PLEURAL

EFFUSION
BETHANY 4TH MAIN AND SAB
 INTRODUCTION
This is the case of Patient X, 79 year-old male who was admitted at
Bethany Hospital last October 15, 2019 at 9:34 am due to chief complaint of
dyspnea and body pain, and an admitting diagnoses of Sepsis, Nasocomial
Pneumonia VS CAP high risk and Pleural Effusion, Left Secondary.
Pleural Effusion, a collection of fluid in the pleural space, is rarely a
primary disease process; it is usually secondary to other diseases. Normally, the
pleural space contains a small amount of fluid (5 to 15Ml), which acts as a
lubricant that allows the pleural surfaces to move without friction. Pleural
effusion may be a complication of heart failure, TB, 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.
 INTRODUCTION (cont.)
In certain disorders, fluid may accumulate in the pleural space to a point
at which it becomes clinically evident. This almost always has pathologic
significance. The effusion can be a relatively clear fluid, or it can be bloody or
purulent. An effusion of clear fluid may be a transudate or an exudate. A
transudate (filtrate of plasma that moves across intact capillary walls) occurs
when factors influencing the formation and reabsorption of pleural fluid are
altered, usually by imbalances in hydrostatic or oncotic pressures. The finding of
a transudative effusion generally implies that the pleural membranes are not
diseased. A transudative effusion most commonly results from heart failure. An
exudate (extravasation of fluid into tissues or cavity) usually results from
inflammation by bacterial products or tumors involving the pleural surfaces.
 INTRODUCTION (cont.)
Usually, the clinical manifestations are caused by the underlying disease.
Pneumonia cause fever, chills, and pleuritic chest pain, whereas malignant
effusion may result in dyspnea, difficulty lying flat, and coughing. The severity of
symptoms is determined by the size of effusion, the speed of its formation, and
the underlying lung disease. A large pleural effusion causes dyspnea. A small to
moderate pleural effusion causes a minimal or no dyspnea.
 PATIENT’S PROFILE
NAME: Patient X
GENDER: Male
AGE: 79 YEARS/OLD
BIRTHDATE: NOVEMBER 22, 1939
BIRTHPLACE: Bauang La Union
NATIONALITY: Filipino
CIVIL STATUS: Married
ADDRESS: #386, Quinavite, Bauang, La Union
RELIGION: Roman Catholic
 PATIENT’S PROFILE (cont.)
ADMISSION: DIAGNOSIS:

DATE: October 15, 2019 ADMITTING DIAGNOSES:

• Sepsis
TIME: 9:24 AM • Nosocomial Pneumonia vs CAP
high risk
ADMITTING PHYSICIAN:
Dr. Mendoza FINAL DIAGNOSIS:
• Massive Pleural effusion
 PATIENT’S PROFILE (cont.)
PATIENT’S MEDICAL HISTORY
FAMILY HISTORY • Enlargement of the heart
( 2008 )
( + ) Hypertension • Prostate enlargement stage 3
( + ) Diabetes benign ( 2016 )
• (+) Hypertension
• (+) Diabetes Mellitus
PATIENT’S PROFILE (cont.)
VITAL SIGNS UPON ADMISSION

Tᵒ: 36ᵒC
RR: 72 beats per minute
PR: 32 cycles per minute
BP: 120/70 mmHg
ANATOMY AND PHYSIOLOGY
( The lungs are pyramid-shaped, paired organs that
are connected to the trachea by the right and left bronchi;

LUNGS
on the inferior surface, the lungs are bordered by the
diaphragm. The diaphragm is the flat, dome-shaped
muscle located at the base of the lungs and thoracic cavity.
The lungs are enclosed by the pleurae, which are attached
to the mediastinum. The right lung is shorter and wider
than the left lung, and the left lung occupies a smaller
volume than the right. The cardiac notch is an indentation
on the surface of the left lung, and it allows space for the
heart. The apex of the lung is the superior region, whereas
the base is the opposite region near the diaphragm. The
costal surface of the lung borders the ribs. The mediastinal
surface faces the midline
ANATOMY AND PHYSIOLOGY
Each lung is composed of smaller units called lobes. Fissures
(cont.)
separate these lobes from each other. The right lung consists of
three lobes: the superior, middle, and inferior lobes. The left lung
LUNGS consists of two lobes: the superior and inferior lobes. A
bronchopulmonary segment is a division of a lobe, and each lobe
houses multiple bronchopulmonary segments. Each segment
receives air from its own tertiary bronchus and is supplied with
blood by its own artery. Some diseases of the lungs typically affect
one or more bronchopulmonary segments, and in some cases, the
diseased segments can be surgically removed with little influence
on neighboring segments. A pulmonary lobule is a subdivision
formed as the bronchi branch into bronchioles. Each lobule
receives its own large bronchiole that has multiple branches. An
interlobular septum is a wall, composed of connective tissue, which
separates lobules from one another.
 ANATOMY AND PHYSIOLOGY A shiny, thin, transparent membrane called the serous coat, or
(cont.) pleura, covers each lung. The inner (visceral) layer of the pleura is attached to
the lungs and the outer (parietal) layer is attached to the chest wall. Both
PLEURAL SPACE layers are covered with mesothelial cells, which secrete a small amount of
fluid (i.e., less than 2 tablespoons) that provides lubrication between the chest
wall and the lung. Both layers are held in place by a film of pleural fluid, like
two glass microscope slides that are wetted and stuck together. The pleural
space is called a potential space because it is virtually nonexistent. The pleural
membranes prevent the lung from making direct contact with the chest wall
and the diaphragm. Cells in the pleural space are primarily mesothelial cells
that line the surfaces of the pleural membranes and some white blood cells.
The pleural membranes are semipermeable. A small amount of fluid
continuously seeps out of the blood vessels through the parietal pleura. The
visceral pleura absorbs fluid, which then drains into the lymphatic system and
returns to the blood. Protein in the circulation and balanced pressures keep
excessive amounts of fluid from seeping out of the blood vessels into the
pleural space.
 ANATOMY AND PHYSIOLOGY
(cont.)
Each lung is enclosed within a cavity that is surrounded
PLEURAL SPACE by the pleura. The pleura is a serous membrane that surrounds
the lung. The right and left pleurae, which enclose the right and
left lungs, respectively, are separated by the mediastinum. The
pleurae consist of two layers. The visceral pleura is the layer that
is superficial to the lungs, and extends into and lines the lung
fissures. In contrast, the parietal pleura is the outer layer that
connects to the thoracic wall, the mediastinum, and the
diaphragm. The visceral and parietal pleurae connect to each
other at the hilum. The pleural cavity is the space between the
visceral and parietal layers.
 ANATOMY AND PHYSIOLOGY
(cont.) The pleurae perform two major functions: They produce
pleural fluid and create cavities that separate the major organs.
PLEURAL SPACE Pleural fluid is secreted by mesothelial cells from both pleural
layers and acts to lubricate their surfaces. This lubrication
reduces friction between the two layers to prevent trauma
during breathing, and creates surface tension that helps
maintain the position of the lungs against the thoracic wall. This
adhesive characteristic of the pleural fluid causes the lungs to
enlarge when the thoracic wall expands during ventilation,
allowing the lungs to fill with air. The pleurae also create a
division between major organs that prevents interference due to
the movement of the organs, while preventing the spread of
infection.
 ANATOMY AND PHYSIOLOGY
(cont.) An excessive amount of pleural fluid probably results from a
combination of fluid draining into the tissues from the blood vessels and
ACCUMULATION the overproduction of fluid by the mesothelial cells. Fluid accumulates in
MECHANISM OF

the pleural space by three mechanisms: increased drainage of fluid into

PLEURAL FLUID

the space, increased production of fluid by cells in the space, and

decreased drainage of fluid from the space. Increased amounts of fluid
drain from the circulation when there is hypertension in the venous
system (creating pressure imbalance) or when there is too little protein in
the blood. Ascites (fluid in the peritoneal space, or abdominal cavity) can
drain through small perforations in the diaphragm. A large amount of
fluid can drain directly into the pleural space this way. Abnormal
mesothelial cells (as in asbestosis) can produce large amounts of fluid.
White blood cells can accumulate in response to infection and
inflammation in the pleural space (empyema).
 ANATOMY AND PHYSIOLOGY
(cont.) These cells produce fluid that is difficult to drain or
that are in such large quantities that normal drainage
ACCUMULATION through the lymphatic system simply cannot keep up.
MECHANISM OF

Malignant tumor cells can migrate (or metastasize) to the

PLEURAL FLUID

pleural space from essentially any type of tumor in the body.

These cells can attach to either the visceral or parietal
pleural surfaces or float freely in the pleural space and
produce large amounts of fluid. When tumor cells block
lymphatic drainage, fluid accumulates. If the blockage is
located in the central lymphatic drainage system that drains
chyle (milky fluid consisting of lymph and fat) to the thoracic
duct, fluid rich in chyle accumulates in the pleural space.
 INITIAL ASSESSMENT
GENERAL SURVEY SKIN
Vital signs are: body temperature of 36.0
C; pulse rate 72 beats per minute with regular Patient has light brown skin complexion
rhythm upon palpitation; respiratory rate of 32 upon inspection. The patient’s skin on the left
cycles per minute with regular rhythm; with upper arm has blister wound approximately 2-3
equal expansion of the chest; blood pressure of inches wide. Skin on the left arm is punctured
systolic 120 and diastolic of 70 mmHg noted due to intravenous fluid infusion with noted
upon auscultation; oxygen saturation of 95%. edema, but no reddening, heat, nor pain.
Patient is awake, conscious and coherent. Speech Puncture site at the left posterolateral side of the
was slightly inadequate, but converses are well thorax due to thoracentesis procedure done. All
oriented. Client is responsive to questions both over skin is warm to touch, with good skin
verbally and physically. Chief complaint of turgor, and with adequate moisture upon
difficulty breathing and body pain with presence palpation.
of facial grimace.
 INITIAL ASSESSMENT (cont.) EYES AND VISION
Eyebrows: The client’s eyebrows are symmetrically
aligned and showed equal movement when asked
HEAD to raise and lower eyebrows.
Eyelids: There were no presence of discharges, no
Head is symmetrical upon discoloration and lids close symmetrically with
inspection. Fine, black, wavy hair noted involuntary blinks approximately 15-20 times per
in thin distribution. Nodular lesions with minute.
Eyes: The sclera appeared white. The palpebral
brown color and equally distributed conjunctiva appeared shiny, smooth and pink.
noted on the face upon inspection. No There is no edema or tearing of the lacrimal gland.
masses noted upon palpitation. The Cornea is translucent, smooth and shiny and the
client doesn’t complain of dizziness, details of the iris are slightly cloudy. Positive blurred
vertigo and headache upon the vision. Wears eyeglasses for daily use and reading.
The client blinks when the cornea was touched. The
interview. pupils of the eyes are black and equal in size. The
iris is flat and round.
 INITIAL ASSESSMENT (cont.)
EARS AND HEARING NECK
The neck muscles are equal in
The Auricles are symmetrical
size. The client showed coordinated,
and has the same color with his smooth head movement with no
facial skin. The auricles are aligned discomfort. The lymph nodes of the
with the outer canthus of eye. client are not palpable. The trachea
When palpating for the texture, is placed in the midline of the neck.
the auricles are mobile, firm and The thyroid gland is not visible on
not tender. The pinna recoils when inspection and the glands ascend
folded. The patient uses no during swallowing but are not
hearing aids to facilitate hearing. visible.
 INITIAL ASSESSMENT (cont.)
HAIR NAILS

The client has a whitish color

The hair of the client is nails and has the shape of convex
thin, unevenly distributed. curve. It is smooth and is intact
There are no signs of infection with the epidermis. When nails
and infestation observed. pressed between the fingers
(Blanch Test), the nails return to
usual color in less than 4 seconds.
 INITIAL ASSESSMENT (cont.)
LUNGS
NOSE AND BREATHING Respiratory rate of 32 cycles per
minute, regular in rhythm, with noted
Nose is symmetrical with good
exertion and use of accessory muscle
septal deviation noted upon inspection. No
upon inspection. Asymmetry chest
lesions and scars noted. Nasal mucosa is
expansion and diminished breath sound
red with adequate nasal hair and
on the left lobe of the lungs. Positive
accumulated mucus secretions noted upon Bibasilar crackles when auscultated.
inspection. Client is breathing with visual Frequent coughing accompanied by
difficulties when one nostril is occluded expectoration. Resonant sounds heard
suggesting nares on both side of the nose upon percussion of the anterior and
are patent. Client is able to smell pleasant posterior chest. On oxygen connected to a
and foul odors suggesting good olfaction. mask at 6 Liters per minute.
 INITIAL ASSESSMENT (cont.)
EXTREMITIES
ABDOMEN
The extremities are symmetrical in size and
length. Muscles: The muscles are not
The abdomen of the client palpable with the absence of tremors but
has an unblemished skin and is positive in pain when palpated. They are
uniform in color. The abdomen has normally firm and showed smooth,
a symmetric contour. There were coordinated movements. Bones: There
were no presence of bone deformities,
symmetric movements caused tenderness and swelling. Joints: There
associated with client’s respiration. were no swelling, tenderness and joints
move smoothly. Patient is ambulatory with
assistance.
PATHOPHYSIOLOGY
Predisposing Factors:
Precipitating Factor:
Age (79 y/o), male,
Community Acquired
Occupation (miner and
Pneumonia
carpenter)

Increased pleural fluid Decreased pleural fluid

formation clearance

Increase permeability

Blockage of lymphatic
stoma
Increase venous
pressure

↓Plasma oncotic pressure

Increase venous
pressure
↓Pleural pressure

PLEURAL
EFFUSION
LABORATORY
RESULTS
 Routine CBC Result Normal Values Remarks
Hemoglobin 62** M:120-170g Decreased hemoglobin
A low level of hemoglobin in the blood relates
directly to a low level of oxygen.
RBC 2.06 M: 4.5-6.0x10 9/L Decreased erythrocyte
- Indicates anemia. If RBC is decreased, the
hemoglobin decreases also. This means that
exchange of gases between the alveoli, and
the capillary beds are affected, and there will
be less oxygenated blood circulating the
body, and hypoxia results.

HEMATOLOGY WBC 30.7** 4.30-10.00x10 9/L Increased

Increased in number indicates infection or
damage caused by bacteria, viruses, etc.
DATE: Differential Count
OCTOBER 14, 2019 Segmenters 0.72 0.50-0.70 Increased
- Presence of infection
Lymphocyte 0.10 0.20-0.40 Decreased Lymphocytes
- Patient is prone to immunosuppression since
his lymphocytes are small in number.

- Lymphocytes play an important role in

immune response (B and T lymphocytes).
Hematocrit 0.18 M:0.4-0.54 Normal
 CLINICAL CHEMISTRY
DATE: OCTOBER 14, 2019

Test Result Normal Values Remarks

HGT 176 70.00-110.0 Hyperglycemic
mg/dL

HEMATOLOGY
DATE: OCTOBER 15, 2019
Test Result Normal Value Remarks
Clotting Time 2 mins 1.00-5.00 mins Normal
Bleeding Time 3-mins-30sec 1.00-5.00 mins Normal
 Hematology Form II Test Result Normal Value Remarks
Time 18.3 sec 12.0-16.0 sec Slightly prolonged
(Prothrombin Time)
- Due to antibiotics/anti-infectives
INR 1.51
DATE: Activity 71.04%
October 15, 2019 Control 13.0 sec

Test Result Normal Value Remarks Clinical Chemistry

LDH 84.0 80.00-285.00 IU/L Normal DATE:
Total Protein 31.6 64.00-83.00 g/L Low protein level October 15, 2019
- malnutrition Remarks: PLEURAL FLUID

Clinical Chemistry
Test Result Normal Value Remarks
DATE: Potassium 4.72 3.50-5.30 mEq/L Normal
October 15, 2019
 Test (Routine CBC) Result Normal Value Remarks
Hemoglobin 99 M:120-170g Decreased
A low level of hemoglobin in the blood relates
directly to a low level of oxygen.
RBC 3.30 M: 4.5-6.0x10 9/L Decreased erythrocyte
- Indicates anemia. If RBC is decreased, the
hemoglobin decreases also. This means
that exchange of gases between the alveoli,
and the capillary beds are affected, and
HEMATOLOGY there will be less oxygenated blood
DATE: October 16, 2019 circulating the body, and hypoxia results.

WBC 29.4 4.30-10.00x10 9/L Increased

Increased in number indicates infection or
damage caused by bacteria, viruses, etc.
Differential Count
Segmenters 0.89 0.50-0.70 Increased
Presence of infection
Lymphocyte 0.01 0.20-0.40 Decreased
Low lymphocytes counts can indicate a possible
infection or other significant illness
Hematocrit 0.30 M:0.4-0.54 Normal
 PLEURAL FLUID ANALYSIS TEST
• Non Gyne Cytology
• 48Ml yellowish clear fluid with inspissated mucus; the
latter processed as a cell block

Date Received Smears:

October 16, 2019
Date Reported • Some lymphocytes
October 17, 2019 • Few mesothelial cells
• No malignant cells

Diagnosis
• Pleural Fluid; Cytology.
• Mild lymphocytic infiltrates.
• Negative for malignant cells
 Test (Routine Result Normal Value Remarks
CBC)
Hemoglobin 118 M:120-170g Slightly decreased
A low level of hemoglobin in the blood relates
directly to a low level of oxygen.
RBC 3.89 M 4.5-6.0x10 Decreased erythrocyte
9/L Indicates anemia. If RBC is decreased, the
hemoglobin decreases also. This means that
HEMATOLOGY
exchange of gases between the alveoli, and the
DATE: October 20, 2019 capillary beds are affected, and there will be less
oxygenated blood circulating the body, and
hypoxia results.
WBC 32.2 4.30-10.00x10 Increased
9/L Increased in number indicates infection or
damage caused by bacteria, viruses, etc.
Differential Count
Segmenters 0.86 0.50-0.70 Increased
Presence of infection
Lymphocyte 0.02 0.20-0.40 Low lymphocytes counts can indicate a possible
infection or other significant illness
Hematocrit 0.35 M:0.4-0.54 Normal
 CLINICAL CHEMISTRY
Test Result Normal Value Remarks
DATE:
Potassium 4.59 3.50-5.30 mEq/L Normal
October 20, 2019

Test Result Normal Value Remarks

Acid fast stain (Pleural Negative for Acid fast No infection is present. MISCELLANEOUS
Fluid) Bacilli Symptoms probably not
due to active mycobacterial
infection. DATE:
Grams stain (Pleural Pus cells/LPF: No bacteria is May have a bacterial October 20, 2019
Fluid) Moderate seen in the pleural infection of the lining of the Remarks: PLEURAL FLUID
fluid lungs (pleura).
 Date: October 14,2019
Procedure: CHEST PA UPRIGHT Date: October 17, 2019
Radiological Findings
Procedure: HEMITHORAX- LEFT
• Homogenous opacification of the left mid to lower
hemithorax obscuring the underlying hemi diaphragm
and costo phrenic sulcus. Impression
• Opacites are seen in both suprahilar and right infrahilar
regions • Free pleural fluid is seen on the
• Few fibrotic densities are seen emanating from the right
suprahilar region opacity.
left approximately amounting
• True cardiac size not access 560 cc. Consolidation and
• Aorta is tortuous and calcified
• Degenerative osseous changes are seen compressive atelectasis are
Impression
• Moderate pleural effusion left noted. No definite mass lesion
• Pneumonia both suprahilar and right infrahilar regions
• Cannot rule out underlying TB in the right upper lobe
is discerned.
• Atherosclerotic aorta
• Degenerative osseous changes
DRUG
STUDY
 ORAL MEDICATIONS

DRUG ACTION INDICATION CONTRAINDICATION ADVERSE REACTION NURSING CONSIDERATION

 Tachycardia, palpitation, Give 400 mg bid-tid. Max:
extra systole 1,200 mg daily.
Doxofylline Bronchodilator Treatment of Acute MI, hypotension
 Hyperglycemia > assess for allergic reaction
pulmonary disease
 Nausea, vomiting, > assess for breath sounds.
with spastic bronchial
abdominal pain,
component and it
epigastric pain
induces blood vessel
 Irritability
relaxation and airway
 Headache, nervousness,
smooth muscle
dizziness
relaxation.
 Insomnia, nervousness
 Albuminuria
 Hypersensitivity Give 600 mg daily (preferably
reactions including in the evening).
Fluimucil Mucolytic Treatment of Hypersensitivity.
anaphylactic shock,
respiratory affections Should be taken with food:
anaphylactic/anaphylact
characterized by thick Dissolve effervescent tab or
oid reaction,
& viscous granules in a glass of water.
bronchospasm,
hypersecretions. Mix if necessary. Drink
angioedema, rash &
directly from the glass.
pruritus. Inhalant Rhinitis
, stomatitis.
 Hypersensitivity. Give 5 mg once daily. Dosage is
individualized and may be
Amlodipine Antihypertensive Management of Severe hypotension  Headaches, dizziness,
increased after at least 1-2 weeks.
hypertension. somnolence,
Shock (including Max: 10 mg once daily.
palpitations, flushing,
cardiogenic shock).
abdominal pain,
Obstruction of the nausea, edema,
May be taken with or without food.
outflow tract of the left fatigue.
ventricle. Monitor BP, heart rate, pulse,
frequency and intensity of angina,
Haemodynamically
weight, and peripheral edema.
unstable heart failure
after acute MI.

 Decrease libido, Give 5 mg once daily.

impotence, May be taken with or without food.

Finasteride Prostate Treatment and control of Hypersensitivity.
ejaculation disorders Swallow whole, do not chew or
disorders benign prostatic
Women, childn and and hypersensitivity crush.
hyperplasia to cause
adolescents. reactions.
regression of the Monitor prostate-specific antigen
(PSA) levels.
enlarged prostate and
Women who are or may become
improve symptoms
pregnant should avoid contact w/
associated with urinary crushed or broken tablets.
flow.
 Give 1 tab OD.

Bicadex Anti-androgen Monotherapy in patients Evidence or history of  Anemia, anorexia,

w/ locally advanced, thyroid dysfunction, iodine decreased libido,
May be taken with or without
nonmetastatic prostate sensitivity, severe resp depression, dizziness
food.
cancer. failure, circulatory collapse, somnolence, hot flush,
severe hypotension, abdominal pain,
cardiogenic shock, sinus constipation, dyspepsia,
Special Precautions
bradycardia, SA heart flatulence, nausea, hepatic
block; 2nd or 3rd degree changes (including elevated Moderate to severe hepatic

AV block, severe levels of transaminases, impairment; preexisting diabetes.

conduction disturbances jaundice), hepatobiliary Periodic liver function test &

(e.g. high grade AV block, disorders, rash, alopecia, monitor blood glucose. Co-

bifascicular/trifascicular hirsutism/hair regrowth, dry administration w/ drugs

block), sinus node disease skin, pruritus, hematuria, metabolized predominantly by

(except in patient w/ gynecomastia, breast CYP3A4. Patients w/ a history

pacemaker). Lactation. tenderness, impotence, of/or risk factors for QT

Concomitant use w/ drugs asthenia, chest pain, edema, prolongation. Patients receiving
that prolong QT interval wt gain, interstitial lung medicinal products that might
disease. prolong the QT interval.
  Bradycardia, hypotension,
Tab: Give 3 tabs/day for 8-10
peripheral neuropathy.
Amiodarone Antiarrhythmic Used to treat ventricular Hypersensitivity to iodine or  Benign intracranial pressure,
days; maintenance: ½ to 2
tachycardia or ventricular amiodarone. Sinus paraesthesia, tremor, tabs/day.
nightmares, sleeplessness,
fibrillation. bradycardia, SA block, sick headache, ataxia.
sinus syndrome, severe AV  Thrombophlebitis.
conduction disorders unless May be taken with or without
 Nausea, vomiting, metallic taste.
a pacemaker is fitted.
 Epididymitis. food.
Thyroid dysfunction.
 Phospholipidosis.

 Haemolytic/aplastic anaemia.

 Myopathy. Avoid exposure to sunlight.

 Benign yellowish-brown corneal This drug may cause eye
micro-deposits, optic
neuropathy/neuritis, blindness. disorders, if affected.
 Hot flushes, sweating, blue-grey
skin discolouration.

 Fatigue.
 Fe: GI side effects eg, nausea, Give 1 tab daily.
vomiting, bloating & upper
Hemarate Multivitamins Nutritional supplement for Hypersensitivity. Primary
abdominal discomfort; diarrhea,
the prevention & treatment hemochromatosis, peptic constipation. Temporary staining
of Fe deficiency anemia & ulcer, regional enteritis, of teeth. Darker stool color. Vit C Should be taken on an empty
vit B-complex deficiencies ulcerative colitis. (prolonged intake & in excess of stomach.
2 g/day): Nausea, abdominal
cramps, diarrhea, nose bleeds.
 Give 40-60 mg daily in divided
doses. Modified-release tab: 35
Trimetazidine Anti-angina Treatment of angina Hypersensitivity  Dizziness, headache,
mg bid.
pectoris. abdominal pain, dyspepsia,
Parkinson's disease,
diarrhoea, nausea, vomiting,
parkinsonian symptoms,
pruritus, rash, urticaria,
tremors, restless leg Should be taken with food.
asthenia. Rarely, tachycardia,
syndrome and other
palpitations, extrasystoles,
movement related
orthostatic hypotension,
disorders. Severe renal
arterial hypotension, flushing.
impairment (CrCl<30
mL/min).
 Nausea, vomiting, diarrhoea, Give 40 mg once daily (increased
constipation, flatulence, up to 80 mg if necessary) for 2-4
Pantoprazole Antacids, Relieves symptoms such as Hypersensitivity.
abdominal pain, dyspepsia, weeks for duodenal ulcer or 4-8
Antiulcerant heartburn, persistent
Low amount of magnesium dry mouth. weeks for benign gastric ulcer.
cough.
in the blood.
 Asthenia, fatigue, malaise. Normal Release: May be taken
Osteoporosis with or without food.
 Headache, dizziness, vertigo.

 Insomnia. Controlled-Release: Should be

taken on an empty stomach. Take
 Rash, pruritus
1 hr before meals. Swallow whole,
do not chew/crush.
  Benign breast neoplasm in Hypokalemia/hypomagnesemia
male; agranulocytosis,
25-100 mg daily.
Aldactone Diuretics Use to treat heart failure, Hypersensitivity. Acute leucopenia,
thrombocytopenia;
high blood pressure and renal insufficiency, anuria,
electrolyte imbalance,
hypokalemia. hyperkalemia. Addison’s hyperkalemia; changes in Should be taken with food.
disease. libido, confusion; dizziness;
nausea, GI disturbances,
abnormal hepatic function;
pruritus, rash, urticaria, toxic
epidermal necrolysis,
Stevens-Johnson syndrome,
drug reaction w/ eosinophilia
& systemic symptoms
(DRESS), alopecia,
hypertrichosis; muscle
spasms; acute kidney injury;
gynecomastia, breast pain,
menstrual disorder; malaise.
Acute abdominal  Abdominal discomfort (e.g. Give 5-10 mg at night, up to 20
conditions (e.g. colic, cramps), diarrhoea, mg may be given as necessary.
Bisacodyl Laxatives Treatment of constipation. appendicitis, intestinal electrolyte disturbance,
inflammatory bowel nausea, vertigo, vomiting,
disease), intestinal haematochezia; irritation and Should be taken on an empty
obstruction, ileus, severe proctitis (rectal). Rarely, stomach. Do not take w/in 1 hr of
dehydration, severe hypersensitivity reactions antacids, milk or other dairy
abdominal pain associated (e.g. angioedema, products.
w/ nausea and vomiting. anaphylactoid reactions).
Presence of anal fissures or
ulcerative colitis w/
mucosal damage (rectal).
  Diarrhea & nausea. 150 g/day (TID) 1 sachet
2-3 /day
Aminoleban Nutritional Dietary supplement Aldosteronism,
product with liver myopathy, Should be taken with
impairment. hypopotassemia. food.
 INTRAVENOUS MEDICATIONS
DRUG ACTION INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING
CONSIDERATIONS
 GI effects (e.g. diarrhea, 0.5-1 g 8 hrly via IV
nausea, vomiting,
inj over approx 3-5
Meropenem Anti- Treatment of Hypersensitivity to constipation), local
reactions (e.g. pain and min or infused over
Infectives susceptible infections. meropenem, other
inflammation at inj site, approx 15-30 min.
carbapenems. History phlebitis or
of anaphylactic thrombophlebitis),
reaction to β-lactams disturbances in LFTs,
positive direct or indirect
(e.g. penicillins,
Coombs' test, Stevens-
cephalosporins) Johnson syndrome, toxic
epidermal necrolysis,
thrombocythemia,
headache,
haemolyticanaemia, rash,
pruritus, sepsis, apnoea,
shock, glossitis, and oral
candidiasis. Rarely,
convulsions.
  Hyponatraemia, 20-50 mg via IM or slow IV inj, may
hypochloraemic alkalosis, increase by increments of 20 mg 2
Furosemide Diuretics Treatment of edema Hypersensitivity to
hypokalaemia, headache, hrly. Doses >50 mg must be given
associated with CHF, furosemide and
drowsiness, muscle cramps, via slow IV infusion. Max: 1,500 mg
pulmonary, renal and sulfonamides. Anuria or
hypotension, dry mouth, daily.
hepatic disorders; renal renal failure, Addison's
thirst, weakness, lethargy,
insufficiency and severe disease, hypovolaemia or
restlessness, oliguria, GI
hypercalcemia. dehydration, precomatose
disturbances, hypovolaemia,
state associated w/ liver
Lasix is particularly useful dehydration, hyperuricaemia,
cirrhosis.
when an agent with greater drug rash w/ eosinophilia
diuretic potential is desired. and systemic symptoms,
reversible or irreversible
hearing impairment,
deafness, tinnitus, severe
anaphylactic or
anaphylactoid reactions (e.g.
w/ shock)
 Headache, rash, diarrhoea, Mild to moderate infections: 1-2 g
nausea, vomiting, local daily in 2 divided doses. Severe
Ceftriaxone Antibiotic Treatment of infection due Hypersensitivity to
reactions (e.g. phlebitis, pain infections: Up to 4 g daily in 2
to susceptible organism. cefepime or other
and/or inflammation), divided doses. Doses are given by
cephalosporins.
neutropenia, positive direct deep IM inj or IV infusion over at
Coombs' test. least 30 min.
NURSING
CARE PLANS
 ASSESMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
IMPLEMENTATION RATIONALE

Subjective: Ineffective After 8 hours of duty, client  Assist patient  Elevation of bed facilities After 8 hours of
“Marigatan nak Breathing will be able to do coping to assume respiratory function by nursing
aganges” as verbalized Pattern mechanisms to improve his position of the use of gravity. It also interventions, the
by the client. related to breathing pattern. comfort e.g. decreases pressure on patient decreased
Decreased elevate head of the abdomen when his respiratory rate
Lung  Patient maintains an bed. assuming the position. from 32 to 20
Expansion effective breathing cycles per minute.
secondary to pattern, as evidenced  Provides patient with
Objective: fluid by relaxed breathing at some means to cope Goal met.
VS taken as follows: accumulation. normal rate and depth.  Encouraged and reduce air tapping.
Bp: 120/70 deep breathing
CR: 72  Patient’s respiratory exercises
RR: 32 rate remains within  Medications may be
T: 36.0 established limits. used for bronchodilator
O2: 94% and to improve
 Patient demonstrates  Administer respiration.
maximum lung medication as
expansion with prescribed by
adequate ventilation. the physician.
 ASSESMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
IMPLEMENTATION RATIONALE

Subjective: Acute Pain related After 8 hours of nursing  Elevate head of the  Elevation of bed After 8 hours of
“Nasakit ti barukong to localized intervention the patient will bed, change position facilities respiratory nursing intervention
ko” as verbalized by the inflammation and display patent airway with frequently. function by the use of patient was able to
client. persistent cough. breath sounds clearing and gravity. It also display patent airway
absence of dyspnea decreases pressure on with breath sounds
the abdomen when clearing and absence
assuming the position. of dyspnea.
 Assist patient with
Objective: deep breathing  Deep breathing  Patient described
 Use of accessory exercises. facilitates maximum satisfactory pain
muscle. expansion of the lungs control at a level 3
 Dyspnea and smaller airways. on a rating scale
 Fatigue  Demonstrate or help of 1 to 10
 Pain Scale 8 out of patient learn to  Coughing is a natural
10 (10 being the perform activity like self-cleaning Goal met.
highest and 1 splinting chest and mechanism. Splinting
being the lowest) effective coughing reduces chest
while in upright discomfort, and an
position and pursed upright position favors
lip breathing. deeper, more forceful
cough effort air
 Advise the patient to tapping.
allow the patient to
rest and limit activities.
 To prevent over
exhaustion and
reduces oxygen
consumption
demands
EVALUATION
 NURSING PRACTICE IMPLICATIONS
Knowledge of the disease will provide the student nurse sufficient knowledge
that we can use to handle pleural effusion and related cases likewise it will develop
through understanding that will enhance our nursing capabilities of caring for patient
afflicted with such diseases not limiting it to each prevention.
NURSING EDUCATION
This case study would help in sharing data or information about the disease condition, which is
body pain, difficulty of breathing and chest pain and its management as well as needed for the promotion
of patient's recovery. With these, nursing students as well as the instructors would gain additional
information about the disease in order to be efficiently equipped in rendering nursing care in the future.
The study will be informative to us nursing students; it will enable them to have prior knowledge and
understanding about the disease.
NURSING RESEARCH
This case study would help in the nursing research as a source of data for example, in tracking the
population of persons with this condition. This information would help in creating awareness and
knowledge on the disease and the need for treatment, sharing important information on the early
detection and prevention of the disease condition. This will ignite the thinking of student nurse and to seek
for further knowledge for its cure, treatment and management. It will likewise spark the interest of
researcher to search for new strategies for the prevention and cure.
 RECOMMENDATION
 A patient with Pleural Effusion requires repeated assessments, which may range
from bedside observations to the use of invasive monitoring. These patients
should be admitted to a facility where close observation can be provided.
 Have a regular check-up and follow therapeutic regimen.
 Provide an extra effort in managing his disease.
 Instruct the client on how to promote and maintain nutritional status.
 Advise the client to avoid alcoholic beverages or to limit his intake because
alcohol interference with the utilization of essential nutrients.
 Advise the client to ensure adequate protein intake such as milk, eggs, oral
nutritional supplemental, chicken, and fish if other treatments not tolerated.
 Advice patient to eat small amounts of high-calorie and protein foods
frequently rather than three daily large meals.