Pleural Effusion

CAPITOL UNIVERSITY College of Nursing Cagayan de Oro City

A Case Study On

Pleural Effusion In Partial Fulfillment Of the course RLE 7

Submitted to: Clinical Instructor

Mrs. Maria Rica Adane, RN

Submitted by:

Caralde, Maricar Cardoza, Roxanne Carlos, Mary Rose Carpo, Jennifer Carreon, Rizza Mae Castillejos, Maryjes Castillo, Bryan Cervantes, Bryle Gil Chavez, Eren Son Chavez, Kirk Don Cimacio, Hannah Lee Cirera, Marlon

RLE 7 Group 7 THFS 3:00 pm – 11:00 pm

TABLE OF CONTENTS I.

Introduction

II.

Client’s Profile

III. III.

Anat Anato omy and Physio siolog logy

IV.

Pathophysiology

V.

Diag Diagno nost stic ic Proc Proced edur ures es and and Lab Lab Resu Result lts s

VI.

Drug Study

VII. VII. Nurs Nursin ing g Car Care e Pla Plans ns

VIII. VIII. Disch Discharg arge e Plan Plan

IX.

Learning Insights

X.

Reference

I. INTRODUCTION

Our group chose this case as interesting to us because it is a common disease entity that is usually underestimated as a cause of mortality and morbidity to patients. We would like to make an outlook of what this case is and gather information that can help us learn how it occurs, manifest, develop and cause a disease.

It is our goal to identify the risk factors that affects people making making them at risk for the disease. How is the disease being treated. And by learning from the inputs we gather from out patient. We discuss pleural effusion as its definition as the collection of at least 10-20 mL of fluid in the pleural space. Pleural effusion develops because of excessive filtration or defe defect ctiv ive e abso absorp rpti tion on of accu accumu mula late ted d flui fluid. d. Pleu Pleura rall effu effusi sion on may may be a prim primar ary y manifes manifestatio tation n or a seconda secondary ry complic complicatio ation n of many disorders. disorders.

Pleural Pleural effusions effusions are

usually usually classifi classified ed as transuda transudates tes and exudates. exudates. Diseases Diseases that affect affect the filtratio filtration n of pleural pleural fluid fluid result result in transuda transudate te formati formation, on, such as in congest congestive ive heart heart

failure failure

and

nephritis. Transudates Transudates usually occur bilaterally bilaterally because of the systemic

nature of the

causative disorders. Inflammation or injury increases pleural membrane permeability to proteins and various types of cells and leads to the formation of exudative effusion Infectious effusions are usually unilateral. However, a recent large Turkish study revealed bilateral effusion in 5% of 515 children. Its frequency occurs, as in the US: American and international frequencies are similar. similar. The prevalen prevalence ce of pleural pleural infections infections appears appears to be increasing increasing in some developed developed

countries; this could be partly due to increased referral of patients with

these conditions to tertiary-care pediatric hospitals.

Nonbacterial infectious agents, such as viruses and Mycoplasma pneumoniae, cause more pleural effusion in children than do bacterial organisms.

Although

bacteria are more more likely likely than viruses to cause cause effusion, effusion, viral viral infections infections in in children occur more frequen frequently tly than than bacteria bacteriall infectio infections, ns, explain explaining ing the observa observation tion

above. above.

many as 20% of the viral infections can cause small and transient effusions

As that

resolve spontaneously, affects internationally and more frequently on developed nations. Several decades ago, pleural effusion was a complication of 70% of all cases of Staphylococcus Staphylococcus aureus pneumonia, pneumonia, with positive cultures resulting from 80% of pleuralfluid fluid specim specimen ens. s. In the late late 1970 1970s, s, pleura pleurall effusi effusion on occurr occurred ed in 75% 75% of cases cases of pneumonia secondary to Haemophilus Haemophilus influenzae influenzae type b. In a report by Murphy et al, empyema complicated the course of pneumonia in 9 of 21 patients with Streptococcus pneumoniae

pneu pneumo moni nia. a.

Char Chartr tran and d

and and

McCr McCrac acke ken n

indi indica cate ted d

that that

empy empyem ema a

complicated the course of pneumonia in 57 of 79 patients with S aureus infections. Pleural effusion occurs in 6-12% of all cases of pulmonary tuberculosis (TB) in children. Of 175 Spanish children with pulmonary TB, 39 (22.1%) had pleural effusion.

Congenital effusions, including chylothorax, occur in 1 per 10,000-15,000 live births annually. In a review of 74 patients with intrathoracic lymphomas, lymphomas, Chaignaud et al found pleural effusions in 10 (71%) of 14 children with lymphoblastic lymphoma lymphoma and in 7 (12%) of 60 children with non-Hodgkin lymphoma. The outcome of this condition affects the morbidity and mortality of patients. Most effusions caused by viral and mycoplasmal infections resolve spontaneously. Empyema has a complicated course if not treated early, especially in children younger than 2 years. Thirty years ago, the mortality rate from empyema was 100%. At present, the mortality rate from empyema is 6-12% in infants younger than 1 year. Malignant effusion worsens the patient's prognosis depending on the underlying tumor. With regards to its ratio. Pleural effusions may be more common in boys than in girls.

II. CLIENT’s PROFILES Patient X is 43 years-old male, Filipino, Roman Catholic from Lapasan, Cagayan de Oro City, Misamis Oriental. Admitted at Cagayan de Oro Medical Center (COMC) last January 16, 2010 at 9:00 PM due to dyspnea and cough. Patient’s vital signs are: Blood Pressure of 130/100 mmHG, mmHG, temperature of 36 degree Celsius, Celsius, respiratory rate of 26 cpm and a pulse rate of 107 bpm bpm.. At present he weighs 59 kls.

HISTORY OF PRESENT ILLNESS One week prior to admission, admission, patient was admitted in Northern Mindanao Medical Center for persistent cough and fever for one week until he is referred to COMC because the patient continue on experiencing difficulty of breathing, thus admitted.

PRE-HOSPITALIZATION

Health Perception-health management pattern : Patient X is a 43 years-old male that is dependent to his own decision and care. Patient X was not active to his daily routine. During onset of coughing the patient verbalizes, “Gasige “ Gasige lng kog ubo-ubo sir ”. sir ”. Due to his illness, illness, he cannot cannot perform his daily routine that he is usually doing when he is still not sick.

Nutritional metabolic pattern: (While confined) Patient X said he takes 1500cc of water a day, and takes 3 meals in a day with a combination of 1-2 cups rice with different viand. He has poor appetite that somet sometime imes s he canno cannott consu consume me his meal. meal. “ Wala koy gana mo kaun sir” as verbalized by the patient. He was ordered to have a Low-salt and Low-Fat Diet . He is also fond of drinking alcoholic beverages beverages for 15 years and a smoker for 10 years.. He can consumed 1 pack of cigarette per day. years

Elimination pattern: (while confined) Patient X has a normal elimination pattern. He defecates one time a day with moderate amount, soft stool, and light-brown in color. There was no problem on his urination; he can urinate 3-5 times per day. . Activity exercise pattern: (while confined ) Prior to confinement, the patient was be able to do the activities of daily living by himself not until a day prior to confinement he always ask for assistance

in doing his activities of daily living because he’s anxious he might fall down. Patien Patientt was was advic advice e to refra refrain in from from doin doing g stren strenuou uous s activi activity ty beca because use of his condition. “Galisud ko ug ginhawa kung mahago ko ” as verbalized by the patient.

Sleep-rest pattern: (while confined ) Patient X has a normal normal sleeping sleeping pattern and would would sleep at most most 6-8 hrs per day, he was easily get distracted and awaken by any environmental stimuli, especially when taking his medications. Watching TV makes him fall asleep.

Cognitive-perceptual pattern: Patient was calm, responsive, conscious, well oriented with time and place and with normal behavior of communication.

Role-relationship pattern: (while confined) Patient X is married, a good provider and was happy being with his family. He’s been wishing that everybody is well, so that it would not add to his daily financial needs.

Sexuality and Reproductive Pattern Patient X said that he is not so much active in his sexual patterns.

Coping-Stress Tolerance Pattern Having this condition makes him challenge, and think that everything will be alright, though he remains to be calm but he is a bit worried.

Value-Belief Pattern He is a Roman Catholic and don’t believe in superstitious beliefs. He said, said, “God is our savior and he is our creator, he has a plan for me”.

PHYSICAL ASSESSMENT ASSESSMENT DATA

ASSESSMENT FINDINGS BEFORE (SEPT 23, 09)

SKIN Color

Fair

Temperature

37.1 º C

Turgor

Good skin turgor

Texture

Moist skin

Lesion

(-) Lesions/Rash Lesions/Rash

Integrity

Intact

Others NAILS Color

Pinkish

Texture

Smooth

Shape

Concave

Others HAIR

Poor capillary refill = 3 sec

Color

Black

Texture

Coarsely dry

Distribution

Evenly distributed

Quantity

Moderate

Others HEAD Shape

Round

Size

Normocephalic

Configuration

Symmetrical

Headache

None

ASSESSMENT DATA EARS Hearing

Good

Tinnitus

None

Vertigo

No vertigo

Earaches

No earaches

Infection

No infection

DischargesS

No discharges

Others

NOSE AND SINUSES Frequent colds

None

Nasal stiffness

None

Nose bleed

None

Sinus trouble

Sinuses are non tender

MOUTH & THROAT Condition of teeth

Incomplete teeth

Bleeding gums

No bleeding

Tongue

Tongue is at midline,

Throat

Throat Non-tender

Hoarseness

None

Mucous membrane

Pinkish

ASSESSMENT DATA

ASSESSMENT FINDING

NECK Symmetry

Symmetrical

Condition of trachea Thyroid

in the midline

Lymph nodes

(-) nonpalpable (-) nonpalpable

LUNG Symmetry

Symmetrical

Shape

A:P diameter 1:2

Respiratory movements

Asymmetrical, use of accessory muscles

# of breath

26cpm

AUSCULTATION: Character of respiration

(+) rales on upper lung lields Decrease breath sounds on left lung field

HEART AND NECK VESSELS: Apical Pulse Cardiac Sounds

107 bpm

Apical/Radial pulse data

(-) murmurs

Blood pressure

Not assessed

Pulse pressure Any special procedure Done

ASSESSMENT DATA ABDOMEN:

ASSESSMENT FINDING

Symmetry

Symmetrical

Contour

Globular

Skin Lesion

none

Masses

(-) Masses

Bowel Sounds

Normoactive bowel sounds

Tenderness

none

MUSCULOSKELETAL SYSTEM: Posture abnormal postures aren’t present

ROM

active-passive

Muscle Strength

4/5

HEAD AND NECK: Facial muscle symmetry

Symmetrical

Swelling

None

Scars

None

Discoloration

None

Weakness

(+) Weakness

ROM

can turn head from side to side

Posterior neck cervical spine Muscle spasm Crepitus

Non-tender (-) Spasm (-) Crepitus heard

MOTOR SYSTEM: Muscle tone

Without hypertrophy or atrophy Muscle strength is 4/5

Ability to move extremities against gravity Spasticity, flaccidity or rigidity, tremors, lies none

MENTAL STATUS: LOC

Conscious

Long term memory

Not assessed

Short Term Memory

III. ANATOMY AND PHYSIOLOGY

Human Respiratory System The respiratory system consists of all the organs involved in breathing. These These inclu include de the the nose, nose, pharynx, pharynx, larynx, larynx , trachea, trachea, bronchi and lungs. lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory respiratory system, such as an infection like pneumonia, pneumonia , it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, cough, and chest pain. pain.

Nose A nose is a protuberance protuberance in vertebrates that houses the nostrils, nostrils , or nares, which admit and expel air for respiration in conjunction with the mouth. mouth. Behind the nose are the olfactory mucosa and the sinuses. sinuses . Behind the nasal cavity, cavity , air next passes through the pharynx, pharynx , shared with the digestive system, and then into the rest of the respiratory system. system . In humans, the nose is located centrally on the face; on most other mammals other mammals,, it is on the upper tip of the snout. snout. In cetaceans, cetaceans , the nose has been reduced to the nostrils, which have migrated to the top of the head, producing a more streamlined body shape and the ability to brea breath the e whil while e most mostly ly subm submer erge ged. d. Conv Conver erse sely ly,, the the

elephant' elephant 's nose has

elaborated into a long, muscular, manipulative organ called the trunk.

Mouth The mouth, buccal cavity, or oral cavity is the first portion of the alimentary canal that receives food and begins digestion by mechanically breaking up the solid food particles into smaller pieces and mixing them with saliva. saliva .[1] The oral mucosa is the mucous membrane epithelium lining the inside of the mouth.In addition to its primary role as the beginning of the digestive system, in humans the mouth also plays a significant role in communication. communication . While primary aspects of the voice are produced in the throat, the tongue, tongue, lips, lips, and jaw and jaw are also needed to prod produc uce e the rang range e of soun sounds ds includ included ed in human human langua language ge.. Anoth Another er nonnon-

digestiv digestive e function function of the mouth is its role in second secondary ary social and/or sexual activity, such as kissing. kissing . The physical appearance of the mouth and lips play a part in defining sexual attractiveness. The mouth is normally moist, and is lined with a mucous membrane. membrane . The lips mark the transition from mucous membrane to skin, skin, which covers most of the body. Pharynx The pharynx (plural: pharynges) pharynges ) is the part of the neck and throat situated immediately posterior to (behind) the mouth and nasal cavity, cavity, and cranial, cranial , or superior superior,, to the esophagus, esophagus , larynx, larynx , and trachea. trachea . The pharynx is part of the digestive system and respiratory respiratory system of many organisms.Because both food and air pass air pass through the pharynx, a flap of connective connective tissue called the epiglottis closes over the trachea when food is swallowed swallowed to prevent choking or aspiration or aspiration.. In humans the pharynx is important in vocalization. Epiglottis The epiglotti epiglottis s is a flap of elastic cartilage tissue covered with a mucus membrane, membrane, attached to the root of the tongue. tongue. It project projects s oblique obliquely ly upward upwards s behind the tongue and the hyoid bone. The term is, like tonsils, tonsils, often incorrectly used to refer to the uvula. uvula. The epiglottis guards the entrance of the glottis, glottis , the opening between the vocal folds. folds. It is normally pointed upward during breathing with its underside functioning as part of the pharynx, pharynx, but during swallowing, swallowing , elevation of the hyoid bone draws the larynx upward; as a result, the epiglottis folds down to a more horizontal position, with its upper side functioning as part of the pharynx. In this manner it prevents food from going into the trachea and instead directs it to the esophagus, esophagus , which is more posterior. The epiglottis is one of nine cartilaginous structures that make up the larynx (voice (voice box). box). While While breat breathin hing, g, it lies lies comple completel tely y withi within n the phary pharynx. nx. When When swallowing it serves as part of the anterior of the larynx. Larynx The larynx (plural larynges), larynges ), colloquially known as the voicebox, voicebox , is an organ in the neck of mammals involved in protection of the trachea and sound production. The larynx houses the vocal folds, folds , and is situated just below where the tract of the pharynx splits into the trachea and the esophagus. esophagus . Sound is

generated in the larynx, and that is where pitch and volume are manipulated. The strength of expiration of expiration from the lungs also contributes to loudness. Fine manipulation of the larynx is used to generate a source sound with a particular fundamental frequency, or pitch. This source sound is altered as it travels through the vocal tract, tract, configured differently based on the position of the tongue, tongue , lips, lips, mouth, mouth, and pharynx. pharynx . The process of altering a source sound as it passes through the filter of the vocal tract creates the many different vowel and consonant sounds of the world's languages as well as tone, certain realizations of stress and other types of linguistic prosody. The larynx also has a similar functi function on as the lungs lungs in creat creating ing press pressure ure differ differenc ences es requir required ed for sound sound production; production; a constricted constricted larynx can be raised or lowered affecting the volume of the oral cavity as necessary in glottalic consonants. Trachea The trachea, or windpipe, is a tube that connects to the pharynx or larynx or larynx,, allowing the passage of air to the lungs. lungs. It is lined with pseudostratified pseudostratified ciliated columnar epithelium epithelium cells with mucosal goblet cells which produce mucus. mucus. This mucus lines the cells of the trachea to trap inhaled foreign particles which the cilia then waft upwards towards their larynx and then the pharynx where it can either be swallowed into the stomach or expelled as phlegm. phlegm.

Bronchi The trachea (windpip (windpipe) e) divides divides into two main main bronchi bronchi (also (also mainste mainstem m bronchi), the left and the right, at the level of the sternal angle at the anatomical anatomical point known as the carina. The right main bronchus is wider, shorter, and more vertical than the left main bronchus. bronchus . The right main bronchus subdivides into three lobar bronchi while the left main bronchus divides into two. The lobar bronchi divide into tertiary bronchi, bronchi , also known as segmental bronchi, each of

which supplies a bronchopulmonary segment. segment . A bronchopulmonary segment is a division of a lung that is separated from the rest of the lung by a connective tissue septum. septum. This This prop proper erty ty allo allows ws a bron bronch chop opul ulmo mona nary ry segm segmen entt to be surgically removed without affecting other segments. There are ten segments per lung, but due to anatomic development, several segmental bronchi in the left lung fuse, fuse, giving giving rise rise to eight eight.. The The segm segmen ental tal bron bronch chii divid divide e into into many many primary bronchioles which divide into terminal bronchioles, bronchioles , each of which then gives rise to several respiratory bronchioles, bronchioles , which go on to divide into 2 to 11 alveolar ducts. ducts. There are 5 or 6 alveolar sacs associated with each alveolar duct. The alveolus is the basic anatomical unit of gas exchange in the lung.

Alveoli An alveol alveolus us (plura (plural: l: alveol alveoli, i, from from Latin Latin alveolus, alveolus , "lit "littl tle e cavi cavity ty") ") is an anatomical structure that has the form of a hollow cavity. Found in the lung, the pulmonary alveoli are spherical outcroppings of the respiratory bronchioles and are the primary sites of gas exchange with the blood. blood. Alveoli are particular to mammalian lungs. Different structures are involved in gas exchange in other vertebrates. Each human lung contains about 150 million alveoli. Each alveolus is wrapped in a fine mesh of capillaries covering about 70% of its area. An adult alveolus has an aver averag age e diame diameter ter of 0.2–0 0.2–0.3 .3 mm, mm, with with an increa increase se in diame diameter ter duri during ng inhalation. inhalation .

IV. PATHOPHYSIOLOGY

Precipitating Factors: Factors: Lifestyle, environmental

Predisposing Factor Age, gender

Inflammation of airways

Bronchial edema

Increased mucus secretion

wheezing

Broncoconstrict -ion

Worsening of obstruction

Bronchial spasm

Dsypnea, cold and clammy skin, diaphoresis

Accumulation of fluids caused by over secretion

Multiplication of growth of organism Inflammation in the epithelial wall Fluid filled alveoli/lobar copartment Shallow breathing, RR increase

Excess fluid accumulate d in spaceperica rdial

Pleural effusion

Rupture of inflamed endothelial cells Mismatch of ventilation and perfusion Mismatch of ventilation and perfusion hypoxemia hypoxia

V. DIAGNOSTIC PROCEDURE AND LABORATORY RESULT

dyspnea

CBC The CBC is used as a broad screening test to check for such disorders as anemia, anemia , infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood. September 24, 2009

Test WBC RBC HEMOGLOBIN HEMATOCRIT MCV MCH MCH-C RDW-CV

Result 18.0 3.47 7.7 25.6 73.8 22.2 30.1 17.1

Unit 1O^3/uL 10^6/uL g/dL % fL Pg g/dL %

References 5.0-10.0 4.2-5.4 12.0-16.0 37.0-47.0 82.0-98.0 27.0-31.0 31.5-35.0 12.0-17.0

IMPRESSION: Increased White Blood Cells may be with infections and inflammation. Red Blood Blood Cell Cell decre decreas ased ed with with anem anemia ia also also with with Hemo Hemogl globi obin n and Hema Hematoc tocrit rit because this mirrors RBC results. Mean Corpuscular Volume decreased with iron defi defici cien ency cy and and thal thalas asse semi mia. a. MCH MCH mirr mirror ors s MCV MCV resu result lts. s. MCHC MCHC may may be decreased decreased when MCV is decreased. decreased. Increased RDW indicates mixed population population of RBCs; immature RBCs tend to be larger. Differential Count The white blood cell differential count determines the number of each type of white blood cell, present in the blood. Monocyte Eosinophils Platelet

11.4 0.9 987

% % 10^3/uL

4.5-10.5 1.0-3.0 1500-4000

IMPRESSION: IMPRESSION : Monocyte levels can increase in response to infection of all kinds as well as to inflammatory disorders. Monocyte counts are also increased in certain malignant disorders, including leukemia. Decreased levels of eosinophils can occur as a result of infection. Platelet decreased decreased when greater numbers used, as with bleeding; decreased with some inherited disorders.

September 25, 2009 Test WBC RBC HEMOGLOBIN HEMATOCRIT MCV MCH MCH-C RDW-CV PDW MPV

Result 21.5 3.65 8.1 27.1 74.2 22.2 29.2 17.2 9.0 8.7

Unit 1O^3/uL 10^6/uL g/dL % fL Pg g/dL % fL fL

References 5.0-10.0 4.2-5.4 12.0-16.0 37.0-47.0 82.0-98.0 27.0-31.0 31.5-35.0 12.0-17.0 9.0-16.0 8.0-12.0

IMPRESSION: IMPRESSION : Based on the table above it was interpreted that the significant elevation of WBC means that an infection occurred inside the body. RBC is below normal, which could reflect the body's inability to produce enough red cells to replenish what, what, has has been been lost lost out out of the the blood blood stream stream.. Decre Decrease ased d hemo hemoglo globin bin and and hemat hematocr ocrit it mirro mirrors rs RBC RBC result results. s. MCH MCH mirror mirrors s MCV MCV result results. s. MCHC MCHC may may be decreased decreased when MCV is decreased. decreased. Increased RDW indicates mixed population population of RBCs; immature RBCs tend to be larger.

Differential Count The white blood cell differential count determines the number of each type of white blood cell, present in the blood. Lymphocyte Neutrophil Monocyte Eosinophils Basophils Platelet

32.3 53.5 13.0 1.0 0.2 1085

% % % % % 10^3/uL

17.4-48.2 43.4-76.2 4.5-10.5 1.0-3.0 0.0-2.0 1500-4000

IMPRESSION: Monocyte levels can increase in response to infection of all kinds as well as to inflammatory disorders. Monocyte counts are also increased in certain malignant disorders, including leukemia. On the other hand, platelet decreased when greater numbers used, as with bleeding; decreased with some inherited disorders.

DRUG ORDER (Generic name, brand name, classification, classification, dosage, route, frequency)

Generic Name: Furosemide Brand Name: Apo-Furosemide, Furosemide special, Lasix

MECHANISM OF ACTION

CONT CONTRA RAIN INDI DICA CAT TIONS ION S INDICATIONS

Inhibits the reabsorption of sodium and chloride from the ascneding limb of the loop of Henle, leading to a sodium-rich diresis

 Acute



Pulmonary edema

Classification: Loop diuretic



Dosage: 1 mg/kg

Contraindicated Contraindicated with allergy to furosemide, sulfonamides; allergy to tartrazine (in oral solution0; anuria,severe renal failure; hepatic coma; pregnancy; lactation Use cautiously with Sle, gout, diabetes mellitus.

Route: IVTT Frequency: 2 hr

ADVE ADVERS R SE E EFFE EFFECT CTS S OF THE DRUG

CNS: Dizziness, weakness,headache, drowsiness,fatigue CV: Orthostatic hypotension, thrombophlebitis Dermatologic: Photosensitivity, rash,pruritus,purpura GI: Nausea, anorexia,vomiting, anorexia,vomiting, oral and gastric irritation, constipation, GU: Polyuria, nocturia, glycosuria, urinary bladder spasm

NURSING RESPONSIBILITIES/ PRECAUTIONS







 

Hematologic: Leukopenia, anemia, thrombocytopenia, thrombocytopenia, fluid and electrolyte imbalances, hyperglycemia

Adminiser with food or milk to prevent GI upset Reduce dosage if given with other antihypertensives; readjust dosae gradually as BP responds Give early in the day so that increased urination will not disturb sleep Avoid IV use of oral use is at all possible Arrange for potassium-rich diet or supplemental potassium as needed.

Other: Muscle cramps and muscle spasms

DRUG ORDER DRUG ORDER (Generic name, brand (Generic name, brand name, classification, classification, name, classification, classification, dosage, route, dosage, route, frequency) frequency) Generic Name: Generic Name: Amikacin sulfate Oxacillin sodium Brand Name: Brand Name: Amikin Antibiotic; Penicillinase-resistant Classification: penicillin Anti-infective Dosage: Dosage: 95 mg 600 mg

MECHANISM OF MECHANISM OF ACTION ACTION

Bactericidal: inhibits Bactericidal:Inhibits protein synthesis in cell wall synthesis of susciptible strains of sensitive organisms, gram-negative causing cell death. bacteria, and the functional integrity of bacterial cell membrane appears to be disrupted, causing cell death.

INDICATIONS INDICATIONS

 Severe Infections due to systemic penicillinase-producing infection staphylococci; staphyloco cci; may be caused by used to initiate sensitive treatment when a straints staphylococci staphylococci infection is suspected.

CONT CONTRA RAIINDIC NDICAT ATIO IONS NS CONT CONTRA RAIN INDI DICA CATI TION ONS S

 

 

Route: Route: IVTT IVTT

Contraindicated with containdicated containdicated with allergy to any allergies to aminoglycosides, penicillins, renal or hepatic cephalosporins, cephalosporins, or disease, preexisting other allergens hearing loss, Use cautiously with myasthenia gravis renal disordes, Use cautiously with pregnancy, lactation elderly patients, any (may cause diarrhea apatient with or candidiasis in deminished hearing, infants). decreased renal function, dehydration

Frequency: q 12 hr Frequency: q 6 hr

ADVE ADVERS R SE E EFFEC EFFE CT TS OF ADVE ADVERS RSE E EFFE EFFECT CTS S OF THE DRUG THE DRUG

CNS:Lethargy, Confusion, CNS: disorientation, hallucinations, hallucination s, seizures depression,

GI: stomatitis, glossitis, gastritis,nausea, gastritis,nau sea, vomiting, CV: diarrhea, abdominal pain Palpitations,hypotension,

hypertension

GU: Nephritis-oliguria, Nephritis-oliguria, proteinuria, hematuria, GI: Nausea, vomiting, pyuria

anorexia

Hematologic: Anemia, GU: nephrotoxicity thrombocytopenia, leukopenia, leukopenia, prolonged Hematologic: bleeding time

Granulocytosis, Hypersensitivity: Hypersensitivi leukopenia, ty: Rash, fever, wheezing, anaphylaxis Hepatic: Hepatic toxicity;

NURSING NURSING RESPONSIBILITIES/ RESPONSIBILITIES/ PRECAUTIONS PRECAUTIONS



and sensitivity reculture if response of infected istesting not as expected area before for IM  Reconstitite use to a dilution of treatment. mg/1.5 mL Give IM dosage by  250 using water deepsterile injection for injection or  Ensure that patient sodium chloride is well hydrated injection. Discard before andatduring after 3 days room therapy or after temperature 7 days if Report pain at  refrigerated. injection site, TP: severe headache, 

hepatomegaly

Local: Pain, phlebitis, thrombosis at injection site

Hypersensitivity: Purpura, rash, exfoliative Other: Superinfections, Superinfections, dermatitisOther: sodium overload leading to Superinfections, Superinfections, pain and CHF irritation at IM injection sites

DRUG ORDER (Generic name, brand name, classification, classification, dosage, route, frequency) Generic Name: Cefuroxime

MECHANISM OF ACTION

CONTRA CONTRAIND INDICA ICATIO TIONS NS

INDICATIONS

Bactericidal: Inhibits



Lower



ADVERS ADVERSE E EFFEC EFFECTS TS OF THE DRUG

contraindicated contraindicated with CNS: Headache,

Culture infection

Arrange forculture  before treatment;

dizziness, loss of

You may changes hearing, experiencethese in urine pattern, side effects: Upset difficulty breathing, stomach, nausea, rash or skin diarrhea, (eat lesions.small frequent meals), mouth ssores (perform mouth care), pain at the injection site


NR:

DRUG ORDER DRUG ORDER (Generic name, brand (Generic name, brand name, classification, classification, name, classification, classification, dosage, route, dosage, route, frequency) frequency) Generic Name: Generic Name: Amikacin sulfate Oxacillin sodium Brand Name: Brand Name: Amikin Antibiotic; Penicillinase-resistant Classification: penicillin Anti-infective Dosage: Dosage: 95 mg 600 mg

MECHANISM OF MECHANISM OF ACTION ACTION

Bactericidal: inhibits Bactericidal:Inhibits protein synthesis in cell wall synthesis of susciptible strains of sensitive organisms, gram-negative causing cell death. bacteria, and the functional integrity of bacterial cell membrane appears to be disrupted, causing cell death.

INDICATIONS INDICATIONS

 Severe Infections due to systemic penicillinase-producing infection staphylococci; staphylococci; may be caused by used to initiate sensitive treatment when a straints staphylococci staphylococci infection is suspected.

CONT CONTRA RAIINDIC NDICAT ATIO IONS NS CONT CONTRA RAIN INDI DICA CATI TION ONS S

 

 

Route: Route: IVTT IVTT

Contraindicated with containdicated containdicated with allergy to any allergies to aminoglycosides, penicillins, renal or hepatic cephalosporins, cephalosporins, or disease, preexisting other allergens hearing loss, Use cautiously with myasthenia gravis renal disordes, Use cautiously with pregnancy, lactation elderly patients, any (may cause diarrhea apatient with or candidiasis in deminished hearing, infants). decreased renal function, dehydration

Frequency: q 12 hr Frequency: q 6 hr

NURSING NURSING RESPONSIBILITIES/ RESPONSIBILITIES/ PRECAUTIONS PRECAUTIONS

ADVE ADVERS R SE E EFFEC EFFE CT TS OF ADVE ADVERS RSE E EFFE EFFECT CTS S OF THE DRUG THE DRUG

CNS:Lethargy, Confusion, CNS: disorientation, hallucinations, hallucination s, seizures



depression,

and sensitivity reculture if response of infected istesting not as expected area before for IM  Reconstitite use to a dilution of treatment. mg/1.5 mL Give IM dosage by  250 using water deepsterile injection for injection or  Ensure that patient sodium chloride is well hydrated injection. Discard before andatduring after 3 days room therapy or after temperature 7 days if Report pain at  refrigerated.

GI: stomatitis, glossitis, gastritis,nausea, gastritis,nau sea, vomiting, CV: diarrhea, abdominal pain Palpitations,hypotension,

hypertension

GU: Nephritis-oliguria, Nephritis-oliguria, proteinuria, hematuria, GI: Nausea, vomiting, pyuria

anorexia

Hematologic: Anemia, GU: nephrotoxicity thrombocytopenia, leukopenia, leukopenia, prolonged Hematologic: bleeding time

Granulocytosis,

injection site,

Hypersensitivity: Hypersensitivi leukopenia, ty: Rash, fever, wheezing, anaphylaxis Hepatic: Hepatic toxicity;

TP: severe headache, 

hepatomegaly

Local: Pain, phlebitis, thrombosis at injection site

Hypersensitivity: Purpura, rash, exfoliative Other: Superinfections, Superinfections, dermatitisOther: sodium overload leading to Superinfections, Superinfections, pain and CHF irritation at IM injection sites

DRUG ORDER (Generic name, brand name, classification, classification, dosage, route, frequency) Generic Name: Cefuroxime Brand Name: Cefuroxime sodium (Zinacef)

MECHANISM OF ACTION


INDICATIONS

Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death



Lower respiratory infections





Classification: Antibiotic

contraindicated contraindicated with allergy to cephalosporins or penicillins Use cautiously with enal failure, lactation, pregnancy

NR: 

GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, liver toxicity GU: Nephrotoxicity Hematologic: Bone marrow deppression ( decreased WBC, decreased platelets, decreased Hct).

Dosage: 385 mg Route: IVTT

Hypersensitivity: Ranging from rash to fever to anaphylaxis, anaphylaxis, serum sickness reaction

Frequency: q.8 hr

Local: Pain, abscess at injection site, phlebitis, inflammation at IV site

ASSESSMENT DATA (Subjective & Objective Cues)

Subjective: “Ga sige rako ug ubo-ubo sir” as verbalized by the patient. Objective:

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVES

dizziness, loss of

You may changes hearing, experiencethese in urine pattern, side effects: Upset difficulty breathing, stomach, nausea, rash or skin diarrhea, (eat lesions.small frequent meals), mouth ssores (perform mouth care), pain at the injection site



CNS: Headache, dizziness, lethargy

Culture infection

Arrange forculture  before treatment;

NURSING INTERVENTIONS AND RATIONALE





Culture infection, nd arrange for sensitivity tests before and during therapy if expected, response is not seen Give oral drug with food to decrease GI upset and enhance absorption Give oral drug to children who can swallow tablets: crushing the drug results in a bitter, unpleasant unpleasant taste

EVALUATION

Ineffecti Ineffective ve airway airway clearanc clearance e Afte Afterr 8 hour hours s of care care Independent: Afte Afterr 8 hour hours s of care care related to retained secretions. patient will be able to: - Elevat Elevate e head head of the bed/c bed/chan hange ge goals partially met . position every 2 hours. Patient was able to: a. mainta intain in airwa irway y R. To take take adva advant ntag age e of grav gravit ity y patency decreasing pressure on the Maintain airway airway a. Maintain b. expect expectora orate/ te/cle clear ar diaphragm. patency.

DRUG ORDER (Generic name, brand name, classification, classification, dosage, route, frequency) Generic Name: Cefuroxime Brand Name: Cefuroxime sodium (Zinacef)

MECHANISM OF ACTION


INDICATIONS

Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death



Lower respiratory infections





Classification: Antibiotic

contraindicated contraindicated with allergy to cephalosporins or penicillins Use cautiously with enal failure, lactation, pregnancy



CNS: Headache, dizziness, lethargy

NR: 

GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, liver toxicity GU: Nephrotoxicity Hematologic: Bone marrow deppression ( decreased WBC, decreased platelets, decreased Hct).

Dosage: 385 mg Route: IVTT



Hypersensitivity: Ranging from rash to fever to anaphylaxis, anaphylaxis, serum sickness reaction

Frequency: q.8 hr

Local: Pain, abscess at injection site, phlebitis, inflammation at IV site






Culture infection, nd arrange for sensitivity tests before and during therapy if expected, response is not seen Give oral drug with food to decrease GI upset and enhance absorption Give oral drug to children who can swallow tablets: crushing the drug results in a bitter, unpleasant unpleasant taste


EVALUATION

Subjective: “Ga sige rako ug ubo-ubo sir” as verbalized by the patient.

Ineffecti Ineffective ve airway airway clearanc clearance e Afte Afterr 8 hour hours s of care care Independent: Afte Afterr 8 hour hours s of care care related to retained secretions. patient will be able to: - Elevat Elevate e head head of the bed/c bed/chan hange ge goals partially met . position every 2 hours. Patient was able to: a. mainta intain in airwa irway y R. To take take adva advant ntag age e of grav gravit ity y Objective: patency decreasing pressure on the Maintain airway airway a. Maintain b. expect expectora orate/ te/cle clear ar diaphragm. patency. cough secretions readily b. Expectorate restlessness - Encourag Encouraged ed deep-brea deep-breathin thing g and clear clear secretion secretions s coughing exercises. yellowish sputum readily as tach tachyc ycar ardi dia a (PR= (PR=10 107 7 R. To mobilize secretions. evid evide enced ced by bpm) less less secret secretion ions s pale - Ausc Auscul ulta tate te brea breath th soun sounds ds and and retained. assess air movement. RR=26 cpm R. To asce ascert rtai ain n stat status us and and note note progress. - Evaluate changes in sleep pattern. R. To assess changes.


Subjective: “Galis “Galisud ud ko ug ginha ginhawa wa kung kung mahago ko” as verbalized by the patient.

Objective: RR=26 -



Impa Impair ired ed gas gas exch exchan ange ge Afte Afterr 8 hour hours s of care care related related to alveolaralveolar-capi capillary llary patient will be able to: membrane changes. in a. Participate treatment regimen b. Demo Demons nstra trate te improve ventilation.


EVALUATION

Independent: - Monit Monitor or vital vital signs signs and and cardia cardiac c rhythm. R. To evaluate degree of compromise.

After After 8 hours hours of duty duty goals met. met. Patient was able to:

- Elevate head of bed/position client appropriately.

a. Participate in treatment regimen. b. Demo Demons nstr trat ate e improve ventilation.





EVALUATION

Subjective: “Ga sige rako ug ubo-ubo sir” as verbalized by the patient.

Ineffecti Ineffective ve airway airway clearanc clearance e Afte Afterr 8 hour hours s of care care Independent: Afte Afterr 8 hour hours s of care care related to retained secretions. patient will be able to: - Elevat Elevate e head head of the bed/c bed/chan hange ge goals partially met . position every 2 hours. Patient was able to: a. mainta intain in airwa irway y R. To take take adva advant ntag age e of grav gravit ity y Objective: patency decreasing pressure on the Maintain airway airway a. Maintain b. expect expectora orate/ te/cle clear ar diaphragm. patency. cough secretions readily b. Expectorate restlessness - Encourag Encouraged ed deep-brea deep-breathin thing g and clear clear secretion secretions s coughing exercises. yellowish sputum readily as tach tachyc ycar ardi dia a (PR= (PR=10 107 7 R. To mobilize secretions. evid evide enced ced by bpm) less less secret secretion ions s pale - Ausc Auscul ulta tate te brea breath th soun sounds ds and and retained. assess air movement. RR=26 cpm R. To asce ascert rtai ain n stat status us and and note note progress. - Evaluate changes in sleep pattern. R. To assess changes.



Objective: RR=26 Dyspnea Restlessness Tach Tachyc ycar ardi dia a bpm) Pale -




(PR= (PR=10 107 7


EVALUATION



- Elevate head of bed/position client appropriately. R. To maintain airway.


- Maintain adequate I/O. R. For mobilization of secretions. Enco Encour urag age e freq frequ uent ent posi positi tion on chan change ges s and and deep deep-b -bre reat athi hing ng coughing exercises. R. To corr correc ect/ t/im impr prov ove e exis existi ting ng deficiencies. Dependent: Dependent : Adm Adminis iniste terr medica icatio tions indicated. R. To treat underlying conditions.




Subjective: Ineffecti Ineffective ve tissue tissue perfusion perfusion Afte Afterr 8 hour hours s of care care “Gal “Galis isod od ko ug ginh ginhaw awa” a” as (cardiopulmonary) related to patient will be able to: verbalized by the patient. impair impaired ed transp transport ortati ation on of the the oxyg xygen acro cross the a. Demo Demons nstr trat ate e Objective: alve alveol olar ar and/ and/or or capi capill llar ary y behaviors/lifestyle membrane. changes to RR=26 cpm improve


Independent:

as

EVALUATION

After After 8 hours hours of care goals met. met. Pati Patien entt was able to:

-Identify changes related to systemic or periph ripher era al alter ltera atio tions in circulation. a. Demonstrate R. To assess contributing factors behaviors/lifestyle chan change ges s to impr improv ove e



Objective: RR=26 Dyspnea Restlessness Tach Tachyc ycar ardi dia a bpm) Pale -




(PR= (PR=10 107 7


EVALUATION



- Elevate head of bed/position client appropriately. R. To maintain airway.


- Maintain adequate I/O. R. For mobilization of secretions. Enco Encour urag age e freq frequ uent ent posi positi tion on chan change ges s and and deep deep-b -bre reat athi hing ng coughing exercises. R. To corr correc ect/ t/im impr prov ove e exis existi ting ng deficiencies. Dependent: Dependent : Adm Adminis iniste terr medica icatio tions indicated. R. To treat underlying conditions.




Subjective: Ineffecti Ineffective ve tissue tissue perfusion perfusion Afte Afterr 8 hour hours s of care care “Gal “Galis isod od ko ug ginh ginhaw awa” a” as (cardiopulmonary) related to patient will be able to: verbalized by the patient. impair impaired ed transp transport ortati ation on of the the oxyg xygen acro cross the a. Demo Demons nstr trat ate e Objective: alve alveol olar ar and/ and/or or capi capill llar ary y behaviors/lifestyle membrane. changes to RR=26 cpm improve Irritability circulation. b. Demo Demons nstr trat ate e Restlessness increased perfusion as individually appropriate.


Independent:

as

EVALUATION


-Identify changes related to systemic or periph ripher era al alter ltera atio tions in circulation. a. Demonstrate R. To assess contributing factors behaviors/lifestyle chan change ges s to impr improv ove e -Determine duration of problem. circulation R. To note degree of impairment b. Demonstrate increased perfusion as -Monitor vital signs individually R. To maximize tissue perfusion appropriate. -Investigate report of chest pain R. To note degree of impairment Dependent: -Administer medication as ordered R. To maximize tissue perfusion




Subjective: Ineffecti Ineffective ve tissue tissue perfusion perfusion Afte Afterr 8 hour hours s of care care “Gal “Galis isod od ko ug ginh ginhaw awa” a” as (cardiopulmonary) related to patient will be able to: verbalized by the patient. impair impaired ed transp transport ortati ation on of the the oxyg xygen acro cross the a. Demo Demons nstr trat ate e Objective: alve alveol olar ar and/ and/or or capi capill llar ary y behaviors/lifestyle membrane. changes to RR=26 cpm improve Irritability circulation. b. Demo Demons nstr trat ate e Restlessness increased perfusion as individually appropriate.


Independent:

EVALUATION


-Identify changes related to systemic or periph ripher era al alter ltera atio tions in circulation. a. Demonstrate R. To assess contributing factors behaviors/lifestyle chan change ges s to impr improv ove e -Determine duration of problem. circulation R. To note degree of impairment b. Demonstrate increased perfusion as -Monitor vital signs individually R. To maximize tissue perfusion appropriate. -Investigate report of chest pain R. To note degree of impairment Dependent: -Administer medication as ordered R. To maximize tissue perfusion

VIII. DISCHARGE PLAN

•

M- Medication Medication includes Amikacin, Cefuroxime, Oxacilin, Furosemide. These medicines


•

M- Medication Medication includes Amikacin, Cefuroxime, Oxacilin, Furosemide. These medicines are taken depending on severity and kind of pleural effusion.

•

E- E xercise Teachin Teaching g breathi breathing ng retainin retaining g exercis exercise e to increase increase diaphrag diaphragmati matic c excursio excursion n and reduce work of breathing.

•

Teach relaxation techniques to reduce anxiety with dyspnea.

•

•

•

•

•

Augment the patient’s ability to cough effectively by splinting the patient’s 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 coun counte terr drug drugs, s, vita vitami mins ns,, herb herbs s or food food supp supple leme ment nts s with withou outt firs firstt talk talkin ing g to caregivers. To decrease your pain; when coughing, hold a pillow over your chest where the pain is. Quit Quit smok smoking ing.. Do not not smoke smoke and do not not allow allow others others to smok smoke e aroun around d you. 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


•

M- Medication Medication includes Amikacin, Cefuroxime, Oxacilin, Furosemide. These medicines are taken depending on severity and kind of pleural effusion.

•

E- E xercise Teachin Teaching g breathi breathing ng retainin retaining g exercis exercise e to increase increase diaphrag diaphragmati matic c excursio excursion n and reduce work of breathing.

•

Teach relaxation techniques to reduce anxiety with dyspnea.

•

•

•

•

•

•

•

•

•

Augment the patient’s ability to cough effectively by splinting the patient’s 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 coun counte terr drug drugs, s, vita vitami mins ns,, herb herbs s or food food supp supple leme ment nts s with withou outt firs firstt talk talkin ing g to caregivers. To decrease your pain; when coughing, hold a pillow over your chest where the pain is. Quit Quit smok smoking ing.. Do not not smoke smoke and do not not allow allow others others to smok smoke e aroun around d you. 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 breathing as deeply as you should. Coughing Coughing and deep breathing 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.

IX. LEARNING EXPERIENCE Caring is our major responsibility. That’s why we have to treat everyone as such, despite the consequences consequences we might to commit, that wouldn’t matter. We learned to always have a presence of mind while on duty.

For all those times, time management best thump us a lot. We learned to adjust and manage time exactly as possible because when you say you are going to do something, you have do it right away! You don’t have to wait for the time to come when it’s too late for you to do such actions. It would be your lose and at the end you’ll realized that you acquire worse. Another thing is to establish a therapeutic therapeutic and a trusting relationship relationship to each patient because that’s one of the ways a person can feel free to open lines communication. And the best experience we had is to be in one piece, helping each other and persevering.

Regarding this case we chose, we found it out to be enjoyable. We thought we don’t have enough time focusing on this one especially that we still have other subjects to be tackled. Surfing the net and printing is money consuming but we still feel happy because doing these things helps us improved our learning about the disease and makes us think of possible task that can also be helpful to the patients

At the end, we’re still thankful because God never put us down. All these things wouldn’t be possible if nobody helps us find ways to finish this requirement. There goes the time we learned to value our selves, we learned how to be “flexible”, and we learn how to adjust things somehow. It’s never easy but we have to be with our selves to make things possible.

X. REFERENCES BOOKS: Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care Plans Guidelines for Individualizing Patient Care , (6th ed.). Thailand Doenges, Doenges, M.E., Moorhouse, Moorhouse, M.F., & Geissler, A.C (2006). Nurse’s pocket Guide; Guide; Diagnos Diagnoses, es, Priorit Prioritized ized Interven Intervention tions, s, and Rationa Rationales. les. ( 10 ( 10thed.). Philadelphia, Pennsylvania Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN, (2004). Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia Karc Karch, h, Amy Amy M. ; 2006 2006 Lipp Lippic icot ott’ t’s s Nurs Nursin ing g Drug Drug Guid Guide, e, 8th 8th edit editio ion. n. Lippincott Williams & Wilkins. Nurses’ Pocket Guide, 10th edition F.A. Davis. Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr. Patient’s Chart Black, Joyce M. et. al, Medical-Surgican Nursing: Clinical Management for Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005 Malseed, Roger T. ; Springhouse Nurses’ Drug Guide 2004, 5th edition. Davis drug handbook, 10 th edition Drug handbook by Saunders

INTERNET: http://cpmcnet.columbia.edu/dept/gi/.html http://digestive.niddk.nih.gov/ddiseases/pubs/_ez/ http://www.angelfire.com/scifi2/lnuphysiology/Blood_Physiology_1.pdf http://www.drstandley.com/labvalues http://www.google.com.ph/search http://www.google.com.ph/search?anatomy&meta= http://www.merck.com/ l

ACKNOWLEDGEMENT In behalf of our group, we would like to thank each member for their unending support and cooperation and for being patient in making this case study possible. For the sleepless nights that we have been together, that despite of each our own differences we were able to stand united through thick and thin.. To our PCI who guides us as we go along in our duties, Thank you Mrs Helen Yorong. To our diligent and responsible CI, who provides us with ample knowledge and skills to make us efficient student nurses, and for helping us develop the right attitude while in this rotation. Thank You so much, Mrs. Maria Rica Adane, RN.

Pleural Effusion

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