Introduction of the Client

Encik Ahmad (not his real name) is a 56-year-old Malay man living in Km. 12 Air
Molek, Melaka. He is admitted in General Hospital Malacca on 09 January 2011 at 10:20 AM
at male medical ward 3-4. For the past 2 days he was complaining of shortness of breath upon
exertion, orthopneic, sore throat and is havinga productive cough with whitish sputum. The
wife was worried of these symptoms because his medical history, decided to go to Hospital
Malacca. Upon examining, his physician advised him to be admitted to undergo further
investigation.
Encik Ahmad has no chest pain, palpitation, syncope attach, loss of consciousness,
diarrhoea, abdominal pain, nausea, vomiting, headacheand no other upper respiratory and
urinary tract infections. His sputum has no blood stain and tolerating orally well and passing
out urine and bowel are normal.

Clinical Examination

On examination, Encik Ismail sitting blood pressure was 138/92 mmHg, his pulse and
respiratory rates were 82 bpm and 16 breaths per min., respectively. His body temperature
was 37.1C; sPO2 was 96% on 3L/min nasal prong oxygen and blood glucose level of
17.6mmol/L.
Encik Ismail was alert, conscious, can speak in full sentences, pink, and his hydration
was good and not tachypneic. His Cardio
Vascular System showed S1S2 Dual Rhythm
No Murmur, lung has bibasal crept more on
right side, no rhenchi, air entry is equal for
both sides. Jugular vein pressure His abdomen
was soft System showed normal.

Diagnosis
After a series of investigation, Encik
Ismail was diagnosed with cardiomegaly,
fluid overload in CCF secondary to noncompliance to fluid restriction and right and
left
pleural
effusionsecondary
to
hypertension.

Medical History
Encik Ismail is a patient with
complicated diseases. He is having hypertension for 1 year, an insulin dependent for 10
years, right side hemiparesis, and has ischemic heart failure with triple vessel disease. He has
done angiogram clone in IJN and on follow up since November 2010.
Chest x-ray showing
bilateral pleural effusion

Case Study on Pleural Effusion1 | P a g e

He is on the following medication for the above diseases and claimed compliance to it
but daughter said he is not complying with fluid restriction:

1. S/C Humulin 30/70

2. T. Simvastatin 40 mg ON
3. T. Aspirin 150 mg OD
4. T. Isordil 10 mg TDS
5. T. Vastarel 20 mg TDS
6. T. Clinidogrel 75 mg OD
7. T. Bisoprolol 1.25 mg OD
8. T. Digoxin 0.0625 mg OD
9. C. Gemtobrozil 300 mg ON
10. T. Frusemide 40 mg BD
He also had a multiple admission due to chest pain at same hospital and his last
admission was December 2010 of which he was treated with stable angina.

Surgical History
Encik Ahmad also has a bilateral basal knee amputation. His right leg was amputated
10 years ago while his left leg was amputated 4 years ago.

Family History
Both parents of Encik Ahmad have a medical history of diabetes mellitus and
hypertension and heart problem. His brothers and sisters inherited the same. His wife is
having hypertension and claimed that his children are all healthy.

Social History
Encik Ismail was previously working as Chef to Selangor Royal Family. He has 7
children and currently staying with his wife and 2 children. Other children are married,
working and staying on their own. He is non-smoker, non-alcohol drinker and never use any
prohibited drugs before. Due to his condition (right side hemiparesis and amputated legs) he
is semi dependent in doing his activities of daily living. He also has financial support from
the social welfare of RM150.00/month.

Food and Drug Allergies

Encik Ismail has noknown allergies.

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ASSESSMENT OF ACTIVITIES OF DAILY LIVING (ADL)

Patient's Name : Encik Ahmad

Registration No.: 679010

DATE

09.1.11

ACTIVITIES OF DAILY LIVING

PATIENT'S PROBLEM

What pateint can or cannot perform by

herself/himself

ACTUAL/POTENTIAL

Maintaining a safe environment

to 14.1.11 Bed and bed side rail are always locked and up
after each procedure/s.

Risk for injury related to

right hemeparesis and loss
of extremities.

Communication
Patient is able to talk clear and in full
sentences.

Breathing
Patient is having short of breath especially
during exertion.

Breathing pattern
impairment related to
pleural fluid build-up.

Eating and Drinking

Risk for body nutrition

excess related to high
glucose level.

Patient can eat and drink by himself and is

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tolerating orally well.

Eliminating
Patient is on bed pan and urinal

Self care deficit: elimination

related to limited mobility
as evidence by patient is
having right hemeparesis
and below knees
amputation.

Personal cleaning and dressing

Patient needs help in bathing, washing and
dressing himself due to right side hemeparesis.

Bathing/hygiene deficit
related to loss of ability to
use the right arm and hand
as evidence by patient is
having right hemeparesis.

Controlling body temperature

Patient is afebrile during his stay in the hospital

Risk for infection

related to pleural
tapping.

Mobility
Patient needs help in moving around. Wife always
around to help.

Impaired physical
mobility related to right
hemeparesis and loss of

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extremities.
Sleep
Sleep on and off due to cough.

Disturbed sleep pattern

related to coughing and
SOB.

Working and Playing

Patient's entertainment are reading newspaper,
watching tv, sitting on wheelchair outside his house
and doing physiotheraphy exercise.

Disturbed body image

related to amputation of
both lower legs

Sexuality
Patient's wife still alive.

Sexuality dysfunction
related to right
hemeparesis and BKA

Dying
NIL

NIL

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PLEURAL EFFUSION

Introduction of Disease
The pleura is a double-layered membrane that
covers the lungs and the inside of the thoracic
cavities. The parietal pleura is adherent to the
inside of the chest wall and the thoracic surface of
the diaphragm. It remains detached from the
adjacent structures in the mediastinum and is
continuous with the visceral pleura, which is
adherent to the lung, covering each lobe and
passing into the fissures that separate them.The
pleural space plays an important role in respiration
by coupling the movement of the chest wall with
that of the lungs in two ways:
1. A relative vacuum in the space keeps the
visceral and parietal pleura in close proximity.
2. The small volume of pleural fluid, which has been calculated at 0.13 ml/kg of body weight
and the normal circumstances, serves as a lubricant to facilitate movement of the pleural
surface against each other in the course of respirations. This small volume of fluid is
maintained through the balance of hydrostatic and
oncotic pressure and lymphatic drainage, disturbance
of which may lead to pathology.
An abnormal collection of this pleural fluid in
the pleural spaces more than 0.13 ml/kg of body
weight is called,pleural effusion.This can either be a
result from a systemic disorders or local diseases.
Systemic disorders include heart failure, liver or renal
diseases and connective disorders, like rheumatoid
arthritis and systemic lupus erythematosus (SLE).
Local diseases include pneumonia, atelectasis,
tuberculosis, lung cancer, and trauma.
Pleural Effusion is not often a primary disease
process; it is usually a secondary to other processesas
mentioned above.

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Pathophysiology
Pleural effusion is an indicator of an underlying disease process that may be
pulmonary or non-pulmonary in origin, acute or chronic.
Normally, pleural fluid has the following characteristics:
Clear ultrafiltrate of plasma that originates from the parietal pleura
pH 7.60-7.64
protein contain less than 2% (1-2g/dL)
fewer than 1000 WBCs per cubic millimetre
glucose contain similar to that of plasma
lactate dehydrogenase (LDH) less than 50% of
plasma
sodium, potassium and calcium concentration
similar to that of the interstitial fluid
Excess pleural fluid can either be in the form of
exudate and transudate. Exudate, is a protein-rich
fluid, developed when the blood vessels leak caused
by inflammation of the pleura and when the patient is
having infection or systemic inflammation.
Transudate on the other hand, is formed when the pressure is high or plasma protein
content is low in the blood vessels, the fluid leaks into the pleural space. It is commonly
caused by heart failure and may also accompany renal failure, nephritis, liver failure and
malignancy.
Moreover, the following processes play a role in the increased production of pleural fluid:
Altered permeability of the pleural membranes(e.g., inflammation, malignancy,
pulmonary embolus)
Reduction in intravascular oncotic pressure(e.g., hypoalbuminemia, cirrhosis)
Increase capillary permeability or vascular disruption(e.g., trauma, malignancy,
inflammation, infection, pulmonary infarction, drug hypersensitivity, uraemia,
pancreatitis)
Increase capillary hydrostatic pressure in the systemic and/or pulmonary circulation
(e.g., CHF, superior vena cava syndrome)
Reduction of pressure in the pleural space, preventing full lung expansion(e.g.,
extensiveatelectasis, mesothelioma)
Decrease lymphatic drainage or complete blockage, including thoracic duct
obstruction or rupture (e.g., malignancy, trauma)
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 Increase peritoneal fluid, with migration across the diaphragm via lymphatic or
structural defect (e.g., cirrhosis, peritoneal dialysis)
Movement of fluid from pulmonary oedema across the visceral pleura
Persistent increase in pleural fluid oncotic pressure from an existing pleural
effusion, causing for the fluid accumulation
The net result of the effusion formation is a flattening or inversion of the diaphragm,
mechanical disassociation of the visceral and parietal pleura, and a restrictive ventilatory
defect.

Possible Signs and Symptoms

The most common manifestations, regardless of the type of fluid in the pleural space
or its causes, are shortness of breath and chest pain because of large pleural effusion that
compresses the adjacent lung tissue. However, some people with pleural effusion have no
symptoms at all. When the parietal pleura is irritated, the patient may have mild pain that
quickly passes or, sometimes, a sharp, stabbing pleuritic type of pain. Pain is often relieved
by formation of an effusion, as the fluid reduces friction between inflamed visceral and
parietal pleura. Some patients also will have a dry and unproductive cough. Tapping on the
chest will show that the usual crisp sounds have become dull, and on listening with a
stethoscope the normal breath sounds are muted. If the pleura is inflamed, there may be a
scratchy sound called a pleural friction rub."
Table 2. Possible and Actual Signs and Symptoms

POSSIBLE
Dry and unproductive cough
Pleuritic pain
Dyspnoea
Dullness over chest wall
Decreased or absence of breath sound
Pleural friction rub

ACTUAL COMPLAINT OF THE PATIENT

Dyspnoea
Orthopneic
Sore throat
Productive cough

Possible Diagnostic Procedure and Laboratory Tests

Chest Radiograph (x-ray).A chest X-ray is a radiology test that involves exposing the
chest briefly to radiation to produce an image of the chest and the internal organs such as
the heart, lungs, and blood vessels. Doctor may order a chest x-ray if you have symptoms
like persistent cough, chest injury, chest pain, coughing up blood and difficulty in
breathing. It can be done also for patient having signs oftuberculosis, lung cancer, or
other chest or lung disease.
A seriesof chest x-ray may be used to evaluate or monitor changes found on a
previous chest x-ray.
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Although the treatment is beneficial to the patient, it poses certain risks or

complications and or side effects like cancer and other defects; nausea, sneezing,
vomiting, itching, hives or anaphylaxis may occur if allergic to iodine; and kidney
problem due the toxic effect of the dye.
Thoracic Computed Tomography
(CT). An imaging method that uses xrays to create cross-sectional pictures
of the chest and upper abdomen.
These cross-sectional images of the
area being studied can then be
examined on a computer monitor,
printed or transferred to a CD. It also
provides greater clarity and reveals
more details than regular x-ray
examination of the body e.g., brain,
chest, spine, and abdomen. The test
may be used to better view the
structures inside the chest.
A thoracic CT may be done: Chest
CT scan showing loculated pleural
effusion and right lung
After a chest injury

Chest CT scans showing loculatedpleural

effusion at right lung

When a tumour or mass (clump of cells) is suspected

To determine the size, shape, and position of organs in the chest and upper abdomen
To look for bleeding or fluid collections in the lungs or other areas
All procedure using radiation and
dyes poses the same complications and
side effects though it varies from person
to person.

Chest

Ultrasound.

chest

ultrasound is a non-invasive procedure used

to assess the organs and structures within
the chest, such as the lungs, mediastinum
(area in the chest containing the heart,
aorta, trachea, oesophagus, thymus, and
lymph nodes), and pleural space (space
between the lungs and the interior wall of
the chest). Ultrasound technology allows quick visualization of the chest organs and

Case Study on Pleural Effusion9 | P a g e

structures from outside the body.

Ultrasound may also be used to assess
blood flow to chest organs.
Thoracentesis. A procedure is used to
remove fluid from the space between
the lungs and the chest wall called the
pleural space. It is done by inserting a
needle (sometimes a plastic catheter)
into the chest wall and the pleural fluid
is aspirated. The procedure is
performed to remove the fluid, prevent
the fluid from building up again and
treating the cause of the fluid build-up.
The procedure can also be performed if you have the following conditions:
Asbestos-related pleural effusion
Collagen vascular disease
Drug reactions
Hemothorax
Pancreatitis
Pneumonia
Pulmonary embolism
Pulmonary veno-occlusive disease
Thyroid disease
Collapse of the lung (pneumothorax)
The risks for thoracentesis include excessive loss of blood, fluid reaccumulation,infection, pulmonary oedema, and respiratory distress. So far no serious
complications have been reported.

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 Pleural Fluid Analysis. An examination ofthe fluid aspirated/collected from the pleural
space during thoracentesis and to look for cancerous or malignant cells, cellular makeup,
chemical content and tiny organisms that can cause the diseases.

Thoracentesis
on progress
Complete Blood Count. This is used as a broad screening test to check
forpleural
disorders
pulling
fluid that examines
as anemia, infection, and many other diseases. It is actually a panel of tests

different parts of the blood which includes the following (Lab Test Online):

White blood cell (WBC) count is a count of the actual number of white blood cells
per volume of blood. Both increases and decreases can be significant.

White blood cell differential looks at the types of white blood cells present. There are
fivedifferent
types
of
white
blood
cells
e.g.,
neutrophils, lymphocytes, monocytes, eosinophil, and basophils. Each has its own
function in protecting us from infection.

Red blood cell (RBC) count. It is a count of the actual number of red blood cells per
volume of blood. Both increases and decreases can point to abnormal conditions.

Hemoglobin measures the amount of oxygen-carrying protein in the blood.

Hematocrit measures the percentage

of red blood cells in a given volume of
whole blood.

The platelet count is the number of

platelets in a given volume of blood.
Both increases and decreases can
point to abnormal conditions of excess
bleeding or clotting.
Mean platelet volume (MPV) is a
machine-calculated measurement of the average size of your platelets. New platelets

Case Study on Pleural Effusion11 | P a g e

are larger, and an increased MPV occurs when increased numbers of platelets are
being produced. MPV gives your doctor information about platelet production in your
bone marrow.

Mean corpuscular volume (MCV) is a measurement of the average size of your

RBCs. The MCV is elevated when your RBCs are larger than normal (macrocytic),
for example in anemia caused by vitamin B12 deficiency. When the MCV is
decreased, your RBCs are smaller than normal (microcytic) as is seen in iron
deficiency anemia or thalassemia.

Mean corpuscular haemoglobin (MCH) is a calculation of the average amount of

oxygen-carrying haemoglobin inside a red blood cell. Macrocytic RBCs are large so
tend to have a higher MCH, while microcytic red cells would have a lower value.
Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the
average concentration of hemoglobin inside a red cell. Decreased MCHC values
(hypochromia) are seen in conditions where the hemoglobin is abnormally diluted
inside the red cells, such as in iron deficiency anemia and in thalassemia. Increased
MCHC values (hyperchromia) are seen in conditions where the hemoglobin is
abnormally concentrated inside the red cells, such as in burn patients and hereditary
spherocytosis, a relatively rare congenital disorder.
Red cell distribution width (RDW) is a calculation of the variation in the size of your
RBCs. In some anemias, such as pernicious anemia, the amount of variation
(anisocytosis) in RBC size (along with variation in shape poikilocytosis) causes an
increase in the RDW.

Actual Diagnostic Procedure and Laboratory Test

Upon admission, the physician ordered a full blood count test and other relevant
haematology test for Encik Ahmad. The following tables showed the results of the laboratory
investigations. He had chest x-ray which revealed no pneumothorax. He was also ordered for
thoracentesis and pleural fluid analysis and was performed on 11 January 2011. They aspirated about
500 ml., of clear fluid and a sample was send for laboratory analysis. Based on the result, the type of
pleural fluid of Encik Ahmad was transudate caused by CCF.Please refer to the table for the fluid
analysis result.

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Table 3. Full Blood Count Test

TYPES OF
INVESTIGATION

HEMATOLOGY

DATE

9/1/2011

TIME

RESULT

REFERENCE
RANGE

UNIT

22:23

Full Blood Count

Haemoglobin

L 121 .0

g/L

130. 0- 170.

T.W.B.C

6.5

10^9/L

4. 0-10 .0

Platelets

218

10^9/L

150- 410

T.R.B.C

L 4.31

10^12/L

4.50 -5. 50

HCT

L 35.6

40.0 -50. 0

MCU

83

fL

83 -101

MCH

28 .0

Pg

27. 0- 32 .0

MCHC

34. 0

g/d L

31. 5- 34. 5

H 14.5

11. 6-14. 0

Lmphocytes#

1.2

10^3/u L

1. 0-3.0

Neutrophil#

4.5

10^3/u L

2. 0-7 .0

Monocytes#

0. 6

10^3/u L

0. 2- 1. 0

Eosinophil#

0. 1

10^3/u L

0 .0- 0. 05

RDW-CV

Basophil#

L 0. 0

Lmphocytes g

L 19.1

20. 0- 40. 0

Neutrophil g

69. 3

40. 0- 80. 0

Monocytes g

10. 0

2. 0- 10. 0

Eosinophil g

1 .2

1. 0- 6. 0

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Basophil g

0. 4

< 1-2

Table 4. BUSE/CRE, Liver Profile, and ESR Tests

TYPES OF
INVESTIGATION

BLOOD
Magnesium

DATE

9/1/2011

TIME

RESULT

REFERENCE
RANGE

UNIT

22:33
0 .65

0. 65- 1.05

BUSE/CRE
Urea

4.9

mmol/L

1.7-8.3

Sodium

136

mmol/L

136-145

Potassium

L 3 .1

mmol/L

3.5- 5.1

Chloride

L 9 .6

mmol/L

98-107

85

mmol/L

62-106

Calcium (Blood)

2.25

mmol/L

2.15- 2.55

Phosphate (Blood)

0 .92

mmol/L

0.87-1.45

Total Bilirubin

9.4

umol/L

< 17.1

Total Protien

75

g/L

64 - 83

L 34

g/L

35 -52

Globulin

41

g/L

23 -45

Alkaline Phosphatase

60

u/L

<129

Creatinine

Liver Profile

Albumin (blood)

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ALT (SGPT)

HEMATOLOGY

9/1/2011

u/L

<41

H 79

mm/hr

0~ 10

22:44

ESR

Table 5. BUSE/CRE and Renal

Profile

TYPES OF
INVESTIGATION

BUSE / CRE

DATE

9/1/20
11

TIME

RESULT

UNIT

REFERENCE
RANGE

11:35

Urea

3.5

mmol/L

1.7-8.3

Sodium

139

mmol/L

136-145

Potassium

3.5

mmol/L

3.5- 5.1

Chloride

99

mmol/L

98- 107

Creatinine

72

umol/L

62- 106

Uric Acid

H 512

umol/L

202.3-416.5

Calcium ( blood)

L 2.01

mmol/L

2.15 -2.55

0.97

mmol/L

0.87- 1.45

Renal Profile

Phosphate (blood)
Table 6. PT/APTT Tests

TYPES OF
INVESTIGATION
HEMATOLOGY - COA

DATE
9/1/2011

TIME

RESULT

UNIT

REFERENC
E RANGE

22:23

PT/APTT
Case Study on Pleural Effusion15 | P a g e

Protrombin Time

11.8

sec

PT Test

10.3

sec

PT Control

1.15

sec

PR

1.15

sec

APTT Test

34. 0

sec

APTT Control

28. 0

sec

APTT / Ratio

1. 21

sec

H 14.8

sec

9.1-12.1

I.N.R
APTT
21.4-36.8

HEMATOLOGY - COA
PROTHROMBIN TIME
PT Test

11/1/2011

17:18

PT Control

10.3

P.R

1.44

I.N.R

1.44

9.1- 12.1

APTT
APTT Test

36 .0

APTT Control

28 .0

APTT / Ratio

1.29

sec 21.4 -6.8

Table 7. Pleural Fluid Analysis

Case Study on Pleural Effusion16 | P a g e

TYPES OF
INVESTIGATION

DATE

TIME

RESULT

UNIT

REFERENCE
RANGE

PLEURAL FLUID
Pleural Fluid
Biochesmistry
Protien (Pleural
Fluid)

11/1/2011

13:34

28
(transudat
e)

<30 Transudate)
>30 (Exudate)

LDH (Pleural Fluid)

184
(transudat
e)

<200 Transudate)
>200 (Exudate)

Possible Treatment
Thoracentesis. A procedure is used to remove fluid from the space between the lungs
and the chest wall called the pleural space. It is done by inserting a needle (sometimes a
plastic catheter) into the chest wall and the pleural fluid is aspirated. The procedure is
performed to remove the fluid, prevent the fluid from building up again and treating the
cause of the fluid build-up.
Under Water Seal Drainage (also called Chest Tube/Chest Drain/Tube
Thoracostomy/Intercostal Drain) is a flexible plastic tube that is inserted through the
side of the chest into the pleural space. It is used to remove air (pneumothorax) or fluid
(pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic
space(Wikipedia). Chest tubes are normally inserted under a local anaesthetic or under a
general anaesthetic if the patient is undergoing chest surgery.
The two common complications are the risk of infection and pain. Good hygiene practices
including hand washing before contact with the patient will help minimize the infection
risk. There can be a degree pain of which differs from patient to patient and should be
discussed with the concern doctors and nurses.

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 Pleurectomy (also known as recurrent pleural effusion). Thisis a surgical procedure to

remove part of the pleura, the lining around the lungs. It is usually done to treat
mesothelioma, a rare form of lung cancer most often related to asbestos exposure. It is
performed under general anaesthesia. An incision is made above the affected area and the
pleural layers are removed. Additional affected lung tissue may also be removed during
the surgery. Stitches are made once the surgery is complete and the incision is cleaned and
bandaged.

There is a risk for bleeding or infection after a pleurectomy. Patients should be on the
lookout for symptoms like fever, drainage from the incision, or redness and swelling
around the area of the incision. Once the patient returns home, he or she can usually
Pleurectomy/decortication: Appearances
resume
normal
of the decorticated
lung after
the activity within a week. It may take longer to gain the energy to perform
vigorous
tasks.
visceral and parietal
pleurae
have been
resected (with diaphragm intact).

Actual Treatment Received by the Patient

During his admission, Encik Ahmad was given nebulizer with salbutamol, continue to
take his old medication for his other diseases e.g., hypertension, diabetes mellitus, heart
medication and etc. Aside from that he was ordered to undergo thoracentesis to confirm his
diagnosis. He finished the procedure successfully with 500 ml. of blood stain pleural fluid
aspirated. Pleural fluid sample was sent for analysis and result showed transudate type of
fluid due to CCF.

His other medications are listed in the table

below.

Table 8. Medication, its action, indication and side effects.

NAME

ACTIONS

INDICATIONS

SIDE EFFECTS

T.
Simvastatin
40mg(ON)

To lower bad cholesterol

(LDL) and triglycerides
in the blood while
increasing the level of
good cholesterol (HDL)

Lower bad cholesterol Constipation, stomach

and triglyceride in the pain, nausea and
blood
headache

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T.Aspirin
150mg (OD)

Reducing substances in
the body that cause pain,
fever, and inflammation.

Is used to treat mild to

moderate pain, and to
reduce fever or
inflammation. It is
sometimes used to
treat/prevent heart
attacks, strokes, and
angina.

Black, bloody or tarry

stool, severe nausea,
vomiting , headache,
coughing up blood

T. Isosorbide
Dinitrate
10mg (TDS)

Dilates (widens) blood

vessels, making it easier
for blood to flow and
easier for the heart to
pump.

Prevent attack of
chest pain

Headache, dizziness,
palpitation, low blood
pressure and weakness

T.Vasteral
20mg (TDS)

Preventive treatment of
episode of angina
pectoris.

Angina pectosis

Gastrointestinal upset,
nausea abd vomiting

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T. Clopidogrel
75mg (OD)

Keeps the platelets in

your blood from
coagulating (clotting) to
prevent unwanted blood
clots that can occur with
certain heart or blood
vessel conditions.

Used to prevent blood

clots after a recent heart
attack or stroke, and in
people with certain
disorders of the heart or
blood vessels.

Gastrointestinal
bleeding, bruising,
haematoma,
haematuria, ocular
haemorrhage,
abdominal pain,
constipation and rashes

T. Bisoprolol
1.25mg (OD)

Betablockers affects the

heart and circulation

Hypertension

Diarrhea, headache,
short of breath and
dizziness

T. Digoxin
0.0625gm(OD)

It helps make the heart

beat stronger and with a
more regular rhythm.

Used to treat atrial

Nausea, vomiting,
fibrillation, a heart
headache, abdominal
rhythm disorder of the
pain and skin rashes
atria (the upper
chambers of the heart
that allow blood to flow
into the heart).

C. Gemfibrozil
300mg (OD)

Helps reduce cholesterol

and triglycerides (fatty
acids) in the blood

Treat very high

cholesterol and
triglyceride levels in
people with
pancreatitis. It also use
to to lower the risk of
stroke, heart attack, or
other heart
complications in people
with high cholesterol
and triglycerides who
have not been helped
by other treatment
methods.

Abdominal pain,
diarrhea, nausea,
myalgia and rashes

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T.Frusemide
40mg (BD)

Reduce the amount of

water in body also treat
hypertension

Reduce the amount of

water in body also treat
hypertension

Dizziness, oedema,
increased blood
potassium, bradycardia,
burning sensation and
gastrointestinal
bleeding

S/C Mixtard 22
unit/14 unit

Lower blood sugar level

in the body

Treatment of diebetes
mellitus.

Skin rashes, oedema,

eye or eyesight
problem, itching, pain
and inflammation

Possible Complications

Pleural effusions compromise lung function by preventing its full expansion for breathing. If
the effusion is not treated and underlying diseases causing effusion, lung scarring and
permanent decrease in lung function will be developed. Fluid that remains for a prolonged
period of time is also at risk for becoming infected and forming an abscess called an
empyema.
Diagnostic and therapeutic procedures like thoracentesis, pneumothorax is a potential
complication. It is also called a collapsed lung, where there is the collection of air in the
pleural space that causes part or all of a lung to collapse. This build-up of air puts pressure on
the lung, decreasing lung expansion and difficulty in breathing.

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Discharge Plan of Pleural Effusion

Encik Ahmad was discharge on 14 January 2011. He was alert, conscious and had good
hydration. His blood pressure was 139/87 mmHg, pulse of 69 bpm, respiratory rate of 20

breath per minute andsPO2 of 97% on room air, body temperature of 37.0 C and blood
glucose level of 15.1 mmol/L. He had no more complaint of chest pain and SOB. His

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physician and staff nurses reiterated their advicesespecially on restriction of fluid intake and
others.
The following were the discharge plan for Encik Ahmed:
A. Follow-up Care

He was advised to come to hospital after 1 month time for regular check-up. Follow
other medical appointmentin orthopaedic clinic and IJN. He was informed that regular
check-up isnecessary to help ensure that any changes in his health are noted and treated if
needed. If any health problems between check-ups are encountered, contact his doctor
immediately or come to the hospital.
B. Medication
Comply with the treatment regimen. Use medication as ordered and complete the entire
prescription. Provide schedule as when to take the medication. Do under dose or overdose by
cutting breaking the medicine using hands. This will lessen the efficacy of the medicine and
will only prolong the disease process.
C. Exercise
Exercise keeps you healthy. It is good for the heart and lungs and promotes blood
circulation. Start with range of motion (ROM) exercises, it is a good choice e.g., stretching
and flexing the joints. Decrease activities if you feel pain and tired. Do deep breathing and
coughing exercise to lessen the pain sensation and promote lung expansion. Do it gradually.
Ask your doctor to help you plan the best exercise program for you. It is best to start slowly
and do more as you get stronger.
D. Treatment
Treatment of pleural effusion is always based on the underlying condition and whether
the effusion is causing symptoms like difficulty in breathing or SOB. However, removal of
fluid is always the first choice if fluid build-up is in large volume, preventing it from
accumulating again and or addressing the underlying cause of the fluid build-up. Removal of
fluid promotes lung expansion and easy breathing.

E. Health Teaching
Good personal hygiene is very important factor in daily living to keep us from getting
infection.

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 Hand washing. Correct technique must be applied especially after using the
bathroom and before eating any food. Hand washing still the most effective way of
eliminating microorganisms.
Shower daily. Keep yourself clean daily to prevent accumulation of microorganisms
on your skin.
Use a deodorant spray instead of antiperspirant. Antiperspirants block sweat
glands which can cause an infection.
Brush teeth two to three times a day.Oral hygiene is the most effective way in
preventing the spread of infection.
Perineum care. Clean perineum area properly each time you pass urine and bowel.
F. Diet
Limit intake of food loaded with salt e.g., salted fish, eggs, sauces, seasoning and
vegetables. Salt causes water retention in people with heart failure and result to
edema in lungs, ankles, and abdomen. Be smart in buying food, read label of
nutritional value in packed food.
Eat variety of healthy foods from all the food groups e.g., whole grains, green leafy
vegetables, apples, soy,oats, olive oils, salmons and almonds Eating healthy foods
may help you feel better and have more energy. You may need to make diet changes
depending on your underlying diseases. Eat small-frequent meal and snacks rather
than 1 big meal to boost your metabolism.
Drink Fluids:Restrict fluid intake from 800 1000 mls. per day or as prescribed by
your physician to avoid fluid overload which causes SOB and dyspnea. Choose
healthy like water, fresh fruit juices, and milk rather than caffeinated/carbonated
drinks which is loaded with sugar.
Rest:Limit your activities in a day to reduce oxygen consumption.
G. Seek Care Immediately If You Have:
Pleuritic pain. An early signs of effusion.
Trouble breathing.
Increasing dyspnea or SOB
Cough and hemoptysis

Bibliography

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Chest Ultrasound. (2008, August 8). Retrieved January 13, 2011, from Care First Blue Cross
Blue Shield: http://carefirst.staywellsolutionsonline.com/RelatedItems/92,P0774
Chest x-ray. (2010, August 20). Retrieved January 13, 2011, from Heart, Lung and Blood
Substitute Disease and Condition Index:
http://www.nhlbi.nih.gov/health/dci/Diseases/cxray_whatis.html
Complete Blood Count Test. (2010, November 24). Retrieved January 23, 2011, from Lab
Tests Online: http:labtestonline.org/understanding/analytes/cbc/test.html
Burke, P. L. (2008). Medical Surgical Nursing (6th ed.). New Jersey, USA: Pearson
Education International.
Dugdale, D. C. (2010, September 15). Pleural Effusion. Retrieved January 22, 2011, from
Medicine Plus: http://www.nlm.nih.gov/medicineplus/ency/article/000086.htm
Grant, A. W. (2006). Anatomy and Physiology in Health and Illness (10th ed.). London:
Churchill Livingstone.
Jegtvig, S. (2008, February 28). Ten Foods for a Healthy Heart. Retrieved January 23, 2011,
from About.com: http://www.nutrition.about.com/od/fooffun/a/healthy_heart.htm
Pleural Effusion. (2010, February 4). Retrieved January 14, 2011, from Medicine Net.Com:
http://medicine.com/pleural_effusion/page5.htm
johnroks. (n.d.). Hemothorax/Pnuemothorax. Retrieved January 23, 2011, from Scribd.com:
htto://www.scribd.com/doc/17471582/nursing-care-plan-for hemothroaxpneumothorax

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