60453137 case-study-pleural-effusion

World Citi Colleges
960 Aurora Blvd. Quezon City
Case Presentation
In
NCM 103
Pleural Effusion
Submitted by:
Alenzuela, Dianne
Aloy, Marlyn
Bacera, Arfel
Boncato, Ronnie jay
Reyes, Daniel
Reyes, Ella
Salazar, James
Sañosa, Jasmine
Saquitan, RJ
Saring, Marie
Sherman, Myrna
Solatre, Carlo
Tabieros, Kristine Joy
Taclas, Josid
Tobari, Diane
Ungos, Abby
Submitted to:
Mr. Dominic Bautista
Ms. Myla Lim
Mr. Sherwin Villegas
Date of Submission:
Aug. 7, 2010

I. Introduction
This is the case of C.J 17 y/o male patient who was admitted at WCMC on July 26, 2010 at
12:15am due to chief complain of DOB. His final diagnosis is Pleural Effusion probable
secondary to PTB stage 3.
Pleural Effusion, a collection of fluid in the pleural space, rarely a primary disease process; it
is usually secondary to other disease. Normally, the pleural space contains a small amount
of fluid (5-15mL), which acts as a lubricant that follows the pleural surfaces to move without
friction. Pleural effusion maybe complication of heart failure, tuberculosis, pneumonia,
pulmonary infections (particularly viral infections), nephrotic syndrome, connective tissue
disease, pulmonary embolus, and neoplastic tumors. The most common malignancy
associated with a pleural effusion is bronchogenic carcinoma. Usually the patient is acutely
ill and has signs and symptoms similar to those of an acute respiratory infection or
pneumonia (fever, night sweats, pleural pain, cough, dyspnea, anorexia, weight loss). If the
patient is immunocompromise, the symptoms may be vague. If the patient has received
anti-microbial therapy, the clinical manifestations maybe less obvious. The severity of
symptoms is determined by the size of the effusion the speed of its formation, and the
underlying lung disease. A large pleural effusion causes dyspnea (SOB) .The diagnosis is
established by chest CT. Usually a diagnostic thoracentesis is performed, often under
ultrasound guidance.
Anatomy of Pleura
• Pleural fluid
•Normally present between the
parietal and the visceral pleura.
• Acts as a lubricant and
• Allows the visceral pleura covering
the lung to slide along the parietal
pleura lining the thoracic cavity
during respiratory movements.
Physiology of Pleural Fluid
• It is believed that the fluid that normally enters the pleural space originates in the capillaries in
the parietal pleura
•Human beings

•Amount of pleural fluid formed daily
in a 50-kg individual =
approximately 15 mL
• The mean lymphatic flow from one
pleural space = 0.40 mL/kg/hour
• Pleural fluid accumulates when the rate of pleural fluid formation exceeds the rate of pleural
fluid absorption.
•Normally, there should be a small amount
(0.01 mL/kg/hour) of fluid constantly
enters the pleural space from the
capillaries in the parietal pleura.
Almost all of this fluid is removed by the
lymphatics in the parietal pleura, which
have a capacity to remove at least 0.20
mL/kg/hour.
• Note that the capacity of the lymphatics to remove fluid exceeds the normal rate of fluid
formation by a factor of 20.
In 2000, tuberculosis was the sixth leading cause of morbidity and mortality in the Philippines.
The burden of the disease is made more serious by the fact that the country has the 8th highest
TB incidence in the world and the 3rd in the Western Pacific Region in 2003. The control of TB,
an airborne infection, is achieved mainly by rendering infectious smear-positive cases
noninfectious soon after diagnosis is made and by curing as many TB cases identified. These
measures reduce disease transmission and minimize the physiological and socio-economic
impact of TB on the patient, his family and community. Only Vietnam, among the countries with
high TB prevalence, has attained the global target of 85 percent cure rate and 70 percent case
detection rate(WHO 2002). The Philippines has already achieved the 85 percent cure rate target
but the case detection rate is still at 61 percent. This means that the country is on the verge of
achieving the 70/85 global target for tuberculosis.

II. Objectives
General:
After the completion of the case presentation, the student will be able to:
Further their knowledge about respiratory system and pleural effusion.
Specific:
After the completion of the case presentation, the student will be able to:
• Determine the health profile of the patient using the nursing assessment guide.
• Discuss the anatomy and physiology of the respiratory disease system that is directly
affected in a Pleural Effusion and relates the concept to the actual situation of the
patient.
• Discuss comprehensively the pathophysiology of Pleural Effusion.
• Relate the diagnostic findings to the pathophysiology of the disease process.
• Discuss the effect of the therapeutic regimen used.
• Relate the nursing care plan to the needs and problem of the patient.
• Discuss comprehensively the nursing care plan.
• Determine the prognosis of the patient.

III. Theoretical Framework
Virginia Henderson
Nursing
Virginia Henderson viewed the patient as an individual requiring help toward achieving
independence. She states that “The unique function of the nurse is to assist individual, sick or
well, in the performance of those activities contributing to health or its recovery (or peaceful
death) that he would perform unaided if he had the necessary strength, will, or knowledge and
to do this in such a way to help him gain independence as rapidly as possible.”
Health
Virginia Henderson did not state her own definition of health. But in her writing, she equated
health with independence.

Environment
Again, Henderson did not give her own definition of environment. Instead, she used Webster’s
New Collegiate Dictionary, 1961, which defined environment as “the aggregate of all the
external conditions and influences affecting the life and development of organism.”
Person
Henderson viewed the patient as an individual who requires assistance to achieve health and
independence or peaceful death. The mind and body are inseparable. The patient and his or her
family are viewed as a unit.
The 14 Basic Human Needs
1. Breathe normally.- In our patient’s case there is presence of difficulty of breathing due
to plural effusion the main goal is to secure patient’s breathing.
2. Eat and drink adequately. – There is presence of malnutrition because of sudden weight
loss due to having PTB. Our concern is to regain patient’s desirable body weight.
3. Eliminate body wastes. – There is presence or impaired gas exchange in the patient. The
nurse’s responsibility is to correct this problem to provide comfort to the patient.
4. Move and maintain desirable postures. – The patient is now bed ridden due to his
illness and can’t even go to the bathroom by him self. The health care provider’s
responsibility is to take care and give as much care as possible to the patient to give the
best care while in recovery.
5. Sleep and rest. – The patient is usually sleeping during his hospitalization period the
goal of the health care provider is to give as much comfort as possible to the patient
while sick.
6. Select suitable clothes--dress and undress. – Give proper clothing to help in breathing
and comfort. Health care provider should advise patient to wear the suitable clothing as
needed.
7. Maintain body temperature within normal range by adjusting clothing and modifying
the environment. – The health care provider’s responsibility is to constantly check the
VS of the patient to check if there are abnormalities or significant changes noted and to
give proper action as soon as possible.

8. Keep the body clean and well groomed and protect the integument. – It is important to
maintain the hygiene of the patient to avoid any complication such as infection and to
give comfort while sick, recovering or well.
9. Avoid dangers in the environment and avoid injuring others. – Make sure that the
patient as well as the people surrounding him is safe the health care provider’s job is to
ensure the safety of the patient and the people around him such as advising relatives or
visitors to wear mask for precaution and as for the patient putting side rails to avoid
falling in from bed.
10. Communicate with others in expressing emotions, needs, fears or opinions.- Proper
communication is a good way to show care, Establishing rapport is a good way of better
relationship as patient nurse interaction.
11. Worship according to one's faith. – Respecting the patient’s spirituality is an important
factor in good relationship between health care provider and patient.
12. Work in such a way that there is a sense of accomplishment. – Make sure to finish what
you start.
13. Play or participate in various forms of recreation.
14. Learn - Discover, or satisfy the curiosity that leads to normal development and health
and use the available health facilities.
IV. Nursing Assessment
A. Personal Data
Name: C.J.
Age: 17 years old
Birthday: February 12, 1993
Nationality: Filipino
Gender: Male

Civil Status: Single
Address: Marikina City
Occupation: HRM 2nd
year Student
Adm. Date: July 26, 2010
Adm. Time: 12:15 am
Chief complaint: DOB – Difficulty of Breathing
Clinical Impression: Pleural effusion probable secondary to PTB stage 3.
B. History of Present illness:
2 days prior to admission the patient complains chest pain and difficulty of
breathing especially at night. When he takes a rest, it lessens the pain. He also
complains stomach ache. Then few hours prior to admission the patient DOB, fever and
accompanying pain in his right lower quadrant. He was then immediately rushed to
WCMC on June 27, 2010
C. Past Health history:
June 17, 2010 he was admitted to St.Victoria Hospital in Marikina City and was
confined for 1 week. Chief Complaint is fever. The doctor gave medication of Myrin P
forte & Iberet ordered to take for a month, because the doctor’s finding was pleural
effusion.
D. Family history:
Both of the patient’s parents have no history of illness. But the grandfather on
his father side died due to Cardiac Arrest. His grandmother on his father side has a
history of Hypertension. Also, his grandfather and grandmother on his mother side has
a history of Hypertension
E. Social History:
The patient is 17 years old. He’s taking up Hotel Restaurant Management 2nd
year student. His usual daily activity is playing basketball 3 times a day. During high
school he was a varsity in basketball on his school. He also spends a lot of time in front
of the computer. The earliest time he finish his stuff is 12 midnight & most late is 2am.
He also wants to hang out with his friends.
PHYSICAL ASSESSMENT

Day 1
HAIR
Black, thin, straight, shiny and short
SCALP
White, oily w/ presence of dandruff
FACE
Symmetrical facial movement, he is exhausted due to lack of sleep and pain
EYES
The outer cantus of the patient eyes were symmetrical to the pinna of his ears. The eyebrows
were thin but evenly distributed and have short eyelashes. Patient’s was observed to have white
sclera, pale conjunctivas, and black equally rounded pupils. Constriction were observed when
light stimulation done at varying distance.
NOSE
The patient has pointed nose, with dry mucus membranes.
EARS
Tip of the ear is aligned with the outer canthus of the eye. Ear wax observed when exposed to
pen light. He is able to hear from both ears because he was able to respond to the questions
that was asked to him.
MOUTH
He is able to open and close with ease.
TEETH
He has a complete white tooth w/ no dentures and any dental carries.
TONGUE
The patient has moist with white patches over the tongue.
LIPS

Dry and pale in color.
NECK
The patient’s neck has fair skin complexion and muscle tone was fairly good and able to move
his head. No masses palpated along lymph nodes. But there’s a presence of wounds & lesions.
The carotid pulse is palpable.
CHEST
Chest is symmetrical during respiration, fair skin in color and smooth with respiratory rate of 28
bpm. The patient has test tube drainage for his pleural effusion.
ABDOMEN
The patient has undergone appendectomy on his RLQ. He is wearing a binder.
UPPER EXTREMETIES
The patient is having difficulty in lifting his left arm due to the presence of edema. Has fair
complexion but pale. Patient’s both arms are edematous and palms were dry and warm to
touch. Capillary refill was within 3 seconds. The patient has an IV fluid of 5% Dextrose in water
250 ml on his right hand.
LOWER EXTREMETIES
The patient’s right and left lower extremities are fair in complexion. Patient’s legs and feet is
edematous were dry and warm to touch. Capillary refill was within 3 seconds.
Day 2
HAIR
Black, thin, straight, shiny and short
SCALP
White, smooth scalp, oily w/ presence of dandruff
FACE

Symmetrical facial movement, he is more exhausted. He is sleeping during assessment because
of Demerol administration to ease his pain on his RLQ.
EYES
The outer cantus of the patient eyes were symmetrical to the pinna of his ears. The eyebrows
were thin but evenly distributed and have short eyelashes. Patient’s was observed to have white
sclera, pale conjunctivas, and black equally rounded pupils. Constriction and dilation were
observed when light stimulation done at varying distance.
NOSE
The patient has pointed nose, with dry mucus membranes
EARS
Tip of the ear is aligned with the outer canthus of the eye. Ear wax observed when exposed to
pen light. He is able to hear from both ears.
MOUTH
The patient is able to open and close with ease.
TEETH
He has a complete white tooth w/ no dentures and any dental carries.
TONGUE
The patient has moist with white patches over the tongue.
LIPS
Dry and pale in color.
NECK
The patient’s neck has fair skin complexion and muscle tone was fairly good and able to move
his head. No masses palpated along lymph nodes. But there’s a presence of wounds & lesions.
The carotid pulse is palpable.
CHEST
Chest is symmetrical during respiration, fair skin in color and smooth with respiratory rate of 28
bpm. The patient has test tube drainage for his pleural effusion.
ABDOMEN

Undergo appendectomy on his RLQ. He is wearing a binder.
UPPER EXTREMETIES
The patient is having difficulty in lifting his left arm due to the edema. Has fair complexion but
pale. Patient’s both arms are edematous and palms were dry, warm to touch with dry. Capillary
refill was within 3 seconds. The patient has an IV fluid of 5% Dextrose in water 250 ml on his
right hand.
LOWER EXTREMETIES
The patient’s right and left lower extremities fair complexion. Patient’s legs and feet is
edematous were dry and warm to touch. Capillary refill was within 3 seconds.
Vital Signs
Day 1, 4pm (August 05, 10): T: 36'C, P: 70bpm, R: 28bpm, BP: 110/80
Day 1, 8pm: 37.1'C, P: 100bpm, R: 28bpm, BP: 110/80 U: 2, S: 1
Day 2, 4pm (August 06, 10): T: 37.6'C, P: 98bpm, R: 25bpm, BP: 120/80
Day 2, 8pm: 37.9'C, P: 90bpm, R: 28bpm, BP: 110/80 U: 2 S: 1
V. Usual pattern of ADL (GORDON’S)
AREA BEFORE
HOSPITALIZATION
DURING
HOSPITALIZATION
(DAY1)
DURING
HOSPITALIZATION
(DAY2)
1. Social history The pt had an active
lifestyle when he was
still well. He plays
He socializes with the
nurses and the doctors.
He was accompanied by
The patient was
asleep throughout
the day.

basketball as his form of
exercise. He socializes
with his friends at
school. At home, he was
playing computer games
such as dota from 7:00
pm until dawn
one of his parents. His
classmates from FEU
also visited him.
2. Mental Conscious and aware of
time, date and reality.
Able to do his task as a
student.
Conscious and aware of
time, date and reality.
Able to answer the
questions when asked
to.
The patient was
asleep throughout
the day.
3. Emotional He was contented with
his life as a student.
He was sad when he
was alone but he cheers
up when his relatives,
classmates and friends
visited him.
The patient was
asleep throughout
the day.
4. Sensory
perception
His sensory were all
working, able to perceive
stimuli.
The patient was able to
perceive stimuli.
The patient was
asleep throughout
the day but wakes
up when feels the
pain on his RLQ.
5. Motor
Capabilities
Able to move his body
with ease.
The patient is in strict
bed rest.
The patient is in
strict bed rest.
6. Respiratory RR: 4pm: 28 bpm
8pm: 27 bpm
RR: 4pm: 25 bpm
8pm: 28 bpm
7. Circulatory PR: 4pm: 70bpm
8pm: 100bpm
BP: 4pm: 110/80mmHg
8pm: 110/80mmHg
PR: 4pm: 98bpm
8pm: 90bpm
BP: 4pm: 120/80
8pm:110/80
mmHg

8. Body
temperature
Temp: 4pm: 36’C
8pm: 37.1’C
Temp:4pm: 37.6’C
8pm: 37.9’C
9. Nutritional He eats all the foods he
likes especially fried
chicken. He just eats
vegetables when his
mother forced him to.
He is in soft diet. He
only eats “lugaw”
He is in soft diet.
He only eats
“lugaw”
10. Elimination He urinates and
defecates regularly.
Urine: 2
Stool: 1
Urine: 2
Stool: 1
11. State of
physical rest
& comfort
He usually sleeps around
10 in the evening when
there’s a class on the ff
morning.
He sleeps anytime of
the day.
He sleeps
throughout the
day.
12. State of skin
and
appendices
Good skin turgor and
warm feeling.
Incision on the RLQ.
Wounds and lesions on
the neck.
Incision on the
RLQ. Wounds and
lesions on the
neck.
VI. ANATOMY AND PHYSIOLOGY

The respiratory system is an intricate arrangement of spaces and passageways that conduct
air from outside the body into the lungs and finally into the blood as well as expelling waste
gasses. This system is responsible for the mechanical process called breathing.
When engaged in strenuous activities, the rate and depth of breathing increases in order to
handle the increased concentrations of carbon dioxide in the blood. Breathing is typically an
involuntary process, but can be consciously stimulated or inhibited as in holding your
breath.
Upper Respiratory System
Nostrils/Nasal Cavities
During inhalation, air enters the nostrils and passes into the nasal cavities where foreign
bodies are removed, the air is heated and moisturized before it is brought further into the
body. It is this part of the body that houses our sense of smell.
Pharynx
The pharynx, or throat carries foods and liquids into the digestive tract and also carries
air into the respiratory tract.
Larynx
The larynx or voice box is located between the pharynx and trachea. It is the location of
the Adam's apple, which in reality is the thyroid gland and houses the vocal cords.
Trachea
The trachea or windpipe is a tube that extends from the lower edge of the larynx to the
upper part of the chest and conducts air between the larynx and the lungs.
Lungs
The lungs are the organ in which the exchange of gasses takes place. The lungs are made
up of extremely thin and delicate tissues. At the lungs, the bronchi subdivides, becoming
progressively smaller as they branch through the lung tissue, until they reach the tiny air
sacks of the lungs called the alveoli. It is at the alveoli that gasses enter and leave the blood
stream.
Lower Respiratory System

Bronchi
The trachea divides into two parts called the bronchi, which enter the lungs.
Bronchioles
The bronchi subdivide creating a network of smaller branches, with the smallest one
being the bronchioles. There are more than one million bronchioles in each lung.
Avleoli
The alveoli are tiny air sacks that are enveloped in a network of capillaries. It is here that
the air we breathe is diffused into the blood, and waste gasses are returned for elimination.
Gas Exchange
The major function of the respiratory system is gas exchange. As gas exchange occurs,
the acid-base balance of the body is maintained as part of homeostasis. If proper ventilation
is not maintained two opposing conditions could occur: 1) respiratory acidosis, a life
threatening condition, and 2) respiratory alkalosis.
VII. Pathophysiology
Organ Affected:
LUNGS
Risk factors:
Presence of Pulmonary
Tuberculosis
Disease Process:
An exudative effusion results from increased
capillary permeability characteristic of the
inflammatory reaction. This type of effusion occurs
secondary to other conditions.

Laboratory Exam Results:
ARTERIAL BLOOD GAS
Date ordered Laboratory exams Results Normal values Significance
July 27, 2010 pH 7.388 7.35-7.45 Increase:
• Hyperventilation
• Anxiety, pain
• Anemia
• Shock
• Some degrees of
Clinical Manifestations:
Some symptoms are caused by the underlying
disease. Size of effusion & the time course of
development determine the severity.
- Large effusion: SOB to acute respiratory distress
- Small – Moderate: Dyspnea may not be present
- Dullness/Flatness to percussion over areas of
fluid, minimal or absence of breath sounds, and
tracheal deviation from affected side.
Medical Management:
- Thoracentesis
- Chest tube and water-seal drainage; left side
- Meds: ethambutol, corticosteroid (Prednisone),
levofloxacin
Diagnostic Evaluation:
- CXR – pleural effusion in left hemithorax
- Thoracentesis
Clinical Manifestations:
DOB
Tachypnea
Chest pain
Medical Management:
- Thoracentesis
- Chest tube and water-seal drainage
- Chemical pleurodesis
- Surgical pleurectomy
- Educate pt and family about management of
drainage system with outpatient therapy
Diagnostic Evaluation:
- CXR (lateral decubitis)
- Chest CT scan
- Ultrasound
-Thoracentesis
- Pleural Biopsy
- Pleural fluid analysis
BOOK Patie
nt

Pulmonary disease
• Some degrees of
Congestive heart
failure
• Myocardial infarction
• Hypokalemia
(decreased
potassium)
• Gastric suctioning or
vomiting
• Antacid
administration
• Aspirin intoxication
Decrease:
• Strenuous physical
exercise
• Obesity
• Starvation
• Diarrhea
• Ventilatory failure
• More severe degrees
of Pulmonary
Disease
• More severe degrees
of Congestive Heart
Failure
• Pulmonary edema
• Cardiac arrest
• Renal failure
• Lactic acidosis
• Ketoacidosis in
diabetes
PCO2 40.1 35-45mmHg Increase:
• Pulmonary edema
• Obstructive lung
disease
Decrease:
• Hyperventilation
• Hypoxia
• Anxiety
• Pregnancy
• Pulmonary Embolism
PO2 94.3 80-100mmHg Increase:
• Increased oxygen
levels in the inhaled
air

• Polycythemia
Decreased
• Decreased oxygen
levels in the inhaled
air
• Anemia
• Heart
decompensation
• Chronic obstructive
pulmonary disease
• Restrictive
pulmonary disease
• Hypoventilation
HCO3 23.6 22-26 mEq/L Decreased HCO3
• Metabolic Acidosis
Increased HCO3
• Metabolic Alkalosis
BE 1.3 +/- 2 mEq/L More Negative Values of
Base Excess may Indicate:
• Lactic Acidosis
• Ketoacidosis
• Ingestion of acids
• Cardiopulmonary
collapse
• Shock
More Positive Values of Base
Excess may Indicate:
• Loss of buffer base
• Hemorrhage
• Diarrhea
• Ingestion of alkali
O2 saturation 97.1% 95-100% Oxygen Saturation will fall if:
• Inspired oxygen
levels are
diminished, such as
at increased
altitudes.
• Upper or middle
airway obstruction
exists (such as during

an acute asthmatic
attack)
• Significant alveolar
lung disease exists,
interfering with the
free flow of oxygen
across the alveolar
membrane.
Oxygen Saturation will rise if:
• Deep or rapid
breathing occurs
• Inspired oxygen
levels are increased,
such as breathing
from a 100% oxygen
source
PO2 (A-a) 55.1 It is an important factor
affecting the amount of
oxygen that is bound to
hemoglobin.
BLOOD CHEMISTRY
Date ordered Laboratory exams Results Normal values Significance
July 27, 2010 AST(SGOT) 25.3 0.00-35.00 U/L Increased-
myocardial
infarction, skeletal
muscle disease,
and liver disease.
ALT(SGPT) 17.9 0.00-45 U/L Same conditions as
AST(SGOT), but
increased is more
marked in liver
disease than

AST(SGOT)
Creatinine 64.4 ↓ 72.00-127.00
umol/L
Increase- mascular
dystrophy, fever,
carcinoma of liver,
Potassium 3.58 3.50-5.50 mmol/L Increased-
hemolysis, chronic
renal failure,
acidosis, cushing’s
diease, corpus
luteum cysts.
Decrease –
diarrhea,
adrenocortical
insuffiency.
Sodium 132.7 ↓ 135.00-148.00
mmol/L
Increased- useful in
detecting gross
changes in water
and salt balanced
COMPLETE BLOOD COUNT
Date
ordered
Laboratory exams results Normal values Significant
August 5,
2010
WBC 11.7 ↑ 4.00-10.00 10^9/L Increased-
neurosyphilis,
anterior
poliomyelitis,
encephalitis
lethargic.
RBC 4.01↓ 4.50-6.50 10^12/L Decreased- iron
deficiency, vit. B6,
b12 or/ and folic

acid deficiency,
chronic disease,
hereditary anemia,
free radical
pathology, toxic
metals, catabolic
methabolism.
HGB 109↓ 130.00-170.00 g/L Decreased in
various anemias,
pregnancy, severe
of prolonged
hemorrhage, and
with excessive
fluid intake.
HCT 0.36↓ 0.40-0.54 Decrease in severe
anemias, anemia
in pregnancy,
acute massive
blood loss.
MCV 89 80.00-100.00 fl Increase in
macrocytic
anemias;
decrease in
microcytic anemia
MCH 27.2 27.00-32.00 pg Increase in
macrocytic
anemias;
decrease in
microcytic anemia
MCHC 306↓ 320.00-360.00 g/L Decreased in
severe hypocromic
anemia.
Increased and
decreased is same
with MCV two
exceptions in
spherocytosis, the

MCHC is elevated
but not in
pernicious anemia
PLT Increased 150.00-350.00
10^9/L
Increased in
malignancy,
myeloproliferative
disease,
rheumatoid
arthritis, and
postoperativerly;
about 50% of
patients with
unexpected
increase of
platelet count will
be found to have a
malignancy;
Lymphocytes 0.19↓ 0.25-0.50 Increase with
infectious
mononucleosis,
viral and some
bacterial
infections,
hepatitis;
decreased with
aplastic anemia,
SLE,
immunodeficiency
including AIDS.
Monocytes 0.01↓ 0.02-0.10 Increase with viral
infections,
parasitic disease,
collagen and
hemolytic
disorder;
decreased with
use of
corticosteroids,
RA, HIV infection.

Neutrophils 0.80 0.50-0.80 Increase with
acute infection,
trauma or surgery,
leukemia,
malignant disease,
necrosis; decrease
with viral
infections, bone
marrow
suppression,
primary bone
marrow disease.
Eosinophils 0.00-0.05 Increase in allergy,
parasitic disease,
collagen disease,
subacute
infections;
decrease with
stress, use of some
medications(ACTH,
epinephrine,
thyroxin
Date
ordered
Laboratory exams results Normal values Significance
August 1,
2010
WBC 18.3↑ 4.00-10.00 10^9/L Increased-
neurosyphilis,
anterior
poliomyelitis,
encephalitis
lethargic.
b12 or/ and folic
acid deficiency,
chronic disease,
hereditary anemia,

free radical
pathology, toxic
metals, catabolic
methabolism.
various anemias,
pregnancy, severe
of prolonged
hemorrhage, and
with excessive
fluid intake.
anemias, anemia
in pregnancy,
acute massive
blood loss.
MCV 80.00-100.00 fl Increase in
macrocytic
anemias;
decrease in
microcytic anemia
MCH 27.00-32.00 pg Increase in
macrocytic
anemias;
decrease in
microcytic anemia
MCHC 320.00-360.00 g/L Decreased in
severe hypocromic
anemia.
Increased and
decreased is same
with MCV two
exceptions in
spherocytosis, the
MCHC is elevated
but not in

pernicious anemia
PLT Increased 150.00-350.00
10^9/L
Increased in
malignancy,
myeloproliferative
disease,
rheumatoid
arthritis, and
postoperativerly;
about 50% of
patients with
unexpected
increase of
platelet count will
be found to have a
malignancy;
infectious
mononucleosis,
viral and some
bacterial
infections,
hepatitis;
decreased with
aplastic anemia,
SLE,
immunodeficiency
including AIDS.
Monocytes 0.02-0.10 Increase with viral
infections,
parasitic disease,
collagen and
hemolytic
disorder;
decreased with
use of
corticosteroids,
RA, HIV infection.
Neutrophils 0.94 ↑ 0.50-0.80 Increase with
acute infection,

trauma or surgery,
leukemia,
malignant disease,
necrosis; decrease
with viral
infections, bone
marrow
suppression,
primary bone
marrow disease.
parasitic disease,
collagen disease,
subacute
infections;
decrease with
stress, use of some
medications(ACTH,
epinephrine,
thyroxin
Date
ordered
Laboratory exams results Normal values Significant
July 27, 2010 WBC 15.2↑ 4.00-10.00 10^9/L Increased-
neurosyphilis,
anterior
poliomyelitis,
encephalitis
lethargic.
b12 or/ and folic
acid deficiency,
chronic disease,
hereditary anemia,
free radical
pathology, toxic

metals, catabolic
methabolism.
various anemias,
pregnancy, severe
of prolonged
hemorrhage, and
with excessive
fluid intake.
anemias, anemia
in pregnancy,
acute massive
blood loss.
MCV 80.00-100.00 fl Increase in
macrocytic
anemias;
decrease in
microcytic anemia
MCH 27.00-32.00 pg Increase in
macrocytic
anemias;
decrease in
microcytic anemia
MCHC 320.00-360.00 g/L Decreased in
severe hypocromic
anemia.
Increased and
decreased is same
with MCV two
exceptions in
spherocytosis, the
MCHC is elevated
but not in
pernicious anemia
PLT 502 150.00-350.00 Increased in

10^9/L malignancy,
myeloproliferative
disease,
rheumatoid
arthritis, and
postoperativerly;
about 50% of
patients with
unexpected
increase of
platelet count will
be found to have a
malignancy;
infectious
mononucleosis,
viral and some
bacterial
infections,
hepatitis;
decreased with
aplastic anemia,
SLE,
immunodeficiency
including AIDS.
Monocytes 0.02-0.10 Increase with viral
infections,
parasitic disease,
collagen and
hemolytic
disorder;
decreased with
use of
corticosteroids,
RA, HIV infection.
Neutrophils 0.92 ↑ 0.50-0.80 Increase with
acute infection,
trauma or surgery,
leukemia,
malignant disease,

necrosis; decrease
with viral
infections, bone
marrow
suppression,
primary bone
marrow disease.
parasitic disease,
collagen disease,
subacute
infections;
decrease with
stress, use of some
medications(ACTH,
epinephrine,
thyroxin

Total Protein and A/G
Date ordered Laboratory
exams
Results Normal
values
Significance
July 27, 2010 Total Protein 65.5 66.00-83.00
G/L
DECREASE
Low total protein levels can
suggest a liver disorder,
a kidney disorder, or a
disorder in which protein is
not digested or absorbed
properly. Low levels may be
seen in
severe malnutrition and with
conditions that cause
malabsorption, such
as Celiac
disease or inflammatory
bowel disease (IBD).
INCREASE
High total protein levels may
be seen
with chronic inflammation or
infections such as viral
hepatitis or HIV. They may
be caused by bone marrow
disorders such as multiple
myeloma.
Albumin 24.6 ↓ 35.00-52.00
G/L
Albumin's role in the body is
to maintain osmotic
pressures and to also
transport hydrophobic
substances
Globulin 40.9 ↑ 15.00-30.00
G/L
A/G ratio 0.60 ↓ 1.50-2.50 A high A/G ratio suggests
underproduction
of immunoglobulins as may
be seen in some genetic
deficiencies and in
some leukemias
A low A/G ratio may reflect
overproduction of globulins,
such as seen in multiple
myeloma or autoimmune
diseases, or
underproduction of albumin,
such as occurs with cirrhosis,

Body Fluid Cell Count (July 27, 2010)
Appearance before centrifugation- yellow/turbid
Appearance after centrifugation- yellow/ clear
Total Volume: 3mL
RBC Count: 1950 cells/ cu.mm
WBC Count: 2250 cells/ cu.mm
Total Cell Count: 4,200
Differential Count:
Neutrophils- 0.49
Lymphocytes: 0.51
RBC Morphology:
Creanated RBC- 100%
Non-creanated-
Gram Stain Result (July 27, 2010)
Polymorphonuclear cells= Few
No microorganisms seen
Chest X-ray(July 30, 2010)
Recheck chest x-ray after 2 days show diminution in the pleural effusion in the left hemithorax
A T-Tube is seen in situ

VIII. Drug Study
Date
Ordered
Medication Action Indication Nursing Intervention
July
28,2010
GN:
BN:
Omeprazole
Dosage: 40mg
Frequency: OD
To treat several
conditions related to
the esophagus,
stomach, and
intestines.
As part of a class of
drugs known as proton
pump inhibitors (PPIs), it
works by decreasing the
amount of acid that is
produced in your
stomach.
Monitor patients
hypersensitivity to
omeprazole and its
components

Route: IV
July 28,
2010
GN:
Piperacillin
BN:Tazocin
Dosage: 2.2g
Frequency: Q8
Route: IV
TAZOCIN is for
treatment of the
following systemic
and/or local bacterial
infections in which
susceptible organisms
have been detected
or are suspected:
Children
Appendicitis
complicated by
rupture with
peritonitis and/or
abscess formation in
children aged 2 12
years.
Bacterial infections in
neutropenic children
in combination with
an aminoglycoside.
TAZOCIN is indicated for
the treatment of
polymicrobic infections
including those where
gram-positive and gram-
negative aerobic and/or
anaerobic organisms are
suspected (intra-
abdominal, skin and skin
structure, lower
respiratory tract)
Monitor bleeding
manifestations or
significant leukopenia
following prolonged
administration have
occurred in some
patients receiving b-
lactam antibiotics,
including piperacillin
July 28,
2010
GN: Digoxin
BN:Lanoxin
Lanoxin is used to treat
congestive heart failure
Lanoxin is also used to
slow the heart rate in
patients with chronic
atrial fibrillation, a heart
rhythm disorder of the
atria (the upper
Before giving the drug
ask the patient about
allergic reactions to
digoxin

Dosage: 25mg
Frequency: OD
Route:
chambers of the heart
that allow blood to flow
into the heart).
August
06,2010
Maalox
Suspenscion
Dosage: 30cc
Frequency:
Stat
Maalox is a balanced
mixture of 2 antacids:
Aluminum hydroxide
is a slow-acting
antacid and
magnesium hydroxide
is fast acting.
Antacid therapy in
gastric and duodenal
ulcer, gastritis,
heartburn and gastric
hyperacidity.
Gastritis & duodenitis
accompanied by
flatulence, post-op gas
pain.
Make sure patient has
food intake 20
minutes – 1 hour
before taking maalox
August
06,2010
GN:
Meperidine
BN:Demerol
Dosage: 25mg
Route: IV
Frequency:
Now
Demerol is used for the
relief of moderate to
severe pain, most
commonly in obstetrics
and post-operative
conditions.
The principal actions of
therapeutic value in
Demerol are analgesia
and sedation. Demerol is
a narcotic analgesic with
effects similar to
morphine.
Monitor patient
include
hyperexcitability,
convulsions,
tachycardia,
hyperpyrexia, and
hypertension
Reassess patient’s
level of pain.

August
04,2010
GN:
Metronidazole
BN: Flagyl
Dosage: 1gm/
tab
Frequency:
Q12
Metronidazole is an
antibiotic effective
against anaerobic
bacteria and certain
parasites
Metronidazole is used
alone or in combination
with other antibiotics in
treating abscesses in the
liver, pelvis, abdomen
and brain caused by
susceptible anaerobic
bacteria.
Safety and
effectiveness in
pediatric patients have
not been established,
except for the
treatment of
amoebiasis.
Medication Action Indication Nursing Consideration
Generic Name:
ethambutol
Brand Name: Myrin
P Forte
3tab
AC breakfast
OD
Inhibits the growth or
other myobacteria.
THERAPEUTIC
EFFECTS:
Tuberculostatic
effects against
susceptible
organisms.
-PHARMACOLOGIC
ACTION:
antituberculars
Active tuberculosis or
other mycobacterial
disease (with at least
one other drug)
- Mycobacterial studies
and susceptibility tests
should be performed
before and
periodically during
therapy to detect
possible resistance.
- Assess lung sounds
and character and the
amount of sputum
periodically during
therapy.
Generic Name:
furosemide
Brand Name: N/A
40mg/IV
STAT
Inhibits the
reabsorption of
sodium and chloride
from the loop of
Henle and distal renal
tubule. Increases
renal excretion of
water, sodium,
chloride, magnesium,
potassium, and
calcium. Effectiveness
Edema due to heart
failure, hepatic
impairment or renal
disease. Hypertension.
- Monitor blood
pressure and pulse
before and during
administration.
Monitor frequency of
prescription refills to
determine compliance
in patient treated for
hypertension.
- Assess patients
receiving digoxin for

persists in impaired
renal function.
THERAPEUTIC
EFFECTS: Diuresis and
subsequent
mobilization of excess
fluid (edema, pleural
effusion). Decrease
blood pressure.
PHARMACOLOGIC
ACTION: loop
diuretics.
anorexia, nausea,
vomiting, muscle
cramps, paresthesia,
and confusion.
Patients taking digoxin
are at risk of digoxin
toxicity because of the
potassium-depleting
effect of diuretics.
Generic Name:
ketorolac
Brand Name:
Ketoradol
30mg/IV
q6
Inhibits prostaglandin
synthesis, producing
peripherally mediated
analgesia. Also has
antipyretic and anti-
inflammatory
properties.
THERAPEUTIC
EFFECTS: Decreased
pain.
PHARMACOLOGIC
EFFECT: pyrroziline
carboxylic acid.
Short-term
management of pain
(no to exceed 5 days
total for all routes
combined)
- Assess pain (note type,
location, and
intensity) prior to and
1-2 hr following
administration.
- May cause prolonged
bleeding time that
may persist for 24-48
hr following
discontinuation of
therapy.
- May cause increased
BUN, serum
creatinine, or
potassium
concentrations.
Generic Name:
tramadol
Brand Name:
Tramadin
100mg/IV
q8
Binds action to mu-
opioid receptors.
Inhibits reuptake of
serotonin and
nonepinephrine in the
CNS. THERAPEUTIC
EFFECTS: Decreased
pain.
PHARMACOLOGIC
ACTION: analgesics
(centrally acting)
Moderate to
moderately severe
pain.
- Assess type, location,
and intensity of pain
before and 2-3hr
(peak) after
administration.
- Assess blood pressure
and respiratory rate
before and
periodically during
administration.
Respiratory
depression has not
occurred with
recommended doses.
Generic Name:
corticosteroids
Brand Name:
Prednisone
Decreases
inflammation by
reversing increased
cell capillary
permeability and
It is prescribed in the
treatment of severe
inflammation and for
immunosuppression.
- Assess patient for
signs of adrenal
insufficiency
(hypotension, weight
loss, weakness,

20mg/tab
1tab BID
inhibiting migration of
polymorphonuclear
leukocytes.
Suppresses immune
system by reducing
lymphatic activity.
THERAPEUTIC EFFECT:
Suppression of
inflammation and
modification of the
normal immune
response.
PHARMACOLOGIC
EFFECT:
corticosteroids
(systemic)
nausea, vomiting,
anorexia, lethargy,
confusion,
restlessness).
- Monitor intake and
output ratios and daily
weights. Observes
patient for peripheral
edem, steady weight
gain, rales/crackles, or
dyspnea. Notify health
care professional if
these occur.
Generic Name:
celocoxib
Brand Name:
Celebrex
400mg/tab
1tab OD
Inhibits the enzyme
COX-2. This enzyme is
required for the
synthesis of
prostaglandins. Has
analgesic, anti-
inflammatory, and
antipyretic properties.
THERAPEUTIC
EFFECTS: Decreased
pain and
inflammation caused
by arthritis or
spondylitis.
Management of acute
pain including primary
dysmenorrhea.
- Assess ROM, degree
swelling, and pain in
affected joints before
and periodically
throughout therapy.
- Assess patient for
allergy to
sulfonamides, aspirins,
or NSAIDs. Patients
with these allergies
should not receive
celecobix.
Generic Name:
scopolamine
Brand Name:
Buscopan
1amp
STAT
Inhibits the muscarine
activity of
acetylcholine.
Corrects the
imbalance of
acetylcholine and
norepinephrine in the
CNS, which may be
responsible for
motion sickness.
THERAPEUTIC EFFECT:
Reduction of nausea
and vomiting.
Preoperative amnesia
and decreased
secretions.
Preoperatively to
produce amnesia and
to decrease salivation
and excessive
respiratory secretion.
- Assess patient for sign
of urinary retention
periodically during
therapy.
- Monitor heart rate
periodically during
parenteral therapy.
- Assess patient for pain
prior to
administration.
Scopolamine may act
as a stimulant in the
presence of pain,
producing delirium if
used without
morphine and

PHARMACOLOGIC
ACTION:
anticholinergics
meperidine.
Generic Name:
levofloxacin
Brand Name: Levox
750mg/tab
1tab OD
Inhibit the bacterial
DNA synthesis by
inhibiting DNA gyrase.
THERAPEUTIC
EFFECTS: Death of
susceptible bacteria.
PHARMACOLOGIC
ACTION:
fluoroquinolones
Treatment of bacterial
infections such as
respiratory tract
infection.
- Assess for infection
(vital signs;
appearance of
wounds, sputum,
urine, and stool; WBC;
urinalysis; frequency
and urgency of
urination; cloudy or
foul-smelling urine)
prior to and during
therapy.
- Obtaining specimens
for culture and
sensitivity before
initiating therapy. First
dose may be given
before receiving
results.
Generic Name:
trimetazidine
Brand Name:
Vastarel Mr
35mg /tab
1tab BID
Reduces the
metabolic damage
caused during
ischemia, by acting on
a critical step in
cardiac metabolism:
fatty acid β-oxidation.

IX. Nursing Management
Assessment Planning Nursing Intervention Evaluation
Subjective:
• Dyspnea
Objectives:
The patient manifested the
following:
• Tachypnea
• RR of 28
The patient may manifest
the following:
• Pallor skin
• Orthopnea
Nursing Diagnosis:
Ineffective Breathing
Pattern RT Decreased Lung
Volume Capacity as
evidenced by tachypnea,
and dyspnea
After 1-2 hours of
nursing interventions
the patient will
demonstrate
appropriate coping
behaviors and
methods to improve
breathing pattern.
• Monitor and record
vital signs
R. To obtain baseline data
• Provide relaxing
environment
R. To promote adequate
rest periods to limit
fatigue
• Assist client in the
use of relaxation
technique
R. To provide relief of
causative factors
• Administer prescribed
medications as
ordered
R. For the
pharmacological
management of the
patient’s condition
• Encourage adequate
rest periods between
activities
R. to limit fatigue
After 1- 2 hours of
nursing intervention
the patient has
demonstrate improve
breathing pattern
because he was able
to answer the
questions that was
being asked to him.

Acute Pain
Assessment Planning Intervention Evalutaion
Subjective:
“Masakit na masakit
po iyong inoperahan,
lalo na pagumuubo
ako.” as verbalized by
the patient.
Pain Scale: 9/10
Objective:
(+) abdominal
guarding
(+) facial grimace
(+) crying during
onset of pain
Restlessness
RR- 28
PR- 98
Nursing Diagnoses:
Acute pain related to
surgical procedure.
After 1-2 hours of
the patient will
verbalize that pain
scale of 9/10 will
reduce to 5/10.
Independent Nursing
Action:
Note location of
surgical procedures.
R: Presence of
known/unknown
complication/s may
make the pain more
severe than
anticipated.
Provide comfort
measures such as
touch therapy,
repositioning,
providing a quite
environment
R: to promote non
pharmacological pain
management.
Encourage use of
relaxation techniques
such as focused
breathing, imaging
and listening to music.
R: To distract
attention and reduce
tension.
Collaborative:
Administer analgesics
as prescribed to
maximum dosage as
needed.
After 1-2 hours of
nursing interventions,
patient verbalized
that pain scale of 9/10
was reduced to 5/10.

R: To maintain
acceptable level of
pain.
Imbalanced Nutrition: Less than body requirements
Assessment Planning Intervention Evaluation
Subjective
Objective:
Weight before
hospitalization: 50 kg
Height: 165 cm
BMI: 18.4
Weight: 45 kg
Height: 165 cm
BMI= 16.5
Underweight: <18.5
Diagnosis:
Imbalanced Nutrition:
Less than body
requirements related
to absence of physical
conditions that would
explain weight loss or
prevent weight gain.
After 1-2 hours of
nursing the patient
and his relatives will
be able to verbalize
and demonstrate
ways of nutritional
status, food and fluid
intake and weight
control
Record the patient’s
weight and height on
intake. Weigh
regularly, maintaining
standard conditions
R: This ensures
accurate record of
weight changes.
Conduct a nutritional
assessment
R: It is critical that the
health care provider
openly discuss and
have an
understanding of the
complex food and
weight-related
behaviors of the
patient so that
appropriate supports
can be integrated into
After 1-2 hours of
nursing the patient
and his relatives has
able to verbalize and
demonstrate ways of
nutritional
status,food and fluid
intake and weight
control

the treatment plan.
Assess cardiovascular,
metabolic, renal,
gastric, hematological,
and endocrine system
functioning.
R: Assessment
provides data on the
severity of
malnutrition.
Monitor intake (i.e.,
daily food plans that
track eating trends
along with emotional
states and triggering
events). Record intake
and output for the
hospitalized patient.
R: These data help
determine the
patient’s actual caloric
intake and eating
behaviors.

Activity Intolerance
Subjective:
“nahihirapan ako
gumalaw dahil masakit
ang tagiliran ko”as
verbalized by the
patient.
Objectives:
- Body weakness
- Limited range
of motion.
- Unable to get
up to go to the
bathroom
Nursing Diagnosis:
Activity intolerance
related to insufficient
oxygen, generalized
weakness and
After 1-2 hours of
nursing interventions,
the patient will use
identified techniques
to improve activity
intolerance
Independent:
*Note client reports
of weakness, fatigue,
pain.
R: Symptoms may be
result of/or
contribute to
intolerance of
activity.
Provide the patient
with a calm and quiet
environment
R: To provide
relaxation
*Promote comfort
measures and
provide for relief of
The patient shall
have used identified
techniques to
improve activity
intolerance

complete bed rest. pain.
R: to enhance ability
to participate in
activities.
*Plan for maximal
activity within the
client’s activity.
R: to determine
current status and
needs associated with
participation in
needed or desired
activities
Risk for Infection

Subjective
none
Objective
*T- 36.5
*P- 73bpm
*R- 27bpm
*BP- 90/70 mmHg
*S/P CTT Insertion
*With CTT connected
to one way water
sealed bottle
*With dry and intact
dressing on
operative/insertion
site
Diagnosis:
Risk for infection
related to tissue
trauma secondary to
surgical procedure
( CTT and
appendectomy)
After 2-3 hours of
the patient and his
relatives will be able
to verbalize and
demonstrate ways
in preventing
infection specifically
proper hand
washing, proper
wound care and
water-sealed
drainage bottle
Independent
Monitor vital signs and
records
R: To provide baseline
data for comparison.
Elevation in rates may
signal infection
Assess insertion site for
signs of infection
R: To check for skin
integrity and identify
need for further
management
Assess patency and
intactness of water
sealed bottle
R: Any obstructions and
kink may delay flow.
Absence of fluctuations
and excessive bubbling
may indicate leaks
Monitor and record
amount and
characteristics of
drainage
R: Increase amount s of
drainage may signal
worsening condition
Provide regular wound
dressing and tube care
R: To promote comfort
and hygiene. To prevent
growth of
microorganisms in
dressings, tube
Change linens and pt’s
robes
R: To promote comfort
and hygiene. To prevent
growth of
microorganisms in linens
and robes
Encourage patient to
verbalize any untoward
feelings esp. discomfort
or pain on
After 2-3 hours of
the patient and his
relatives has able to
verbalize and
demonstrate ways
in preventing
infection specifically
proper hand
washing, proper
wound care and
water-sealed
drainage bottle

X. Evaluation
I. Evaluation
Medication: Continue prescribed medications for PULMONARY TUBERCULOSOS, and be aware
of their complications.
These include:
- Omeprazol
- Tazocin
- Lanoxin
- Maalox Suspension
- Demerol
- Flagyl
-Myrin
-Vastarel
-Furosemide
-Ketoradol
-Tramadin
-Prednisone
-Celebrex
-Buscopan
Exercise: Avoid strenuous activities, such as heavy lifting and any other extreme sports or
activities that may trigger an increase in heart rate. After recovery if the patient discharged the
patient should start with short slow walks for about 10-15 minutes and with time gradually
increase the duration and intensity of the walk. Patient should also be advised to “take it easy”
to do activates that their body can handle.
Treatment: Educate the patient how to properly take the medications and explain the action of
it and the considerations to be taken during medication intake.

Hygiene: Educate patient on the proper self hygiene techniques to prevent any further
complications. Like brushing teeth to avoid any further infections.
Out Patient: Remind patient about upcoming check ups needed to increase the patients health.
Also advice patient about any further appointments that need to be made. Educate the patient
about physical limitations and the time needed to make a full recovery before resuming normal
activates before hospitalization.
Diet: low sodium and low fat diet. Avoid foods that will cause constipation and strain during
bowel movements. Stick to a soft diet to ease the digestion process. To avoid any further
complications with the patient’s condition.
Spiritualism – joining to some activities like bible studies and attending events to further
develop the client’s condition after being discharged from the hospital.
Prognosis
The client’s prognosis is not that good though he is showing some progress like being
able to communicate well to the relatives and nurses, able to move on his own and even smiling
while talking even though he is suffering from pain.
After having been admitted at WCMC, the patient is more comfortable and showed an
increase in sense of energy and communication.
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