Pleural Effusion

Probably secondary to Parapneumonia Process

Pleural Effusion

Caliwag, Rey Mark B.Calixihan, Jennyvieve H.Camba, Veronica T.Candido, Katreen Luz T.Canoza, Lowreen Anne R.

Presented to:

Group members

GENERAL OBJECTIVE

This case study intends to enhance the group’s understanding of the illness and to help them provide proficient nursing management while promoting the well-being of a patient with Pleural Effusion probably secondary to Parapneumonic Process. This study also aims to make other student nurses prepared in handling the same case in the future.

SPECIFIC OBJECTIVES

In accordance to the general objective, the group aims to attain the following specific objectives: To be knowledgeable in:

The etiology of the disease and how it progresses Identifying the clinical manifestations, its signs and symptoms The appropriate pharmacologic and non-pharmacologic interventions Evaluating the outcome of the interventions advised and recommended

To help the patient become more comfortable, it is necessary for the student nurses to acquire the following skills:

Accurate overall assessment Providing effective management of the disease Preparing appropriate nursing interventions Determining suitable health teachings Making appropriate, prioritized, and effective nursing care plans

To instill a positive and caring attitude in order to:

Converse with the patient in a manner that would not in any way offend his identity Promote cooperation and good communication among the group while conducting the case and attending to the patient’s

needs Learn new and innovative ways in helping the patient adjust to his current condition

Objectives

BACKGROUND OF THE CASE This presents the case of Mr. RC, a 44 year-old male, of Filipino

descent, who recently received medical treatment from Amang Rodriguez Memorial Medical Center (ARMMC) in Marikina City. He was diagnosed with Pleural Effusion probably secondary to parapneumonic process.

Since his prognosis is way better compared to the other patients in the payward, we opted to take his case as the subject of this case analysis, as it would be a definite advantage in the gathering and availability of information. Moreover, his length of stay in the ward is essential for the group to be able to carefully observe and assess the patient and to impart to him whatever knowledge and skills we may acquire from the course of the study.

Upon encountering the patient’s diagnosis, the group decided that they will tackle this case, since it is a little bit unusual but highly interesting. To boot, the group would very much like to discover a lot about the chosen case, and that is the reason for this case analysis.

Introduction

DEFINITION OF THE CASE Pleural effusion is abnormal and excessive accumulation of fluid in the pleural space

resulting from excess fluid production and decreased absorption. Accumulation of fluid in the pleural space results from a large number of disorders, including infections, injuries, heart or liver failure, and blood clots in the lung blood vessels (pulmonary emboli).

Depending on the cause, the fluid may have different characteristics. It may be either rich in protein (exudate) or watery (transudate). Doctors use this distinction to help determine the cause.

Blood in the pleural space (hemothorax) usually results from a chest injury. Rarely, a blood vessel ruptures into the pleural space when no injury has occurred, or a bulging area in the aorta (aortic aneurysm) leaks blood into the pleural space.

Pus in the pleural space (empyema) can accumulate when pneumonia or a lung abscess spreads into the space. Empyema may also complicate an infection from chest wounds, chest surgery, rupture of the esophagus, or an abscess in the abdomen.

Lymphatic (milky) fluid in the pleural space (chylothorax) is caused by an injury to the main lymphatic duct in the chest (thoracic duct) or by a blockage of the duct by a tumor.

Fluid in the pleural space that contains excessive amounts of cholesterol results from a long-standing pleural effusion caused by a condition such as tuberculosis or rheumatoid arthritis.

Introduction

GENERAL SIGNS AND SYMPTOMSChest pain, usually a sharp pain that is worse

with cough or deep breathsCough FeverHiccups Rapid breathing Shortness of breath

Introduction

ETIOLOGY Exudative

Parapneumonic Simple Complicated Empyema

Tuberculosis Other infections

Fungal Parasitic

Malignant Metastatic disease Mesothelioma

Pulmonary Embolism Collagen Vascular Disease Abdominal Disease

Pancreatitis Subphrenic abscess Esophageal rupture Postoperative

Others Atelectasis Acute respiratory distress syndrome, (ARDS) Asbestos exposure Hemothorax Chylothorax Cholesterol effusions Drug reactions Dressler’s syndrome Meigs’ syndrome Uremia

Introduction

Transudative Congestive heart failureCirrhosisNephrotic syndromePeritoneal dialysisSuperior vena cava syndromeMyxedemaAtelectasis (early)

Introduction

INCIDENCE Because pleural effusion is a manifestation of underlying disease, its

precise incidence is difficult to determine. However, the incidence in the United States is estimated to be at least 1.5 million cases annually. Congestive heart failure, bacterial pneumonia, malignancy, and pulmonary embolus are responsible for most of these cases.

The annual incidence of pleural effusion is estimated to be 320 cases per 100,000 people in industrialized countries. A study from part of what is now the Czech Republic yielded an annual incidence of 0.32%. The most common causes, in decreasing frequency, were congestive heart failure, malignancy, parapneumonic effusions, and pulmonary emboli. When extrapolating these figures to apply to other countries, the distribution and incidence of pleural effusion causes are dependent on the population studied. For instance, in areas where tuberculosis (TB) is prevalent, a higher percentage of pleural effusions from TB may be observed.

Introduction

DEMOGRAPHIC DATA Name: Mr. R.C. Address: Cogeo, Antipolo City Gender: Male Civil Status: Married Age: 44 years old Birthplace: Antipolo City Occupation: Security Guard Nationality: Filipino Religion: Roman Catholic Date of Admission: January 14, 2010 Admitting Diagnosis: Pleural Effusion probably secondary to

Parapneumonic process CHIEF COMPLAINT Difficulty of Breathing

Patient's Profile

ASSESSMENT

Vital signs a. Temperature: 37.0 C b. Cardiac rate: 120 bpm c. Respiratory rate: 32 cpm d. Blood pressure: 140/80 Integumentary a. Moisture: Normal b. Edema: None c. Condition of IV line: Intact d. Skin integrity: Normal e. Minor wounds: None. Face, Eyes, Ears, Nose, and Mouth a. Facial Asymmetry: Slight b. Vision: Slightly blurred c. Sclera: Slightly icteric d. Hearing: No impairment e. Nose: No nasal flaring f. Dentures: None Cardiovascular a. Apical pulse: Strong b. Radial pulse: Strong c. Brachial pulse: Strong d. Pedal pulse: Strong

Patient's Profile

Respiratory a. (-) chest pain b. (+) DOB c. (+) cough and hemoptysis d. Breath Sounds: Crackles on expiration e. Lung expansion: Normal and equal bilaterally Gastro - Intestinal a. Abdomen: Soft, Large diameter b. Tenderness: N/A c. Bowel Sounds: Normoactive d. Feeding: Low salt, low fat e. NGT feeding: None f. Bowel movement: Infrequent Neurologic Assessment a. Sensorium: Conscious b. Coherence: responds to verbal command c. Signs of Distress: Slight d. Headache: Absent

Patient's Profile

Respiratory a. (-) chest pain b. (+) DOB c. (+) cough and hemoptysis d. Breath Sounds: Crackles on expiration e. Lung expansion: Normal and equal bilaterally Gastro - Intestinal a. Abdomen: Soft, Large diameter b. Tenderness: N/A c. Bowel Sounds: Normoactive d. Feeding: Low salt, low fat e. NGT feeding: None f. Bowel movement: Infrequent Neurologic Assessment a. Sensorium: Conscious b. Coherence: responds to verbal command c. Signs of Distress: Slight d. Headache: Absent

Patient's Profile

Patient's Profile

CATEGORY SCOR

E

1 2 3 4 5 6

Eye

Opening

4 No

respon

se

Responds to

pain

Responds

to verbal

command

Spontaneo

us eye

opening

Verbal

Response

5 No

respon

se

Incomprehensi

ble sounds

Inappropria

te Words

Confused

words

Oriente

d to

situatio

n

Motor

Response

6 No

respon

se

Extension to

pain

(decerebrate)

Flexion to

pain

(decorticat

e)

Withdraws

to pain

Localiz

es pain

Obeys

comma

nd

Total GCS 15/15

VIII. Genito – Urinarya. Urination: normal (approximately 20-30cc

per hour)b. Genital Area: Normal (no discharge) IX. Psychosociala. Lives with: Familyb. Behavior: Cooperative when ablec. Activities of Daily living: Can participate on

activities of daily living

Patient's Profile

NURSING INTEGRATED ASSESSMENT DIAGNOSIS (NIAD)

BASED ON GORDON’S FUNCTIONAL NEEDSHealth Perception and Health Management PatternPatient RC experienced fever for approximately 2 weeks and

managed it by taking paracetamol. The patient mentioned that when he feels ill he doesn’t go to a quack doctor or faith healer, instead he consults a doctor. After having 2 weeks of intermittent fever, he immediately went to the hospital for consultation. The patient doesn’t practice self medication. He also doesn’t smoke and drink alcohol.

During hospitalization, the patient was given treatment regimen. He is now more conscious about his condition. He instantly complies with the orders given by the doctor.

Patient's Profile

Nutritional and Metabolic PatternThe patient eats 4 times a day including

snacks. He eats about two cups of rice each meal. He drinks water at least 5-6 glasses of water per day. He does not have any vitamins or supplements. His skin is in good condition and doesn’t have any wounds or lesions. In the hospital, the patient’s diet is based on the doctor’s order which is low salt and low fat diet. The patient rarely eats during his first few days but exhibits improved appetite during the succeeding days. The patient’s skin is moist and no presence of wound.

Patient's Profile

Bowel-Elimination PatternThe patient’s GI motility is normal and usually

defecates once a day and says he regularly pass out stool. He does not complain of difficulty of passing out stool and doesn’t have diarrhea or constipation. He usually urinates 3-4 times a day and doesn’t complain of pain or other unusual color of urine. He does not take any medication like laxatives. After hospitalization, the patient still has normal GI motility and defecates once a day usually at the morning. He urinates 4-5 times a day. It is because of one of his drugs, Aldactone which increases urine output. He does not complain of any pain in defecating or urinating.

Patient's Profile

Activity-Exercise Pattern Patient RC was a security guard at ARMMC. He is

physically active and does exercise 2-3 times a week. He can perform activities of daily living like feeding, bathing and grooming without any help. In his spare time, he is usually watching TV. During hospitalization, the patient is usually at bed, lying, sitting or just taking a nap because of his difficulty in breathing. He is not physically active during his admission. He will get up if he needs to eat, drink, take some medications, and if he needs to go to the comfort room. The patient doesn’t need assistance in doing these things.

Patient's Profile

Perceived ability for: Feeding : 0 Bathing : 0 Toileting : 0 Bed Mobility : 0 Dressing : 2 Grooming : 0 General Mobility : 0

Patient's Profile

Patient's Profile

LEVEL SELF-CARE ABILITY

0 Full self-care

1 Requires use of equipment or device

2 Requires assistance or supervision from another person

3 Requires assistance or supervision from another person

or device

4 Is dependent and does not participate

Sleep-Rest PatternThe patient usually sleeps 6-8 hours a day. He

does not have any problems falling asleep. He usually watches TV and spends time with his children as means of relaxation. While admitted to the hospital, the patient still sleeps for 6-8 hours with plenty of naps during the day. He does not complain of getting asleep in the hospital. He watches TV and lays on his bed as means of relaxation.

Patient's Profile

Cognitive-Perceptual PatternThe patient still comprehends and follows instructions

given to him. He can answer questions being asked and still can recall the important events in his life. During his hospital stay, the patient can comprehend and follow instructions and understands command easily.

Self-perception and Self-concept PatternThe patient still feels good and still has a good sense of

self-esteem. the patient feels good about himself and doesn’t apply anything on his face just to look good.

Patient's Profile

Role-Relationship Pattern The patients’ family has been supportive of

him, providing all of his needs in the hospital. They encourage him to get well soon. As part of the family, the patient is well taken care of. He is very cooperative and welcoming to us. The patient lives with his wife and children and has good relationship with them and other family members. When problems occur in their family, they usually help each other in solving whatever problem they have. He is working as a security guard in order to support his family’s financial needs.

Patient's Profile

Sexuality-Reproductive PatternAt his stage, patient is not affectionate anymore and is

hypoactive towards sexual matters due to his health status and age. The patient has a wife and they have 3 children. The patient said he and his wife regularly make love.

Coping-stress Tolerance PatternThe patient said when he feels stressed; he usually takes a

nap, watches television to relieve his uneasy feeling. The patient admits that it is stressful in the hospital, when stressed he usually takes a nap or watches television. He finds way to relax. He usually voice out his needs in the family.

Patient's Profile

Value-belief PatternThe patient says that he prays to GOD that He

may heal him in his disease. He also seeks guidance from the Lord. The patient is a Roman Catholic and believes in GOD. He says he prays rarely. The patient does not believe in quack doctors or faith healers.

Patient's Profile

PAST MEDICAL HISTORYWith complete immunizationsNo known allergies for food, medicines and

othersNo history of accidents and injuriesNo history of hospitalization(-) Asthma and DM(+) Hypertension for four years (+) PTB for 6months by 2009

Patient's Profile

FAMILY MEDICAL HISTORYFamilial history of Diabetes (mother)No familial history of hypertension, asthma, or

cancer PERSONAL AND SOCIAL HISTORY Non-smokerDrinks alcohol, consuming an average of 6

bottles everyday

Patient's Profile

HISTORY OF PRESENT ILLNESSFour months PTA, patient experienced

productive cough with yellowish sputum accompanied with afternoon fever, with no other signs and symptoms noted. Patient sought consult at a institution and was given attention and was advised admission but refused.

Few hours PTA, still with the above condition, now accompanied with difficulty of breathing. Persistence of the above condition prompted consult and was subsequently admitted in ARMMC.

Patient's Profile

In human anatomy, the pleural cavity is the body cavity that surrounds the lungs. The pleura is a serous membrane which folds back upon itself to form a two-layered, membrane structure. The thin space between the two pleural layers is known as the pleural cavity; it normally contains a small amount of pleural fluid. The outer pleura (parietal pleura) is attached to the chest wall. The inner pleura (visceral pleura) covers the lungs and adjoining structures, viz. blood vessels, bronchi and nerves.

Anatomy and Physiology

The pleural cavity, with its associated pleurae, aids optimal functioning of the lungs during respiration. The pleural cavity also contains pleural fluid, which allows the pleurae to slide effortlessly against each other during ventilation. Surface tension of the pleural fluid also leads to close apposition of the lung surfaces with the chest wall. This physical relationship allows for optimal inflation of the alveoli during respiration. The pleural cavity transmits movements of the chest wall to the lungs, particularly during heavy breathing. This occurs because the closely opposed chest wall transmits pressures to the visceral pleural surface and hence to the lung itself. An easier way to say it is it is the space between the pleural membrane and the lung.


Pleural fluid is a serous fluid produced by the normal pleurae. Most fluid is produced by the parietal circulation (intercostal arteries) via bulk flow and reabsorbed by the lymphatic system. Thus, pleural fluid is produced and reabsorbed continuously. In a normal 70 kg human, a few milliliters of pleural fluid is always present within the intrapleural space. Larger quantities of fluid can accumulate in the pleural space only when the rate of production exceeds the rate of reabsorption. Normally, the rate of reabsorption increases as a physiological response to accumulating fluid, with the reabsorption rate increasing up to 40 times the normal rate before significant amounts of fluid accumulate within the pleural space. Thus, a profound increase in the production of plural fluid—or some blocking of the reabsorbing lymphatic system—is required for fluid to accumulate in the pleural space.


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.


Pathophysiology

Radiology Report: (January 15, 2010)There is a homogenous density in the right lower lung

field with meniscus pattern. Suspicious infiltrates are seen in both upper lobes.

Heart is silhouetted.The right hemidiaphragm is obliterated. The left

eostophrenic angle is blunted.Bony thorax is unremarkable.Impresssion: Bilateral pleural effusion (right more than the left) Suspicious densities as described. Suggest lordotic view.

Laboratory and Diagnostics

Radiometer (ABL 520) F10₂d: 21% Temperature: 37.0 PC Sample type: arterial BLOOD GAS values pH: 7.454 pCO₂: 37.0 mmHg pO₂: 70.3 mmHg BLOOD OXIMETRY values sO₂: 94.1% TEMPERATURE CORRECTED values pH: (37.0 P C) 7.454 pCO₂ (37.0 P C) 37.0 mmHg pO₂ (37.0 P C) 70.3 mmHg ACID-BASE STATUS ABEс: 2.3 mmol/L HCO₃̄Sс: 25.6 mmol/L


Ultrasound Report: (January 19, 2010) Whole abdomen:The liver is enlarged measuring about 14.2 cm at the right

midclavicular line. It exhibits heterogenous parenchyma. Echogenicity and nodular borders. Intrahepatic ducts are not dilated. Portal vein and tributaries are unremarkable.

Gallbladder is dilated measuring 4.4 cm in diameter. Lumen is echo-free. Wall is not thickened. Pancreas is obscured.

The spleen is within normal size, exhibiting homogenous parenchymal echo pattern.

No focal mass lesion seen. Splenic vessels are not dilated.


Spleen=11.9 cm x 6.8cm Right kidney=10.8cm x 5.7cm Left kidney=10.8cm x 5.7cm Both kidneys are within normal size. No evident lithiasis, no focal mass lesions. Both pelvocalyceal systems are not dilated. The urinary bladder is physiologically distented with normal sonolucent

echopattern. No abnormal intraluminal echo seen. The wall is not thickened. There is note of massive ascites. Impression: Hepatomegaly with diffuse parenchymal disease and nodular borders. Dilated gallbladder. Obscured pancreas. Massive ascites. Normal sonogram of the kidneys and urinary bladder.


Laboratory and DiagnosticsRESULTS NORMAL

VALUESWBC Count 7.0 10³/ µ L 5-10 10^3/ µLRBC Count 4.56 10⁶/µL 4.2-5.4^3/ µLHemoglobin 13.6 g/dL 12-16^3/ µLHematocrit 42.9% 35-47%Platelet Count 279 10^3/ µ L 150-450 10^3g/L

RESULTS NORMAL VALUES

Segmenters 71.5% ↑ 0.45-0.65%

Lymphocyte 19.3%↓ 20-40%

Monocyte 8.8% ↑ 2-8%

Eosinophil 0.4% ↑ 0.02-0.01%

Basophil 0% 0.1-1.0%

Results Normal valuesBUN 3.33mmol/L 1.7-8.3 mmol/LCreatinine 92.1 mmol/L 53-115 mmol/LSodium 139.1 mmol/L 135-148mmol/LPotassium 4.30 mmol/L 3.5-5.5 mmol/LUric Acid 497 mmol/L↑ 180-420 mmol/L

HPL 0.744mmol/L↓ 0.78-1.95mmol/L

Drug StudyDRUG ACTION DOSAGE INDICATION NURSING CONSIDERATION

Generic name: cefuroximeBrand name: CeftinClass: Cephalosporin

>Inhibits cell wall synthesis, promoting osmotic instability; usually bactericidal.

50mg\TIV q 8 >Pharingitis, tonsillitis, infections of the urinary tract and lower respiratory tracts

1. Absorption of cefuroxime is enhanced by food.2. Monitor patient for signs and symptoms of superinfection.

Generic name: clarithromycinBrand name: BiaxinClass: Macrolide anti-infective

>Binds to the 50S subunit of bacterial ribosomes, blocking protein synthesis.

500mg/tab BID >Broncitis, pharyngitis, tonsillitis, maxillary sinusitis, community acquired pnuemonia

1. Monitor for superinfection. Drug may cause overgrowth of non-susceptible bacteria or fungi.2. Tell patient to take drug as prescribed, even if he feels better.

Generic name: amlopidineBrand name: NorvascClass: Antianginals

>Decreased myocardial contractility and oxygen demand; also dilates coronary arteries and arterioles

5mg/tab OD >For chronic, stable angina and hypertension 1. Monitor blood pressure frequently during initiation of drug.2. Notify prescriber if signs of heart failure occurs, such as swelling of hands and feet or shortness of breath

Generic name: ketorolacBrand name: ToradolClass: NSAIDs

>Inhibits prostaglandin synthesis to produce anti-inflammatory, antipyretic and analgesic effects.

10 mg/tab TID >Short term management for moderately severe pain 1. Correct hypovolemia before giving ketorolac.2. Tell patient to take drug with milk if Gastrointestinal adverse reactions occurs.

Generic name: spirinolactoneBrand name: AldactoneClass: Diuretics

>Antagonizes aldosterone in distal tubules, increasing sodium and water excretion.

25mg/tab TID >Edema, hypertension, diuretic-induced hypokalemia, hyperaldesteronism

1. Give drug with meals to enhance absorption.2. Monitor electrolyte levels, fluid intake and output, weight and blood pressure.

Generic name:omeprazoleBrand name: Prilosec, LosecClass: Anti ulcer drugProton pump inhibitor

>Inhibits activity of acid pump and binds to hydrogen-potassium adenosine triphosphatase at secretory surface of gastric parietal cells to block formation of gatric acid.

20mg/tab OD >GERD>short term treatment of duodenal ulcer>Short term treatment of active benign gastric ulcer>frequent heartburn (2 or more days a week)

1. Omeprazole increases its own availability with repeated dosage, drug is labile in gastric acid; less drug is lost to hydrolysis because drug increases gastric pH2. Gastrin level rises in most patients during first 2 weeks of therapy3. Dosage adjustments may be necessary in patients with hepatic impairment4. Tell the patient to swallow tablets or capsules whole and not to open, crush, or chew them

Generic name: domperidoneBrand name: MotiliumClass: GIT Regulators and anti-flatulent

>Relieves dyspeptic symptoms such as epigastric sense of fullness, early satiety, feeling of abdominal distention and upper abdominal pain, bloating, eructation and flatulence.

10mg/tab TID >Dyspepsia with delayed gastric emptying>GERD>Esophagitis

>Drug should be given cautiously in patients with hepatic and renal impairment>Advised patient to report adverse effects such as GI hemorrhage

Generic name: ipratopium + salbutamolBrand name: Combivent, DuaventClass: Bronchodilators

>Antagonizes the effect of acetylcholine. Causes local bronchodilation by preventing the increase in intracellular cGMP which is produced by the interaction of ACTH with the muscarinic receptors of bronchial smooth muscles

Neb q 8 hrs. >Management of reversible bronchospasm associated with obstructive airway disease.

>Assess patient’s condition before and after therapy. Monitor peak expiratory flow.>Monitor evidence for possible drug induced adverse reactions such as dry mouth, headache, and blurred vision.

Drug StudyGeneric name: spirinolactoneBrand name: AldactoneClass: Diuretics

>Antagonizes aldosterone in distal tubules, increasing sodium and water excretion.

25mg/tab TID >Edema, hypertension, diuretic-induced hypokalemia, hyperaldesteronism

1. Give drug with meals to enhance absorption.2. Monitor electrolyte levels, fluid intake and output, weight and blood pressure.

Generic name:omeprazoleBrand name: Prilosec, LosecClass: Anti ulcer drugProton pump inhibitor

>Inhibits activity of acid pump and binds to hydrogen-potassium adenosine triphosphatase at secretory surface of gastric parietal cells to block formation of gatric acid.

20mg/tab OD >GERD>short term treatment of duodenal ulcer>Short term treatment of active benign gastric ulcer>frequent heartburn (2 or more days a week)

1. Omeprazole increases its own availability with repeated dosage, drug is labile in gastric acid; less drug is lost to hydrolysis because drug increases gastric pH2. Gastrin level rises in most patients during first 2 weeks of therapy3. Dosage adjustments may be necessary in patients with hepatic impairment4. Tell the patient to swallow tablets or capsules whole and not to open, crush, or chew them

Generic name: domperidoneBrand name: MotiliumClass: GIT Regulators and anti-flatulent

>Relieves dyspeptic symptoms such as epigastric sense of fullness, early satiety, feeling of abdominal distention and upper abdominal pain, bloating, eructation and flatulence.

10mg/tab TID >Dyspepsia with delayed gastric emptying>GERD>Esophagitis

>Drug should be given cautiously in patients with hepatic and renal impairment>Advised patient to report adverse effects such as GI hemorrhage

Generic name: ipratopium + salbutamolBrand name: Combivent, DuaventClass: Bronchodilators

>Antagonizes the effect of acetylcholine. Causes local bronchodilation by preventing the increase in intracellular cGMP which is produced by the interaction of ACTH with the muscarinic receptors of bronchial smooth muscles

Neb q 8 hrs. >Management of reversible bronchospasm associated with obstructive airway disease.

>Assess patient’s condition before and after therapy. Monitor peak expiratory flow.>Monitor evidence for possible drug induced adverse reactions such as dry mouth, headache, and blurred vision.

The Neuman’s system model has two major components i.e. stress and reaction to stress. The client in the Neuman’s system model is viewed as an open system in which repeated cycles of input, process, output and feedback constitute a dynamic organizational pattern.

The system may adjust to the environment to itself. The idea is to achieve optimal stability. As an open system the client, the client system has propensity to seek or maintain a balance among the various factors, both within and outside the system, that seek to disrupt it. Neuman seeks these forces as stressors and views them as capable of having either positive or negative effects. Reaction to the stressors may be possible or actual with identifiable responses and symptom.

The layers, usually represented by concentric circle, consist of the central core, lines of resistance, lines of normal defense, and lines of flexible defense. The basic core structure is comprised of survival mechanisms including: organ function, temperature control, genetic structure, response patterns, ego, and what Neuman terms 'knowns and commonalities'. Lines of resistance and two lines of defense protect this core. The person may in fact be an individual, a family, a group, or a community in Neuman's model. The person, with a core of basic structures, is seen as being in constant, dynamic interaction with the environment. Around the basic core structures are lines of defense and resistance (shown diagrammatically as concentric circles, with the lines of resistance nearer to the core. The person is seen as being in a state of constant change and-as an open system-in reciprocal interaction with the environment (i.e. affecting, and being affected by it).

Theoretical Framework

Nursing Care PlansASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: “Nahihirapan akong huminga lalo na kapag hinihingal,” patient verbalized.Objective: Cough with yellowish

sputum Use of accessory

muscles during expiration

Orthopnea RR: 32cpm

Ineffective Airway Clearance related to Pleural Effusion

Short-term goal: After 1 hour of

nursing intervention, the patient will be able to perform deep breathing and coughing exercises to expectorate secretions and maintain airway patency.

Long-term goal: After 8 hours of

nursing intervention, the patient will be able to gain understanding about management of ineffective airway clearance.

1. Position head midline with flexion appropriate for age and condition.2. Monitor client’s respiratory status at least every 4 hours.3. Encourage the client to drink at least 2000 ml of fluid daily if not contraindicated.4. Encourage deep breathing and coughing exercises.5. Assist the client To assume an appropriate breathing and cough position such as high fowler’s position.

1. To open or maintain open airway in at-rest patient.2. Monitoring respiratory status facilitates early detection of complications.3. Adequate fluids hydrate the pulmonary mucous membranes and decrease the viscosity of the secretions.4. Deep breathing expands lung tissue and moves secretions.5. High fowler’s position provides maximum chest expansion.

After 1 hour of nursing intervention, the patient has performed deep breathing and coughing exercises and has expectorated secretions and maintain airway patency.

After 8 hours of nursing intervention, the patient had gained understanding about management of ineffective airway clearance.

Nursing Care PlansASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:Patient verbalized, “Madalas akong parang kinakapos sa paghinga.”Objective:(+) DOB-orthopnea-RR: 32-Use of accessory muscles to breath(+)Nasal flaring

Ineffective Breathing Pattern related to hypoventilation syndrome

Short-term goal:After 30 minutes of nursing intervention, patient’s RR will decrease from 32 to 27.Long-term goal:After 8 hours of nursing intervention, patient’s RR will remain at 27cpm or less.

1. Note emotional responses.2. Suction airway as needed3. Elevate HOB and have client sit up in chair4. Encourage slower/deeper respirations, use of pursed-lip technique5. Stress importance of good posture and effective use of accessory muscles

1. Anxiety may be causing/exacerbating acute or chronic hyperventilation.2. to clear secretions3. To promote physiological ease of maximal inspiration4. to assist cient in “taking control of the situation.”5. to maximize respiratory effort

After 30 minutes of nursing intervention, patient’s respiratory rate decreased from 32 to 27.Within 8 hours of nursing intervention, patient’s RR did not increase over 27.

Medication Encourage the patient to comply with medications the physician has

prescribed Explain the significance of compliance and continuation of medications Explain the significance of taking the right dose and frequency Clarify to the patient and relatives the indications and action of drugs

prescribed to help in understanding its importance Inform the patient not to abruptly stop the medication when he feels

sudden relief Environment Encourage the patient to ensure safe and clean environment for better and

faster healing. Treatment Advise to immediately see a doctor if any signs of infection and if any signs

and symptoms still persists. Advise the patient to have a routine cleaning of wounds to prevent and

minimize the risk for infection.

Discharge Planning

Health TeachingAdvise to properly comply with his medications to promote

faster wound healing and to avoid risk for infection.Encourage to eat nutritious foods that may help him to

recover early.Out-patientAdvise patient to avoid rigorous activities.Encourage patient to take extra care to avoid future

accidents and injuries.DietEncourage the patient to have small frequent feeding.Advise the patient to eat nutritious foods. Advise to increase fluid intake.

Discharge Planning

Thank You for listening

Documents

Pleural Effusion