Pleural Effusion Presented By: Aguado, John Prose Almarra, Edrianne Paul Antonino, Jelaine Bacena, Dianne Jamaica Marpa, Ian Rafael Marquez, Charmaine Ong, Julie Ann Taguba, Neilson John Villanueva, Irish Saligumba, Emyl Cyril Soliven, Kathlene Chelo Zacarias, Andrea III-CN Presented To: Dr. Concordia Eva Garcia RMT, RN, MD ~A Case Presentation~ As a partial requirement for Medical-Surgical Nursing I
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Pleural Effusion
Presented By:Aguado, John Prose
Almarra, Edrianne Paul Antonino, Jelaine
Bacena, Dianne JamaicaMarpa, Ian Rafael
Marquez, CharmaineOng, Julie Ann
Taguba, Neilson JohnVillanueva, Irish
Saligumba, Emyl CyrilSoliven, Kathlene Chelo
Zacarias, AndreaIII-CN
Presented To:Dr. Concordia Eva Garcia RMT, RN, MD
~A Case Presentation~As a partial requirement for Medical-Surgical Nursing I
• 1st time to encounter
• Secondary illness
• Secondary to Tuberculosis
Why Pleural Effusion?
What is Pleural Effusion?
• It is the abnormal accumulation of fluid in the pleural space resulting from excess fluid production or decreased absorption .
• Normally, the pleural space approximately contains 1mL of fluid
Classifications of Pleural Effusion:
1. Transudative Effusion
2. Exudative Effusion
• Clear, pale yellow, watery substance
• Influenced by systemic factors that alter the formation or absorption of fluid
• Contains few protein cells
• Common causes: CHF and liver or kidney disease
Transudative effusions
• Pale yellow and cloudy substance• Influenced by local factors where fluid absorption is
altered (inflammation, infection, cancer) • Rich in protein (serum protein greater than 0.5)• Ratio of pleural fluid LDH and serum LDH is >0.6• Pleural fluid LDH is more the two-thirds normal upper
limit for serum• Rich in white blood cells and immune cells• Always has a low pH• Common causes: tuberculosis, pneumonia, cancer,
and trauma
Exudative effusions
Light’s criteria
Pleural fluid protein divided by serum protein is greater than 0.5. Pleural fluid LDH divided by serum LDH is greater than 0.6. Pleural fluid LDH is greater than two-thirds the upper limit of normal for the serum LDH. If none of these criteria is met, the patient has a transudative pleural effusion
StatisticsStatistics According to WHO:According to WHO:
The estimated prevalence The estimated prevalence of pleural effusion is of pleural effusion is 320 cases 320 cases per 100,000 peopleper 100,000 people in third in third world countries.world countries.
In developed countries the In developed countries the common causes of pleural common causes of pleural effusions in adults are effusions in adults are cardiac cardiac failure, malignancy and failure, malignancy and pneumoniapneumonia, whereas in , whereas in developing countries are developing countries are tuberculosis and parapneumonic tuberculosis and parapneumonic effusionseffusions are more prevalent. are more prevalent.
According to DOH:According to DOH:
The Philippines currently has The Philippines currently has 250,000 cases of Tuberculosis250,000 cases of Tuberculosis, as of , as of the year 2009. Pleural Effusion the year 2009. Pleural Effusion accounts to approximately accounts to approximately 38%38% of of patients with Tuberculosis. patients with Tuberculosis.
StatisticsStatistics
www.doh.gov.phwww.doh.gov.ph
www.doh.gov.phwww.doh.gov.ph
NAME: Mrs. MADDRESS: Brgy CemboAGE: 42 y/oGENDER: FemaleBIRTHDATE: May 30, 1969RELIGION: Roman CatholicDATE OF ADMISSION: July 17, 2011MODE OF ADMISSION: Medicine Ward
BIOGRAPHICAL DATA
CHIEF COMPLAINT
“Nahihirapan akong huminga”, as verbalized by the client
History of Present Illness
• Four months prior to admission, the client experienced productive cough with greenish phlegm, and night sweats. She failed to seek for consultation because she believed that it was just an ordinary cough that is self-limiting.
• Three months prior to admission, the client still experienced productive cough (greenish phlegm) and night sweats. She also experienced fever (39C), chest tightness, and paroxysmal nocturnal dyspnea. She consulted a private doctor and was given Lagundi TID x 7days and Clarithromycin 500 mg BID x 7days. She had taken these drugs as prescribed by the physician. After a week, the patient still complains of the same symptoms. She failed to have a follow up check up due to lack of time
History of Present Illness
• Two months prior to admission, the client still manifested symptoms such as productive cough (greenish phlegm), persistent fever (39C) in the afternoon, and night sweats. The client now had anorexia and lost a total of 3 kg from her previous weight of 47 kg. She began to experience orthopnea of 2 pillows, easy fatigability and paroxysmal nocturnal dyspnea.
History of Present Illness
• She also began to complain of chest pain P: right thoraxQ: Sharp pain R: non-radiatingS: 4/10 T: upon deep inspiration, relieved after shallow breathing).
History of Present Illness
• She now consulted a private doctor and was subjected for chest x-ray revealing pleural effusion of the right lung. The client had undergone thoracentesis and 450cc of fluids was collected from her right lung.
History of Present Illness
Normal CXR Right Pleural Effusion
Thoracentesis
• The patient was relieved from pain after the procedure and was sent home with stable vital signs. The patient was prescribed to take Acetylcystein 600 mg/tab TID, Paracetamol 500 mg/tab TID. She was advised to have a follow up chest x-ray after two weeks. The patient failed to have a follow up chest x-ray due to financial problem
History of Present Illness
• One month prior to admission, the patient still experienced productive cough, chest pain on deep inspiration (P: right thorax, Q: Sharp pain R: non-radiating, S: 7/10, T: upon deep inspiration, relieved after shallow breathing). The client still had anorexia and lost 4 kg from her previous weight of 44 kg.
History of Present Illness
• The patient consulted again a private MD. She was subjected again for chest x-ray and pleural effusion on the right lung was detected. Second thoracentesis was done and 1,000 mL of fluids was collected. She was relieved from pain after the procedure and was sent home with stable vital signs. The patient was advised to have a follow up chest x-ray after two weeks.
History of Present Illness
• Two weeks prior to admission, the patient again experienced productive cough and dyspnea, and easy fatigability. She was subjected to chest x-ray. Third thoracentesis was done and 800ml of fluid from the right lung was collected.
• The patient finally decided to be subsequently admitted to Ospital ng Makati.
History of Present Illness
Neurological System none
Cardiovascular System none
Respiratory System (+) dyspnea (+) paroxysmal nocturnal
dyspnea(+)chest pain (P-pain in right thorax during deep inspiration and movements Q- Sharp pain
R-Non-radiating S-7/10 T- relieved by shallow
breathing(+) orthopnea of 2 pillows
Integumentary System (+)night sweats
Endocrine System none
Urinary System none
Reproductive System none
REVIEW OF SYSTEMSREVIEW OF SYSTEMS
PAST MEDICAL HISTORY
• The client only had hospitalization in the past due to child delivery. The client has no known allergies to certain kind of foods and medication. She had no history of injury or falls. She had also completed her immunizations.
FAMILY HISTORY
The client has history of cancer, specifically; her mother has been diagnosed to have breast cancer while his father has been diagnosed to have prostate cancer.
GENOGRAM of Mrs. M’s Family:
Male prostate Ca
Female breast Ca
Deceased healthy
JoeTherese
Mary49
Maricar45
Mrs. M42
Mercy36
Mark38
Mr. Husband
Marj16
Jeff20
LEGEND:
Personal and Personal and Social HistorySocial History
Health Perception and Health Management Pattern:
Mrs. M described a healthy person as someone without an illness and still manages to do his/her daily activities. Mrs. M rated her general health status as 6/10, She added that she still has a positive outlook in life even though she has a disease.
With regards to self breast examination, the client is familiar with it but doesn’t have enough knowledge on how to perform it.
Mrs. M takes care of her body through bathing, trimming of fingernails, wearing of slippers at home, brushing teeth, and using deodorant.
The patient doesn’t smoke and doesn’t drink any alcoholic beverage.
Health Perception and Health Management Pattern:
Mrs. M lives in Brgy. Cembo with her husband and two siblings. Her family is renting a half of a bungalow house situated along a road. The house has two rooms with a wall that divides it. The wall is not touching the roof, leaving an open space between the two rooms. Mrs M. suspected that one of the family members living in the other side of the house has tuberculosis. She admitted that the air is polluted around their area because she can even inhale the smoke around their compound. Their house is poorly-ventilated and poorly-lighted.
Health Perception and Health Management Pattern:
Nutritional and Metabolic Pattern3-Day Diet Recall
August 30, 2011 August 29, 2011 August 28, 2011
Breakfast(7:30AM)
1 bowl of Arozcaldo1 glass of milk
1 glass of water
1 bowl of soup1 glass of milk
½ bowl of goto2pcs. Medium-sized
pandesal1 glass of milk
Lunch(12:30NN)
½ cup of steamed rice½ serving of menudo1 glass of orange juice
1 bowl champorado1 glass of water
½ bowl of ginataan2 slices of tasty bread1 glass of orange juice
2 glasses of water
Snack(3:00PM)
1 stick of bananaQ1 glass of water
- -
Dinner(7:00PM)
½ cup of steamed rice1 serving of pakbet2 glasses of water
1 glass of milk
½ cup of steamed rice½ serving of monggo
2 glasses of water
½ cup of steamed rice 1 pc. Lumpiang sariwa
1 glass of milk1-2 glass of water
Mrs. M is the one who prepares the food for her family before. Most of the time, she cooks Filipino dishes such as pork adobo & pork sinigang. Mrs. M does not forget to wash her hands everytime before she prepares the food.
Mrs. M stated that she is not taking any vitamins since before.
The patient lost a total of 7 kg in her weight before hospital admission.
Nutritional and Metabolic Pattern3-Day Diet Recall
Elimination Pattern:
Regarding her defecation, she usually defecates once a day and the stool is dark brown in color and the consistency is solid. The patient doesn’t have any discomforts upon defecation. She seldom experiences constipation or diarrhea.
Regarding her urinary elimination pattern, Mrs. M frequently urinates (4-5x/day) because she is taking Furosemide every night. She stated that she doesn’t feel any discomfort or pain during micturition.
Activity-Exercise Pattern:
• Mrs. M is a high school teacher. She goes to school in the morning and goes home at 1:00 pm. She said that before she felt the symptoms of easy fatigability, she exercises during weekend morning for 30 minutes using a waist twisting disc. She also considers walking to her school for work as an exercise.
Sleep and Rest Pattern:
• Mrs. M had difficulty of sleeping in the hospital because she is not comfortable sleeping with the hospital environment and also, because of the pain she has been experiencing on the thoracostomy site upon trunk movements. She described the pain as sharp, and rated it as 7/10. During the interview, facial grimace is evident. She sometimes nods her head just to agree. She also speaks at a low-volume voice.
Sleep DiaryAugust 30, 2011 August 29, 2011 August 28, 2011
Hours of Sleep during Night
(12AM-5AM)5 hours
(11AM-4:30AM)5 1/2 hours
(12AM-4:30AM)4 1/2 hours
Hours of NapDuring
Afternoon
(1:30PM-3:00PM)
1 ½ hours
(4:30PM – 6:00PM)1 ½ hours
(1:00-3:00 PM)2 hours
Quality of Sleep
Continuous Continuous Not Continuous. Awakened at 3am due to pain on the thoracostomy site. Fell asleep after pain subsided.
Feeling upon waking up
Refreshed Refreshed Not Refreshed
PHYSICAL EXAMINATION
General Appearance: During the interview, the client is conscious and coherent. The client has evident facial grimace.
capacity• Acute Pain r/t accumulation of fluid in the pleural space and
rubbing of thoracostomy tube to the lungs• Imbalanced Nutrition: less than body requirement r/t inability
to ingest adequate nutrients• Hyperthermia r/t disease process• Sleep Deprivation r/t Paroxysmal nocturnal dyspnea • Risk for fluid volume deficit related to administration of
diuretic drugs• Risk for Injury related to thoracentesis• Risk for infection r/t presence of ctt
Pathophysiology
Inhalation of TB Bacilli
Tubercle Formation (Primary Infection)
Exposure to Air Pollutants
Exposure to TB
Formation of Granuloma
Living in Poorly-lighted and
overcrowded house
PTB
Productive cough, Fever 39C, Anorexia,
weight loss, easy fatigability
AFB (+)
Vigorous inflammatory response associated with an exudation of white blood cells and proteins.
Increase WBC count(16.6 x 10^9 mm/ L)
Increase Monocyte count(0.13 g/L)
Mycobacterial antigens enter the pleural space
Not early detected
subpleural caseous focus in the lung ruptures into the pleural space
PTB
Vigorous inflammatory response associated with an exudation of white blood cells and proteins.
Increase pulmonary interstitial fluid
PLEURAL EFFUSION(Accumulation of fluid in
the pleural cavity)
Low serum albumin level:
25 g/LChanges in
permeability of capillaries
Intense inflammation obstructs the lymphatic pores in the
parietal pleura
Decrease in lymphatic drainage
PLEURAL EFFUSION(Accumulation of fluid in the
pleural cavity)
Irritation of sensory nerves in the parietal pleura during deep
inspiration
Increase in intra-alveolar & intra-pleural pressure
Significance: The patient has respiratory alkalosis. This may be due to rapid & shallow breathing.
Procedure/Item
Abnormal flags
Result Units Reference Range
Albumin *Low 25 g/L ( 34 - 50 )
AST (SGOT) 35 u/L ( 15 - 37 )
ALT (SGPT) 33 u/L ( 30 - 65 )
Alkaline Phospha
tase
143 u/L (50-165)
Acid-fast Bacillus (AFB)
(July 20, 2011) Specimen: Sputum Result: AFB (+)
Gram Stain
(August 20, 2011) Specimen: Pleural Fluid Result: Smear shows no presence of
gram (-) bacilli.
CYTOPATHOLOGY
(August 20, 2011) Specimen: Pleural Fluid Pathologic Diagnosis: Negative for
malignant cells
Chest X-ray
(July 14, 2011) Impression: Consider
moderate pleural effusion; right
Right Lateral Decubitus: Evidence of minimal pleural fluid
Chest X-ray
Right Lateral Decubitus
CT-SCAN of Chest
Result: PTB with organizing Pneumonia, Superior and postero-medial right lower lobe with right hilar lymphadenopathies and right pleural effusion.
CT – MRI
(August 11, 2011) Findings: Mediastinal lymphadenopathies Right pleural effusion with thick
pleural density Heart not enlarged Pulmonary Fibrosis in Left Lower
Lobes
COURSE IN THE WARD AUGUST
31,2011 Wednesday
(6:00AM – 2:00 PM)
Patient received lying on bed, awake, calm and coherent Patient was febrile Patient was ambulatory Has an IVF of 1L PNSS at 31-32 gtts/min for 8 hours infusing well Patient’s vital signs were taken and recorded Temperature: 39°C Cardiac Rate: 109bpm Respiratory Rate: 22cpm Blood Pressure: 100/70
Tepid sponge bath was done to lower hyperthermic state Endorsed elevated temperature to the nurse-in-charge Bed rails were raise to promote patient’s safety Instruct the significant other how to do the tepid sponge bath if fever is
present Intake and output strictly monitored Intake Output Oral- 400 mL Urine- 500 mL IV- 500 mL Chest tube – 60mL Total - 900mL Total - 560mL No. of stool – 0• Checked thoracostomy tube for leak, kinks, patency and output. Noted fluctuations in every inspiration on the drainage bottlez Secured bottle lower than the client (under the bed).
Drug Study
Drug Name Classification Action Dosage/Frequency Nursing responsibilities Evaluation
Generic:Acetylcysteine
Mucolytics Breaksdown the link that binds mucus together
Liquifies mucus
Makes cough more productive
600 mg PO q4 Evaluates client’s respiratory status (respiratory rate, depth, rhythm)Check sputum for color, consistency and amount.If bronchospasm occurs, stop the treatment and notify the physician.Instruct patient to notify prescriber immediatelyabout nausea, rash, or vomiting.
Warn patient about acetylcysteine’sunpleasant smell; reassure him that it subsidesas treatment progresses.
To decrease mucus viscosity, urge patientto consume 2 to 3 L of fluid daily unlesscontraindicated by another condition.
Evaluate the effectiveness of Acetylcysteine through assessing the respiratory status of the client and amount of sputum expectorated.
Drug Name Classification Action Dosage/Frequency Nursing responsibilities Evaluation
Generic Name:Pyrazinamide + Ethambutol
Anti-TB Agents Inhibits cell action of Mycobacterium tuberculosis
Bacteriostatic
400mg + 275mg PO
Take it continously and never skip doses to avoid multi-drug resistance.
Monitor Vision of patient. Ethambutol causes optic neuritis.
Examine patients at regular intervals and question about possible signs of toxicity: Liver enlargement or tenderness, jaundice, fever, anorexia, malaise, impaired vascular integrity
Report to physician onset of difficulty in voiding. Keep fluid intake at 2000 mL/d if possible.
Evaluate effectiveness of medication through observing the clients coughing and coping mechanism with the drug
Drug Name Classification Action Dosage/Frequency Nursing responsibilities Evaluation
Generic Name:Rifampicin
Antituberculosis agent
Inhibits DNA and RNA polymerase activity
Cell death
300 mg PO OD Administer on an empty stomach, 1 hr before or 2 hr after meals.Administer in a single daily dose.Give with meals because it causes gastric irritation.Prepare patient for the reddish-orange coloring of body fluids (urine, sweat, sputum, tears, feces, saliva); soft contact lenses may be permanently stained; advise patients not to wear them during therapy.arrange for follow-up visits for liver and renal function tests, CBC, and ophthalmic examinations.Advise client to avoid omission of dose to prevent drug resistance
Evaluate effectiveness of medication through monitoring hemoptysis production, liver fxn test and CXR
Drug Name Classification Action Dosage/Frequency Nursing responsibilities Evaluation
Generic:Piperacillin + Tazobactam
AntibioticBinds to bacterial cell membrane and inhibits beta-lactamase
Cell lysis
4.5 g/ml TIV q6 Perform skin test before giving the initial dose.Assess client for allergy to penicillin. Check C&S result.
Monitor client for 30 mins when given parenterally; administer epinephrine if anaphylaxis occurs.
Do not mix aminoglycosides with penicillin in the same IV infusion – deactivates aminoglycoside
Check for CBC result and Monitor for hemorrhagic manifestations because high doses may induce coagulation abnormalities.
Drug Name Classification Action Dosage/Frequency Nursing responsibilities Evaluation
Generic: Furosemide
Loop diuretic Acts in loop of Henle, proximal and distal tubule
Inhibits Na and Cl reabsorption
10 mg/mL TIV q8 Monitor for adequate intake and output and potassium loss.
Monitor client’s weight and vital signs esp BPMonitor for signs and symptoms of hearing loss, which may last from 1 to 24 hrs.
Teach client to take Furosemide early in the day to decrease nocturia.
Teach client to report any hearing loss or signs of gout.monitor for S/s of hypokalemia; such as muscle weakness and cramps
Monitor for sideeffects such as dizziness, lightheadedness, or fainting spells, Signs of dehydration or low electrolytes,
Evaluate effectiveness of Furosemide through frequently monitoring urinary output.
200 mg PO Assess for infection at beginning of and throughout therapy.
Ask patient for allergies to penicillin or cephalosporins.
Perform skin test before the initial administration.
Obtain specimens for culture and sensitivity before initiating therapy.
Observe patient for signs and symptoms of anaphylaxis ( rash, pruritus, laryngeal edema, wheezing)
Evaluate the effectiveness of medicine
Drug Name Classification Action Dosage/Frequency
Nursing responsibilities
Evaluation
Generic Name:Tramadol
Opioids/analgesic binds to µ-
opiate receptors and inhibits reuptake of norepinephrine and serotonin
reduces intensity of pain stimuli sponse to pain.
50mg/2mL TIV Assess onset, type, location, and duration of pain.Effect of medication is reduced if full pain recurs before next dose. Assess drug history especially carbamazepine, CNS depressant medication, MAOIs.Review past medical history, especially epilepsy or seizures.Assess renal or hepatic function laboratory values.Give without regards to mealsMonitor pulse and blood pressure.Assist with ambulation if dizziness or vertigo occurs.
Evaluate effectiveness of medication through monitoring vital signs of client and assessing pain recurrence.
Drug Name Classification Action Dosage/Frequency
Nursing responsibilities
Evaluation
Generic Name:
Streptokinase
Thrombolytic enzyme Produces
plasmin
Breaks down fibrin
Dissolves blood clots
250,000 units intrapleurally
Continuous monitoring of HR and rhythm throughout thrombolytic administration.
Vital observations : record 15 minutely for at least 1 hour from onset of infusion until stable.
Notify physician if allergic reactions may include fever increased liver enzymes, reduced renal function, polyarthralgia, polyarthritis and rash.
Evaluate effectiveness of Streptokinase through checking for blood in the chest tube drainage.
Drug Name Classification Action Dosage/Frequency Nursing responsibilities Evaluation
Generic Name:Paracetamol
Anti-pyretic inhibiting the
hypothalamic
heat-regulating centre.
Inhibits fever
300g TIV Check vital signs of the client esp temperature.
Inspect IM and IVinjection sitesfrequently for signs of phlebitis.
Report onset of loose stools or diarrhea
Monitor I&O rates and pattern:
Evaluate effectiveness of Paracetamol through monitoring a decrease in the temperature of the client.
DISCHARGE PLANNING
• Medication: After handling the patient for one day, we advice the client and significant others that the client should continue the prescribed medications as follows: Rifampicin 300 mg PO OD, Pyrazinamide + Ethambutol 400mg + 275mg PO as ordered by the doctor.
• Exercise: We have encouraged the client to perform mild exercise such as jogging for 30 minutes each day after the woundcompletely healed.
• Treatment: • Health Teaching: Teach the client to avoid omission of doses of
antituberculosis drugs such as Rifampicin, Pyrazinamide and Ethambutol. We have advised the client to expect reddish to orange color of urine, sweats, etc. We have advised the client to seek for consultation if she experienced blurring of vision and jaundice.
• We also taught the client that Mycobacterium Tuberculosis is killed by heat and sunshine that’s why appropriate lighting and ventilation of the house is important.
• Out-Patient Follow-up Care: Advised the client for a follow up check up and for chest xray.
• Diet: We advised the client to increase intake of protein to increase healing of wound brought about by chest tube thoracostomy. We also advised to take 8-10 glasses of water everyday to avoid dehydration.