St.

Josephs College of Quezon City

Institute of Nursing

Case Presentation
Of
Pleural Effusion
Pasay General Hospital
Medical Ward
September 2015
Adrian Jess Galindo
BSN-IV

I. OBJECTIVES OF THE STUDY

GENERAL OBJECTIVE:
At the end of the presentation, students will be able to understand Pleural Effusion
and its relationship to our patient.
SPECIFIC OBJECTIVE:
At the end of the discussion, the student reporters will be able to
Present an overview of Pleural Effusion
Present and interpret the patients profile
Demographic data
State past and present health history of the patient
Present the systems involved
Discuss the anatomy and physiology/etiology and pathophysiology of the patients
condition
Present and interpret the Theoretical Frameworks
Present and interpret the Assessment Data gathered
Present a specific, measurable, attainable, realistic and time-bounded Nursing Care
Plan for the client
Present the provided discharge plan for the patient and family

II. INTRODUCTION
OVERVIEW
A Pleural Effusion is defined as an accumulation of fluid in the pleural space. Pleural
fluid normally seeps continually into the pleural space from the capillaries lining the parietal
pleura and is reabsorbed by the visceral pleura, capillaries and lymphatics system. Any
condition that interferes with either secretion or drainage of this fluid leads to pleural
effusion. Clinical manifestations depend of the amount of fluid present and the severity of
lung compression. If the effusion is small (ie 250 cc) its presence may be discovered only on
a chest radiograph. For larger effusions, lung expansion may be restricted and the client may
experience dyspnea primarily on exertion, and a dry, non-productive cough caused by
bronchial irritation or mediastinal shift. (Black, Hawk. 2008. Vol. 2 p1631)
Effusions also occur when the rate of fluid formation exceeds the rate of fluid
absorption. Pleural effusions are commonly classified as being either exudative or
transudative. An exudative pleural effusion implies that there is a disease process that is
affecting the pleura directly, causing the pleura to be damaged. A transudative pleural
effusion results when the pleura itself is healthy and implies that a disease process is
affecting hydrostatic and/or oncotic factors that either increase the formation of pleural fluid
or decrease the absorption of pleural fluid. Deciding if the pleura is injured or intact helps in
formulating a concise differential diagnosis for potential causes (Kollef et al., 2012, p.105).
Factors that increase the chance of developing pleural effusion include: pneumonia,
tuberculosis or other lung diseases, heart attack, heart failure, or infections such as
pericarditis, recent cardiac surgery, pleurisy, tumors, cancers, such as lung, breast, surgery,
especially involving the heart, lungs, abdomen and organ transplantation. Tests to diagnose
pleural effusion include chest x-ray, ultrasound, CT scan, thoracentesis, pulmonary function
tests and biopsy.

SIGNIFICANCE OF THE STUDY

In nursing education, this case analysis serves as a tool for better understanding of the
selected case. It will guide student nurses in planning an effective nursing care towards their
clients of different health problems in the clinical area guided by the facts and data gathered
geared towards providing quality nursing care. In nursing research, this case will serve as an
update to the many trends in the nursing profession. The facts and data gathered will enable
student nurses by providing more information on what could be the possible research works
that could be done relating to the said case. Lastly, in nursing practice, this case is directed in
aiding student nurses in enhancing their knowledge and skills in effectively rendering quality
nursing care to their clients in different areas as well as providing more opportunities for
learning experiences which will hone them in becoming good and effective healthcare
providers
EPIDEMIOLOGY
According to WHO:
The estimated prevalence of pleural effusion is 320 cases per 100,000 people in third
world countries.
In developed countries the common causes of pleural effusions in adults are cardiac
failure, malignancy and pneumonia, whereas in developing countries are tuberculosis and
parapneumonic effusions are more prevalent.
According to DOH:
The Philippines currently has 250,000 cases of Tuberculosis, as of the year 2010.
Pleural Effusion accounts to approximately 38% of patients with Tuberculosis.

THEORETICAL FRAMEWORK
Environmental Theory
by Florence Nightingale
Florence Nightingale Lady with the Lamp defined nursing as the act of utilizing the
patients environment to assist him in his recovery. She states that nurses must focus on
changing the environment to place the patient in the best possible condition available.
Nightingale have identified twelve environmental canons namely ventilation and warmth,
light, cleanliness, health of house, noise, bed and bedding, personal cleanliness, variety,
chattering hope and advices, taking food, petty management and observation of the sick.
Upon following the nursing process and thought suggested by Nightingale, these are
the needed action to be done. The nursing diagnosis formulated upon assessing the
environment and its effect to the patient are as follows:

Disturbed sleep pattern;

lack of sleep privacy;
interruptions for therapeutics, monitoring

Florence Nightingales Environmental Theory is a fundamental guide in providing care of

patient X. As I observed, Manipulating the environment to support the patients healing and
recovery have great impact to the patients condition.

III. HEALTH HISTORY

A. Biological Data
NAME: A.H
AGE: 21 y/o
GENDER: Male
ADDRESS: Pasay City
DATE OF BIRTH: 10/08/1993
BIRTH PLACE: Manila
OCCUPATION: N/A
NATIONALITY: Filipino
CIVIL STATUS: Single
RELIGION: Catholic
CHIEF COMPLAINT: Dyspnea
FINAL DIAGNOSIS: Pleural Effusion, Right
ATTENDING PHYSICIAN: Dr. Arceo
DATE ADMITTED: 08/25/2015
TIME ADMITTED: 1:12 pm
ADMITTING INSTITUTION: Pasay General Hospital
B. Reason for Seeking Care:
Dyspnea
C. Present Health History:
5 Days prior to admission, the patient experiencing difficulty of breathing with fever.
He verbalize that he often plays basketball then take a bath after the game.
D. Past Health History:
According to the patient, the patient did not yet experienced having serious health
problems. Just colds and cough, the patient never had accidents or injuries. No known
allergies. Doesnt take any medicines not even vitamin supplements.

GORDONS FUNCTIONAL ASSESSMENT

FUNCTIONAL PATTERN
Health-Perception Health
Management

BEFORE
ADMISSION
Patient did not know
the importance of
being healthy.

DURING ADMISSION

Patient mentioned that

he takes Multivitamins
whenever he
remembers

He regularly takes his

Multivitamins and the drugs
that was prescribed to him by
his physician

After being familiar with the

disease, he realized that his
lifestyle was unhealthy

Patient has time for his

Patient usually has
personal care during the
time for his personal
morning with the help of his
care/hygiene during the watcher
morning
Patient does not have
any known allergies
Nutritional- metabolic
pattern
Elimination pattern

Patient does not have any

known allergies
Patient was on NPO

Patient defecates every

morning; Urinates 3
times a day. Patient did
not feel any
discomforts upon
voiding or urinating.

usually defecates once a and

the consistency is solid. The
patient doesnt have any
discomforts upon defecation.
She seldom experiences
constipation or diarrhea.
urinates (4-5x/day) he stated
that he doesnt feel any
discomfort or pain

Activity exercise pattern

Sleep- rest Pattern

He plays basketball 2-3 Due to confinement, the patient

times a day
has no form of exercise and
only lies in bed.
The Patient usually
Pt had difficulty of sleeping in
sleeps around 9:00pm- the hospital because he is not
10:00pm every day and comfortable sleeping with the
wakes up around
hospital environment and also,
7:00am-8:00am.
because of the pain he has been

experiencing on the
thoracostomy site upon trunk
movements. he described the
pain as sharp, and rated it as
6/10. During the interview,
facial grimace is evident.
Cognitive perceptual pattern

Self- perceptual pattern

Can easily comprehend His brother helps him in

questions and answers responding to any questions.
with no difficulty.
Consciously aware of his
surroundings.
Respond to any
questions with
confidence.
Consciously aware and
stable in critical
thinking.
The patient has a good The patient has a good
perception towards
perception towards himself
himself

Role- relationship pattern

Coping- stress pattern

Sexual- reproduction pattern

Value belief pattern

Patient is still
dependent to his
parents

His parents experiences

financial problems due to the
medications and confinement
fee,

Patient is catholic, and

goes to church
regularly.

Never forgets to pray.

REVIEW OF SYSTEM
Neurological System

none

Cardiovascular System

none

Respiratory System

(+) dyspnea
(+) chest pain (P-pain in right
thorax during deep
inspiration and movements
S-6/10 T- relieved by shallow
breathing

Integumentary System

(+)sweats

Endocrine System

none

Urinary System

none

Reproductive System

none

IV. PHYSICAL ASSESSMENT

ASSESSMENT DATA
SKIN
Color
Temperature
Turgor
Texture
Lesion
Integrity
NAILS
Color
Texture
Shape
HAIR
Color
Texture
Distribution
HEAD
Shape
Size
Configuration
Headache

ASSESSMENT FINDINGS
Fair
36.5 C
Good skin turgor
Moist skin
(-) Lesions/Rash
Intact
Pinkish
Smooth
Concave
Black
Coarsely dry
Evenly distributed

Round
Normocephalic
Symmetrical
None

ASSESSMENT DATA
EARS
Hearing
Tinnitus
Vertigo
Earaches
Infection
Discharges
Others
NOSE AND SINUSES
Frequent colds
Nasal stiffness
Nose bleed
Sinus trouble

Good
None
No vertigo
No earaches
No infection
No discharges

None
None
None
Sinuses are non tender

MOUTH & THROAT

Condition of teeth
Bleeding gums
Tongue
Throat
Hoarseness
Mucous membrane

ASSESSMENT DATA
NECK
Symmetry

complete teeth
No bleeding
Tongue is at midline,
Throat Non-tender
None
Pinkish

ASSESSMENT FINDING
Symmetrical
in the midline

LUNG
Symmetry
Respiratory movements

Symmetrical
Asymmetrical, use of accessory muscles

AUSCULTATION:
Character of respiration

(+) wheezing sounds

ASSESSMENT DATA
ABDOMEN:
Symmetry
Skin Lesion
Masses
Tenderness

ASSESSMENT FINDING
Symmetrical
none
(-) Masses
none

HEAD AND NECK:

Facial muscle symmetry
Swelling
Scars
Discoloration
Weakness
ROM
Posterior neck cervical spine
Muscle spasm
Crepitus

Symmetrical
None
None
None
(+) Weakness
can turn head from side to side
Non-tender
(-) Spasm
(-) Crepitus heard

MOTOR SYSTEM:
Muscle tone
extremities

Without hypertrophy or atrophy

Ability to move extremities

MENTAL STATUS:
LOC
Long term memory
Short Term Memory

Conscious
Not assessed
Not assessed

VI. DIAGNOSTICS
8/26/15
TEST
WBC
Hemoglobin

RESULT
4.56
119

Hematocrit

0.365

RBC

4.30

Neutrophils
Lymphocytes
Monocytes
Platelet
MCV
MCH
RDW

NORMAL FINDINGS
4.0-10.0 x10 ^9/L
M:130-180 g/L
F:120-160 g/L
M: 0.40-0.50
F: 0.37-0.43
M: 4.5-6.2x10^12/L
F: 4.0-5.42x10^12/L

ANALYSIS
Normal
Normal

0.58
0.23
0.17
Adequate
84.9
27.7
13.5

0.45-0.65%
0.25-0.50%
0.02-0.06%
150-450 x10 ^9/L
80-100 ft.
27-32
11.5-14.5

Normal
Normal
Normal
Normal
Normal
Normal
Normal

TEST
WBC
Hemoglobin

RESULT
5.09
130

ANALYSIS
Normal
Normal

Hematocrit

0.410

RBC

4.82

NORMAL FINDINGS
4.0-10.0 x10 ^9/L
M:130-180 g/L
F:120-160 g/L
M: 0.40-0.50
F: 0.37-0.43
M: 4.5-6.2x10^12/L
F: 4.0-5.42x10^12/L

Neutrophils
Lymphocytes
Monocytes
Platelet
MCV
MCH
RDW

0.67
0.20
0.09
401
85.1
27
14.0

0.45-0.65%
0.25-0.50%
0.02-0.06%
150-450 x10 ^9/L
80-100 ft.
27-32
11.5-14.5

Normal
Normal
Normal
Normal
Normal
Normal
Normal

Normal
Normal

Date: 9/5/15

8/29/15
TEST
Creatinine
ALT/SGPT

RESULT
81.1
79.2

NORMAL FINDINGS
53-97
0.0-48.0

Normal
Normal

ANALYSIS
Normal

ULTRASOUND
There is pleural effusion approximately 773.9cc in the right mid lateral to lower hemithorax
Septations are noted in the pleural fluid
Pleural thickening is also seen in the right
There is a passive compression of the right lower lobe
No mass
Impression: Loculated Pleural effusion, right
Pleural thickening, right

VII. ANATOMY AND PHYSIOLOGY

RESPIRATORY SYSTEM
The pleural space is approximately 10-20 um wide and encompasses the
area between the mesothelium of the parietal and
visceral pleura (the two layers of the pleura). The
pleural space actually contains a tiny amount of fluid (0.3
mL/kg body mass) with a low concentration of protein (~1
g/dL). The pressures of the pleural space are important
determinants of the mechanical properties of the lung and
chest wall and, thus, of the total respiratory system. This
is because the distending pressure of the lung and chest
wall is critically dependent on the relevant pressures of
the pleural space. Any distortion of the pressures of
pleural space affects the distending pressure of the lung
and chest wall and this the relevant volumes, which in
turn influences the gas exchange properties of the lung
via several mechanisms. It follows that pleural effusion,
which alters both the liquid and surface pleural pressures affect the mechanical properties of
the respiratory system as well as the gas exchange properties (Demosthenes Bouros, 2004,
p.61)
The accumulation of pleural effusion has important effects on respiratory system function. It
changes the elastic equilibrium volumes of the lung and chest wall, resulting in a restrictive
ventilatory effect, chest wall expansion and reduced efficiency of the inspiratory muscles.
The magnitude of these alterations depends on the pleural fluid volume and the underlying
disease of the respiratory system (Mitrouska et al., 2004).
On physical examination, signs that an effusion is present include dullness to percussion over
the effusion, loss of fremitus, decreased breath sounds, and crackles immediately above the
effusion. Presence of crackles on both lung fields upon auscultation is due to a friction
created by the excess fluid. Hyporesonance percussion sound which is dull suggests a
consolidation such as effusion. Dyspnea is noted as the effusion can affect the mechanics of
the diaphragm, cause a restrictive ventilator defect, and/or cause compressive atelectasis
leading to hypoxemia. Tactile fremitus is absent or attenuated because the fluid absorbs the
vibrations emanating from the lung (Kollef et al., 2012, p.105).
CARDIOVASCULAR SYSTEM
The cardiovascular system has three basic functions: to maintain normal systemic arterial
pressure, to maintain normal tissue blood flow, and to maintain normal systemic and
capillary pressures. Elaborate control mechanisms are present throughout the body to
maintain these functions within normal limits (Slatter, 2003, p.915).
In addition to deleterious effects on lung ventilation, perfusion, and mechanics, intrapleural
air and/or fluid collections can significantly affect the cardiovascular system. Air and/or fluid

in the pleural space not only occupy intrapleural volume, but also may increase the relative
pressure inside the thorax and sometimes shift the position of the mediastinum. Cardiac
output diminishes further if the pressure becomes great enough to shift the mediastinal
position, distorting and obstructing vessels. Pressure alterations within the thorax from
pleural air and/or fluid collections also can affect ECG tracings and invasive hemodynamic
monitoring values and waveforms (Kinget al., 2008, p.359)
Significant tachypnea, dyspnea, tachycardia, hypoxemia, or changing mental status should
raise concerns that pulmonary or cardiovascular compromise is not being adequately
tolerated or is worsening (King et al.).
Hypertensive cardiovascular disease also known as hypertensive heart disease occurs due to
the complication of hypertension or high blood pressure. In this condition the workload of
the heart is increased manifold and with time this causes the heart muscles to
thicken. Eventually hypertensive heart disease can also lead to congestive heart failure. Some
symptoms of hypertension and the eventual congestive heart failure include arrhythmias,
shortness of breath, weakness and fatigue, and swelling in lower extremities. Hypertensive
cardiovascular disease may also result in ischemic heart condition and in this case there
might be chest pain, sweating and dizziness, nausea and shortness of breath. Hypertrophic
cardiomyopathy could also be a result of cardiovascular disease (Ambekar, 2008).
MUSCULOSKELETAL SYSTEM
The skeletal system includes the bones of the skeleton and the cartilages, ligaments, and
other connective tissue that stabilize or connect the bones. In addition to supporting the
weight of the body, bones work together with muscles to maintain body position and to
produce controlled, precise movements. Without the skeleton to pull against, contracting
muscle fibers could not make us sit, stand, walk, or run (The Cleveland Clinic Foundation,
2009)
Two common symptoms of muscular disorders are pain and weakness in the affected skeletal
muscles. The potential causes of muscle pain include the problems with the nervous system.
Muscle pain may be experienced due to inflammation of sensory neurons or stimulation of
pain pathways in the CNS.
INTEGUMENTARY SYSTEM
The integumentary system is the organ system that protects the body from various kinds of
damage, such as loss of water or abrasion from outside. The system comprises the skin and
its appendages. The integumentary system has a variety of functions; it may serve to
waterproof, cushion, and protect the deeper tissues, excrete wastes, and regulate temperature,
and is the attachment site for sensory receptors to detect pain, sensation, pressure, and
temperature (Wikipedia, 2013)

Chest tube thoracostomy is done to drain fluid, blood, or air from the space around the lungs.
Some diseases, such as tuberculosis, pneumonia and cancer, can cause an excess amount of
fluid or blood to build up in the space around the lungs (called a pleural effusion). Also, some
severe injuries of the chest wall can cause bleeding around the lungs. Sometimes, the lung
can be accidentally punctured allowing air to gather outside the lung, causing its collapse
(called a pneumothorax). Chest tube thoracostomy (commonly referred to as "putting in a
chest tube") involves placing a hollow plastic tube between the ribs and into the chest to
drain fluid or air from around the lungs. Thus a disruption of the skin happens. The tube is
often hooked up to a suction machine to help with drainage. The tube remains in the chest
until all or most of the air or fluid has drained out, usually a few days. Occasionally special
medicines are given through a
chest tube (American Thoracic Society, 2013)

PATHOPHYSIOLOGY

Predisposing Factor
Age, gender

Precipitating Factors:
Lifestyle, environmental

Inflammation of airways

Bronchial edema

Increased mucus Broncoconstrict-ionBronchial spasm

secretion

Dsypnea, cold and clammy skin, diaphoresis

Worsening of obstruction

Accumulation of fluids caused by over secretion

Multiplication of growth of organism

Inflammation in the epithelial wall
Rupture of inflamed endothelial cells
Shallow breathing, RR increase

Mismatch of ventilation and perfusion

Excess fluid
dyspnea

Pleural effusion

X DISHCARGE PLANNING

M- Medication
Medication includes Vit B, Cefuroxime, Geocet.
E- E xercise
Teaching breathing retaining exercise to increase diaphragmatic excursion and reduce
work of breathing.
Teach relaxation techniques to reduce anxiety with dyspnea.
Augment the patients ability to cough effectively by splinting the patients chest
manually.
T- Treatment
Follow strict compliance to treatment regimen given to improve condition especially
medications, diet and lifestyle.
H- Health Teachings
Keep a list of your medicines: Keep a written list of the medicines you take, the
amounts and when and why you take them. Bring the list of your medicines or the pill
bottles when you see your caregivers. Do not take any medicines, over the counter
drugs, vitamins, herbs or food supplements without first talking to caregivers.
To decrease your pain; when coughing, hold a pillow over your chest where the pain
is.
Quit smoking. Do not smoke and do not allow others to smoke around you. Smoking
increases your risk of lung infections such as pneumonia. Smoking also makes it
harder for you to get better after having a lung problem. Talk to your caregiver if you
need help quitting smoking.
Drink enough liquids and get plenty of rest. Be sure to drink enough liquids every
day. Most people should drink at least 8(oz.) Cups of water a day. This help to keep
your air passages moist and better able to get rid of germs and other irritants. You
may feel like resting more. Slowly start to do more each day. Rest when you feel it is
needed.
Exercise your lungs. The discomfort of pleural effusion may cause you to avoid
breathing as deeply as you should. Coughing and deep breathing can help prevent a
new or worsening lung infection. Take a deep breath and hold the breath as long as
you can then push the air out of your lungs with a deep, strong cough. Take 10 deep
breaths in a row every hour that you are awake. Remember to follow each deep
breathe with a cough.
O- Out patient
Compliance to home medication regimen.
D- Diet
Ensure adequate protein intake such as milk, eggs, oral nutritional supplements,
chicken, and fish if other treatments not tolerated.
Advice patient to eat small amounts of high-calorie and protein foods frequently
rather than three daily large meals