamis Oriental. She was admitted at Northern Mindanao

Medical Center last August 17, 2010 at 3:00 PM due to shortness of breath,

Tightness of the chest, dry cough and abdominal enlargement.

Patient’s vital signs are: Blood Pressure of 130/90 mmHG, temperature of

36.7 degree Celsius, respiratory rate of 29 cpm and a heart rate of 110 bpm. At

present she weighs 58 kls.

HISTORY OF PRESENT ILLNESS

One month prior to admission, patient Ω started having shortness of

breath. She endured that condition for a month.

One week Prior to admission, patient submitted self for a medical check

up by Dr. Alejo at a polyclinic due to body malaise and was diagnosed as having

U.T.I. She was then referred to an Internal Medicine specialist, Dr. Ampong for

further assessment. Dr. Ampong Diagnosed her as having Pleural Effusion,

Massive Ascites and some abnormalities in her ovary. She was again referred to

another specialist, an OB-GYNE, Dr. Mangganges. The OB-GYNE found some

abnormal growth in her ovary and suggested her to undergo a treatment. But The

OB-GYNE refused to start the treatment unless pleurais cleared from the edema.

So, She then was admitted at the Northern Mindanao Medical Center Payward,

Annex 3 floor 2 to undergo Chest Thoracostomy for Excessive Pleural Fluid

clearance.

PRE-HOSPITALIZATION

Health Perception-health management pattern:

Patient X is a 43 years-old male that is dependent to his own decision and

care. Patient X was not active to his daily routine. During onset of coughing the

patient verbalizes, “Gasige lng kog ubo-ubo sir”. Due to his illness, he cannot

perform his daily routine that he is usually doing when he is still not sick.

Nutritional metabolic pattern: (While confined)

Patient X said he takes 1500cc of water a day, and takes 3 meals in a day

with a combination of 1-2 cups rice with different viand. He has poor appetite that

sometimes he cannot consume his meal. “Wala koy gana mo kaun sir” as

verbalized by the patient. He was ordered to have a Low-salt and Low-Fat Diet.

He is also fond of drinking alcoholic beverages for 15 years and a smoker for 10

years. He can consumed 1 pack of cigarette per day.

Elimination pattern: (while confined)

Patient X has a normal elimination pattern. He defecates one time a day

with moderate amount, soft stool, and light-brown in color. There was no problem

on his urination; he can urinate 3-5 times per day.

.

Activity exercise pattern: (while confined)

Prior to confinement, the patient was be able to do the activities of daily

living by himself not until a day prior to confinement he always ask for assistance

in doing his activities of daily living because he’s anxious he might fall down.

Patient was advice to refrain from doing strenuous activity because of his

condition. “Galisud ko ug ginhawa kung mahago ko” as verbalized by the patient.

Sleep-rest pattern: (while confined)

Patient X has a normal sleeping pattern and would sleep at most 6-8 hrs

per day, he was easily get distracted and awaken by any environmental stimuli,

especially when taking his medications. Watching TV makes him fall asleep.

Cognitive-perceptual pattern:

Patient was calm, responsive, conscious, well oriented with time and place

and with normal behavior of communication.

Role-relationship pattern: (while confined)

Patient X is married, a good provider and was happy being with his family.

He’s been wishing that everybody is well, so that it would not add to his daily

financial needs.

Sexuality and Reproductive Pattern

Patient X said that he is not so much active in his sexual patterns.

Coping-Stress Tolerance Pattern

Having this condition makes him challenge, and think that everything will

be alright, though he remains to be calm but he is a bit worried.

Value-Belief Pattern

He is a Roman Catholic and don’t believe in superstitious beliefs. He said,

“God is our savior and he is our creator, he has a plan for me”.

PHYSICAL ASSESSMENT

ASSESSMENT DATAASSESSMENT FINDINGS

BEFORE (SEPT 23, 09)

SKIN

Color

Temperature

Turgor

Texture

Lesion

Integrity

Others

Fair

37.1 º C

Good skin turgor

Moist skin

(-) Lesions/Rash

Intact

NAILS

Color

Texture

Shape

Others

Pinkish

Smooth

Concave

Poor capillary refill = 3 sec

HAIR

Color

Texture

Distribution

Quantity

Others

Black

Coarsely dry

Evenly distributed

Moderate

HEAD

Shape

Size

Configuration

Headache

Round

Normocephalic

Symmetrical

None

ASSESSMENT DATA

EARS

Hearing

Tinnitus

Vertigo

Earaches

Infection

DischargesS

Others

Good

None

No vertigo

No earaches

No infection

No discharges

NOSE AND SINUSES

Frequent colds

Nasal stiffness

Nose bleed

Sinus trouble

None

None

None

Sinuses are non tender

MOUTH & THROAT

Condition of teeth

Bleeding gums

Tongue

Throat

Hoarseness

Mucous membrane

Incomplete teeth

No bleeding

Tongue is at midline,

Throat Non-tender

None

Pinkish

ASSESSMENT DATA ASSESSMENT FINDING

NECK

Symmetry

Condition of trachea Thyroid

Lymph nodes

Symmetrical

in the midline

(-) nonpalpable

(-) nonpalpable

LUNG

Symmetry

Shape

Respiratory movements

# of breath

Symmetrical

A:P diameter 1:2

Asymmetrical, use of accessory muscles

26cpm

AUSCULTATION:

Character of respiration (+) rales on upper lung lields

Decrease breath sounds on left lung field

HEART AND NECK VESSELS:

Apical Pulse

Cardiac Sounds

Apical/Radial pulse data

Blood pressure

Pulse pressure

Any special procedure

Done

107 bpm

(-) murmurs

Not assessed

ASSESSMENT DATA ASSESSMENT FINDING

ABDOMEN:

Symmetry

Contour

Skin Lesion

Masses

Bowel Sounds

Tenderness

Symmetrical

Globular

none

(-) Masses

Normoactive bowel sounds

none

MUSCULOSKELETAL SYSTEM:

Posture

ROM

Muscle Strength

abnormal postures aren’t present

active-passive

4/5

HEAD AND NECK:

Facial muscle symmetry

Swelling

Scars

Discoloration

Weakness

ROM

Posterior neck cervical spine

Muscle spasm

Crepitus

Symmetrical

None

None

None

(+) Weakness

can turn head from side to side

Non-tender

(-) Spasm

(-) Crepitus heard

MOTOR SYSTEM:

Muscle tone

Ability to move extremities against gravity

Spasticity, flaccidity or rigidity, tremors, lies

Without hypertrophy or atrophy

Muscle strength is 4/5

none

MENTAL STATUS:

LOC

Long term memory

Short Term Memory

Conscious

Not assessed

III. ANATOMY AND PHYSIOLOGY

Human Respiratory System

The respiratory system consists of all the organs involved in breathing.

These include the nose, pharynx, larynx, trachea, bronchi and lungs. The

respiratory system does two very important things: it brings oxygen into our

bodies, which we need for our cells to live and function properly; and it helps us

get rid of carbon dioxide, which is a waste product of cellular function. The nose,

pharynx, larynx, trachea and bronchi all work like a system of pipes through

which the air is funneled down into our lungs. There, in very small air sacs called

alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed

from the blood out into the air. When something goes wrong with part of the

respiratory system, such as an infection like pneumonia, it makes it harder for us

to get the oxygen we need and to get rid of the waste product carbon dioxide.

Common respiratory symptoms include breathlessness, cough, and chest pain.

Nose

A nose is a protuberance in vertebrates that houses the nostrils, or nares,

which admit and expel air for respiration in conjunction with the mouth. Behind

the nose are the olfactory mucosa and the sinuses. Behind the nasal cavity, air

next passes through the pharynx, shared with the digestive system, and then into

the rest of the respiratory system. In humans, the nose is located centrally on the

face; on most other mammals, it is on the upper tip of the snout.

In cetaceans, the nose has been reduced to the nostrils, which have migrated to

the top of the head, producing a more streamlined body shape and the ability to

breathe while mostly submerged. Conversely, the elephant's nose has

elaborated into a long, muscular, manipulative organ called the trunk.

Mouth

The mouth, buccal cavity, or oral cavity is the first portion of the alimentary

canal that receives food and begins digestion by mechanically breaking up the

solid food particles into smaller pieces and mixing them with saliva.[1] The oral

mucosa is the mucous membrane epithelium lining the inside of the mouth.In

addition to its primary role as the beginning of the digestive system, in humans

the mouth also plays a significant role in communication. While primary aspects

of the voice are produced in the throat, the tongue, lips, and jaw are also needed

to produce the range of sounds included in human language. Another non-

digestive function of the mouth is its role in secondary social and/or sexual

activity, such as kissing. The physical appearance of the mouth and lips play a

part in defining sexual attractiveness.

The mouth is normally moist, and is lined with a mucous membrane. The lips

mark the transition from mucous membrane to skin, which covers most of the

body.

Pharynx

The pharynx (plural: pharynges) is the part of the neck and throat situated

immediately posterior to (behind) the mouth and nasal cavity, and cranial, or

superior, to the esophagus, larynx, and trachea. The pharynx is part of the

digestive system and respiratory system of many organisms.Because both food

and air pass through the pharynx, a flap of connective tissue called the epiglottis

closes over the trachea when food is swallowed to prevent choking or aspiration.

In humans the pharynx is important in vocalization.

Epiglottis

The epiglottis is a flap of elastic cartilage tissue covered with a mucus

membrane, attached to the root of the tongue. It projects obliquely upwards

behind the tongue and the hyoid bone. The term is, like tonsils, often incorrectly

used to refer to the uvula. The epiglottis guards the entrance of the glottis, the

opening between the vocal folds. It is normally pointed upward during breathing

with its underside functioning as part of the pharynx, but during swallowing,

elevation of the hyoid bone draws the larynx upward; as a result, the epiglottis

folds down to a more horizontal position, with its upper side functioning as part of

the pharynx. In this manner it prevents food from going into the trachea and

instead directs it to the esophagus, which is more posterior.

The epiglottis is one of nine cartilaginous structures that make up the larynx

(voice box). While breathing, it lies completely within the pharynx. When

swallowing it serves as part of the anterior of the larynx.

Larynx

The larynx (plural larynges), colloquially known as the voicebox, is an

organ in the neck of mammals involved in protection of the trachea and sound

production. The larynx houses the vocal folds, and is situated just below where

the tract of the pharynx splits into the trachea and the esophagus. Sound is

generated in the larynx, and that is where pitch and volume are manipulated. The

strength of expiration from the lungs also contributes to loudness.

Fine manipulation of the larynx is used to generate a source sound with a

particular fundamental frequency, or pitch. This source sound is altered as it

travels through the vocal tract, configured differently based on the position of the

tongue, lips, mouth, and pharynx. The process of altering a source sound as it

passes through the filter of the vocal tract creates the many different vowel and

consonant sounds of the world's languages as well as tone, certain realizations

of stress and other types of linguistic prosody. The larynx also has a similar

function as the lungs in creating pressure differences required for sound

production; a constricted larynx can be raised or lowered affecting the volume of

the oral cavity as necessary in glottalic consonants.

Trachea

The trachea, or windpipe, is a tube that connects to the pharynx or larynx,

allowing the passage of air to the lungs. It is lined with pseudostratified ciliated

columnar epithelium cells with mucosal goblet cells which produce mucus. This

mucus lines the cells of the trachea to trap inhaled foreign particles which the

cilia then waft upwards towards their larynx and then the pharynx where it can

either be swallowed into the stomach or expelled as phlegm.

Bronchi

The trachea (windpipe) divides into two main bronchi (also mainstem

bronchi), the left and the right, at the level of the sternal angle at the anatomical

point known as the carina. The right main bronchus is wider, shorter, and more

vertical than the left main bronchus. The right main bronchus subdivides into

three lobar bronchi while the left main bronchus divides into two. The lobar

bronchi divide into tertiary bronchi, also known as segmental bronchi, each of

which supplies a bronchopulmonary segment. A bronchopulmonary segment is a

division of a lung that is separated from the rest of the lung by a connective

tissue septum. This property allows a bronchopulmonary segment to be

surgically removed without affecting other segments. There are ten segments per

lung, but due to anatomic development, several segmental bronchi in the left lung

fuse, giving rise to eight. The segmental bronchi divide into many primary

bronchioles which divide into terminal bronchioles, each of which then gives rise

to several respiratory bronchioles, which go on to divide into 2 to 11 alveolar

ducts. There are 5 or 6 alveolar sacs associated with each alveolar duct. The

alveolus is the basic anatomical unit of gas exchange in the lung.

Alveoli

An alveolus (plural: alveoli, from Latin alveolus, "little cavity") is an

anatomical structure that has the form of a hollow cavity. Found in the lung, the

pulmonary alveoli are spherical outcroppings of the respiratory bronchioles and

are the primary sites of gas exchange with the blood. Alveoli are particular to

mammalian lungs. Different structures are involved in gas exchange in other

vertebrates.

Each human lung contains about 150 million alveoli. Each alveolus is wrapped in

a fine mesh of capillaries covering about 70% of its area. An adult alveolus has

an average diameter of 0.2–0.3 mm, with an increase in diameter during

inhalation.

IV. PATHOPHYSIOLOGY

V. DIAGNOSTIC PROCEDURE AND LABORATORY RESULT

Predisposing FactorAge, gender

Inflammation of airways wheezing

Bronchial edema Increased mucussecretion

Broncoconstrict-ion

Bronchial spasm

Worsening of obstruction

Dsypnea, cold and clammy skin, diaphoresis

Accumulation of fluids caused by over secretion

Multiplication of growth of organism

Inflammation in the epithelial wall

Fluid filled alveoli/lobar copartment

Rupture of inflamed endothelial cellsExcess fluid accumulated in spacepericardial

Shallow breathing, RR increase Mismatch of ventilation and perfusion

dyspneaMismatch of ventilation and perfusion

hypoxemia

hypoxia

Pleural effusion

Precipitating Factors:Lifestyle, environmental

CBC

The CBC is used as a broad screening test to check for such disorders as

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

examines different parts of the blood.

September 24, 2009

Test Result Unit ReferencesWBC 18.0 1O^3/uL 5.0-10.0RBC 3.47 10^6/uL 4.2-5.4

HEMOGLOBIN 7.7 g/dL 12.0-16.0HEMATOCRIT 25.6 % 37.0-47.0

MCV 73.8 fL 82.0-98.0MCH 22.2 Pg 27.0-31.0

MCH-C 30.1 g/dL 31.5-35.0RDW-CV 17.1 % 12.0-17.0

IMPRESSION:Increased White Blood Cells may be with infections and inflammation. Red

Blood Cell decreased with anemia also with Hemoglobin and Hematocrit

because this mirrors RBC results. Mean Corpuscular Volume decreased with iron

deficiency and thalassemia. MCH mirrors MCV results. MCHC may be

decreased when MCV is decreased. Increased RDW indicates mixed population

of RBCs; immature RBCs tend to be larger.

Differential CountThe white blood cell differential count determines the number of each type

of white blood cell, present in the blood.

Monocyte 11.4 % 4.5-10.5Eosinophils 0.9 % 1.0-3.0

Platelet 987 10^3/uL 1500-4000

IMPRESSION:Monocyte levels can increase in response to infection of all kinds as well

as to inflammatory disorders. Monocyte counts are also increased in certain

malignant disorders, including leukemia. Decreased levels of eosinophils can

occur as a result of infection. Platelet decreased when greater numbers used, as

with bleeding; decreased with some inherited disorders.

September 25, 2009

Test Result Unit ReferencesWBC 21.5 1O^3/uL 5.0-10.0RBC 3.65 10^6/uL 4.2-5.4

HEMOGLOBIN 8.1 g/dL 12.0-16.0HEMATOCRIT 27.1 % 37.0-47.0

MCV 74.2 fL 82.0-98.0MCH 22.2 Pg 27.0-31.0

MCH-C 29.2 g/dL 31.5-35.0RDW-CV 17.2 % 12.0-17.0

PDW 9.0 fL 9.0-16.0MPV 8.7 fL 8.0-12.0

IMPRESSION:Based on the table above it was interpreted that the significant elevation of

WBC means that an infection occurred inside the body. RBC is below normal,

which could reflect the body's inability to produce enough red cells to replenish

what, has been lost out of the blood stream. Decreased hemoglobin and

hematocrit mirrors RBC results. MCH mirrors MCV results. MCHC may be

decreased when MCV is decreased. Increased RDW indicates mixed population

of RBCs; immature RBCs tend to be larger.

Differential CountThe white blood cell differential count determines the number of each type

of white blood cell, present in the blood.

Lymphocyte 32.3 % 17.4-48.2Neutrophil 53.5 % 43.4-76.2Monocyte 13.0 % 4.5-10.5

Eosinophils 1.0 % 1.0-3.0Basophils 0.2 % 0.0-2.0Platelet 1085 10^3/uL 1500-4000

IMPRESSION:Monocyte levels can increase in response to infection of all kinds as well

as to inflammatory disorders. Monocyte counts are also increased in certain

malignant disorders, including leukemia. On the other hand, platelet decreased

when greater numbers used, as with bleeding; decreased with some inherited

disorders.

DRUG ORDER

(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONSCONTRAINDICATIONS ADVERSE EFFECTS OF

THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

Generic Name: Furosemide

Brand Name: Apo-Furosemide, Furosemide special, Lasix

Classification: Loop diuretic

Dosage: 1 mg/kg

Route:IVTT

Frequency:2 hr

Inhibits the reabsorption of sodium and chloride from the ascneding limb of the loop of Henle, leading to a sodium-rich diresis

Acute Pulmonary edema

Contraindicated with allergy to furosemide, sulfonamides; allergy to tartrazine (in oral solution0; anuria,severe renal failure; hepatic coma; pregnancy; lactation

Use cautiously with Sle, gout, diabetes mellitus.

CNS: Dizziness, weakness,headache, drowsiness,fatigueCV: Orthostatic hypotension, thrombophlebitis

Dermatologic: Photosensitivity, rash,pruritus,purpura

GI: Nausea, anorexia,vomiting, oral and gastric irritation, constipation,

GU: Polyuria, nocturia, glycosuria, urinary bladder spasm

Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and electrolyte imbalances, hyperglycemia

Other: Muscle cramps and muscle spasms

Adminiser with food or milk to prevent GI upset

Reduce dosage if given with other antihypertensives; readjust dosae gradually as BP responds

Give early in the day so that increased urination will not disturb sleep

Avoid IV use of oral use is at all possible

Arrange for potassium-rich diet or supplemental potassium as needed.

DRUG ORDER

(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONSCONTRAINDICATIONS ADVERSE EFFECTS OF

THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

Generic Name:Amikacin sulfate

Brand Name:Amikin

Classification:Anti-infective

Dosage:95 mg

Route:IVTT

Frequency:q 12 hr

Bactericidal: inhibits protein synthesis in susciptible strains of gram-negative bacteria, and the functional integrity of bacterial cell membrane appears to be disrupted, causing cell death.

Severe systemic infection caused by sensitive straints

Contraindicated with allergy to any aminoglycosides, renal or hepatic disease, preexisting hearing loss, myasthenia gravis

Use cautiously with elderly patients, any apatient with deminished hearing, decreased renal function, dehydration

CNS: Confusion, disorientation, depression,

CV: Palpitations,hypotension, hypertension

GI: Nausea, vomiting, anorexia

GU: nephrotoxicity

Hematologic: Granulocytosis, leukopenia,

Hepatic: Hepatic toxicity; hepatomegaly

Hypersensitivity: Purpura, rash, exfoliative dermatitisOther: Superinfections, pain and irritation at IM injection sites

Arrange forculture and sensitivity testing of infected area before treatment.

Give IM dosage by deep injection

Ensure that patient is well hydrated before and during therapy

Report pain at injection site, severe headache, dizziness, loss of hearing, changes in urine pattern, difficulty breathing, rash or skin lesions.

DRUG ORDER

(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONSCONTRAINDICATIONS ADVERSE EFFECTS OF

THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

Generic Name:Oxacillin sodium

Brand Name:Antibiotic; Penicillinase-resistant penicillin

Dosage:600 mg

Route:IVTT

Frequency:q 6 hr

Bactericidal:Inhibits cell wall synthesis of sensitive organisms, causing cell death.

Infections due to penicillinase-producing staphylococci; may be used to initiate treatment when a staphylococci infection is suspected.

containdicated with allergies to penicillins, cephalosporins, or other allergens

Use cautiously with renal disordes, pregnancy, lactation (may cause diarrhea or candidiasis in infants).

CNS: Lethargy, hallucinations, seizures

GI: stomatitis, glossitis, gastritis,nausea, vomiting, diarrhea, abdominal pain

GU: Nephritis-oliguria, proteinuria, hematuria, pyuria

Hematologic: Anemia, thrombocytopenia, leukopenia, prolonged bleeding time

Hypersensitivity: Rash, fever, wheezing, anaphylaxis

Local: Pain, phlebitis, thrombosis at injection site

Other: Superinfections, sodium overload leading to CHF

Culture infection before treatment; reculture if response is not as expected

Reconstitite for IM use to a dilution of 250 mg/1.5 mL using sterile water for injection or sodium chloride injection. Discard after 3 days at room temperature or after 7 days if refrigerated.

TP:

You may experiencethese side effects: Upset stomach, nausea, diarrhea, (eat frequent small meals), mouth ssores (perform mouth care), pain at the injection site

DRUG ORDER

(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONSCONTRAINDICATIONS ADVERSE EFFECTS OF

THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

Generic Name:Cefuroxime

Brand Name:Cefuroxime sodium (Zinacef)

Classification:Antibiotic

Dosage:385 mg

Route:IVTT

Frequency:q.8 hr

Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death

Lower respiratory infections

contraindicated with allergy to cephalosporins or penicillins

Use cautiously with enal failure, lactation, pregnancy

CNS: Headache, dizziness, lethargy

GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, liver toxicity

GU: Nephrotoxicity

Hematologic: Bone marrow deppression ( decreased WBC, decreased platelets, decreased Hct).

Hypersensitivity: Ranging from rash to fever to anaphylaxis, serum sickness reaction

Local: Pain, abscess at injection site, phlebitis, inflammation at IV site

NR:

Culture infection, nd arrange for sensitivity tests before and during therapy if expected, response is not seen

Give oral drug with food to decrease GI upset and enhance absorption

Give oral drug to children who can swallow tablets: crushing the drug results in a bitter, unpleasant taste

ASSESSMENT DATA(Subjective & Objective Cues) NURSING DIAGNOSIS

(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective: “Ga sige rako ug ubo-ubo sir” as verbalized by the patient.

Objective: - cough- restlessness- yellowish sputum- tachycardia (PR=107

bpm)- pale- RR=26 cpm

Ineffective airway clearance related to retained secretions.

After 8 hours of care patient will be able to:

a. maintain airway patency

b. expectorate/clear secretions readily

Independent:- Elevate head of the bed/change position every 2 hours.R. To take advantage of gravity decreasing pressure on the diaphragm.

- Encouraged deep-breathing and coughing exercises.R. To mobilize secretions.

- Auscultate breath sounds and assess air movement.R. To ascertain status and note progress.

- Evaluate changes in sleep pattern.R. To assess changes.

After 8 hours of care goals partially met. Patient was able to:

a. Maintain airway patency.

b. Expectorate clear secretions readily as evidenced by less secretions retained.

ASSESSMENT DATA(Subjective & Objective Cues)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective:“Galisud ko ug ginhawa kung mahago ko” as verbalized by the patient.

Objective:- RR=26- Dyspnea- Restlessness- Tachycardia (PR=107

bpm)- Pale

Impaired gas exchange related to alveolar-capillary membrane changes.

After 8 hours of care patient will be able to:

a. Participate in treatment regimen

b. Demonstrate improve ventilation.

Independent:- Monitor vital signs and cardiac rhythm.R. To evaluate degree of compromise.

- Elevate head of bed/position client appropriately.R. To maintain airway.

- Maintain adequate I/O.R. For mobilization of secretions.

- Encourage frequent position changes and deep-breathing coughing exercises.R. To correct/improve existing deficiencies.

Dependent:- Administer medications as indicated.R. To treat underlying conditions.

After 8 hours of duty goals met. Patient was able to:

a. Participate in treatment regimen. b. Demonstrate improve ventilation.

ASSESSMENT DATA(Subjective & Objective Cues) NURSING DIAGNOSIS

(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective:“Galisod ko ug ginhawa” as verbalized by the patient.

Objective:

- RR=26 cpm- Irritability- Restlessness

Ineffective tissue perfusion (cardiopulmonary) related to impaired transportation of the oxygen across the alveolar and/or capillary membrane.

After 8 hours of care patient will be able to:

a. Demonstrate behaviors/lifestyle changes to improve circulation.

b. Demonstrate increased perfusion as individually appropriate.

Independent:

-Identify changes related to systemic or peripheral alterations in circulation.R. To assess contributing factors

-Determine duration of problem.R. To note degree of impairment

-Monitor vital signsR. To maximize tissue perfusion

-Investigate report of chest painR. To note degree of impairment

Dependent:-Administer medication as orderedR. To maximize tissue perfusion

After 8 hours of care goals met. Patient was able to:

a. Demonstrate behaviors/lifestyle changes to improve circulation b. Demonstrate increased perfusion as individually appropriate.

ASSESSMENT DATA(Subjective & Objective Cues) NURSING DIAGNOSIS

(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective:“Wala ko’y gana mo kaon sir” as verbalized by the mother.

Objective:

- Poor muscle tone- Pale- Weakness

Imbalanced nutrition, less than body requirement related to illness.

After 8 hours of care patient will be able to demonstrate progressive good appetite.

Independent:-Identify underlying condition involved.R. To assess causative factors.

-Identify clients at risk for malnutrition.R. to assess contributing factors.

- Discuss eating habits, including food preferences, intolerance.R. To appeal to clients like and dislike.

-Assess weight, age, body build, and strength of the client.R. To evaluate degree of deficit.

Dependent:-Administer pharmaceutical agents as indicated.R. To evaluate degree deficit.

After 8 hours of care goals met. Patient was able to demonstrate progressive good appetite.

VIII. DISCHARGE PLAN

M- Medication Medication includes Amikacin, Cefuroxime, Oxacilin, Furosemide. These medicines are taken depending on severity and kind of pleural effusion.

E- E xercise Teaching breathing retaining exercise to increase diaphragmatic excursion and reduce work of breathing. Teach relaxation techniques to reduce anxiety with dyspnea. Augment the patient’s ability to cough effectively by splinting the patient’s chest manually.

T- Treatment Follow strict compliance to treatment regimen given to improve condition especially medications, diet and lifestyle.

H- Health Teachings Keep a list of your medicines: Keep a written list of the medicines you take, the amounts and when and why you take them. Bring the list of your medicines or the pill bottles when you see your caregivers. Do not take any medicines, over the counter drugs, vitamins, herbs or food supplements without first talking to caregivers. To decrease your pain; when coughing, hold a pillow over your chest where the pain is. Quit smoking. Do not smoke and do not allow others to smoke around you. Smoking increases your risk of lung infections such as pneumonia. Smoking also makes it harder for you to get better after having a lung problem. Talk to your caregiver if you need help quitting smoking. Drink enough liquids and get plenty of rest. Be sure to drink enough liquids every day. Most people should drink at least 8(oz.) Cups of water a day. This help to keep your air passages moist and better able to get rid of germs and other irritants. You may feel like resting more. Slowly start to do more each day. Rest when you feel it is needed. Exercise your lungs. The discomfort of pleural effusion may cause you to avoid breathing as deeply as you should. Coughing and deep breathing can help prevent a new or worsening lung infection. Take a deep breath and hold the breath as long as you can then push the air out of your lungs with a deep, strong cough. Take 10 deep breaths in a row every hour that you are awake. Remember to follow each deep breathe with a cough.

O- Out patient Compliance to home medication regimen.

D- Diet Ensure adequate protein intake such as milk, eggs, oral nutritional supplements, chicken, and fish if other treatments not tolerated. Advice patient to eat small amounts of high-calorie and protein foods frequently rather than three daily large meals.

IX. LEARNING EXPERIENCE

Caring is our major responsibility. That’s why we have to treat everyone as such,

despite the consequences we might to commit, that wouldn’t matter. We learned to always

have a presence of mind while on duty.

For all those times, time management best thump us a lot. We learned to adjust and

manage time exactly as possible because when you say you are going to do something,

you have do it right away! You don’t have to wait for the time to come when it’s too late for

you to do such actions. It would be your lose and at the end you’ll realized that you acquire

worse. Another thing is to establish a therapeutic and a trusting relationship to each patient

because that’s one of the ways a person can feel free to open lines communication. And

the best experience we had is to be in one piece, helping each other and persevering.

Regarding this case we chose, we found it out to be enjoyable. We thought we don’t

have enough time focusing on this one especially that we still have other subjects to be

tackled. Surfing the net and printing is money consuming but we still feel happy because

doing these things helps us improved our learning about the disease and makes us think of

possible task that can also be helpful to the patients

At the end, we’re still thankful because God never put us down. All these things

wouldn’t be possible if nobody helps us find ways to finish this requirement. There goes the

time we learned to value our selves, we learned how to be “flexible”, and we learn how to

adjust things somehow. It’s never easy but we have to be with our selves to make things

possible.

X. REFERENCES

BOOKS:

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurse’s pocket Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.). Philadelphia, Pennsylvania

Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN,(2004). Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia

Karch, Amy M. ; 2006 Lippicott’s Nursing Drug Guide, 8th edition. Lippincott Williams & Wilkins.

Nurses’ Pocket Guide, 10th edition F.A. Davis.

Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr.Patient’s Chart

Black, Joyce M. et. al, Medical-Surgican Nursing: Clinical Management for Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005

Malseed, Roger T. ; Springhouse Nurses’ Drug Guide 2004, 5th edition.

Davis drug handbook, 10th edition

Drug handbook by Saunders

INTERNET:

http://cpmcnet.columbia.edu/dept/gi/.html

http://digestive.niddk.nih.gov/ddiseases/pubs/_ez/

http://www.angelfire.com/scifi2/lnuphysiology/Blood_Physiology_1.pdf

http://www.drstandley.com/labvalues

http://www.google.com.ph/search

http://www.google.com.ph/search?anatomy&meta=

http://www.merck.com/ l

ACKNOWLEDGEMENT

In behalf of our group, we would like to thank each member

for their unending support and cooperation and for being patient in

making this case study possible.

For the sleepless nights that we have been together, that despite of each our

own differences we were able to stand united through thick and thin..

To our PCI who guides us as we go along in our duties,

Thank you Mrs Helen Yorong.

To our diligent and responsible CI,

who provides us with ample knowledge and skills to make us efficient student

nurses,

and for helping us develop the right attitude while in this rotation.

Thank You so much, Mrs. Maria Rica Adane, RN.