Bukidnon State University

COLLEGE OF NURSING
City of Malaybalay
A Case Study
on

PLEURAL EFFUSION
In partial fulfilment of all the requirements in NCM 103
CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID
ELECTROLYTE BALANCE, METABOLISM AND ENDOCRINE

by
DIONEFLOR P. ARTANA
LUCKY CHARM D. ROSOS
LYRA DAIN O. LORCA
MA. VANESSA L. RONOLO
MARVIN C. TELIN

SY 2013 2014
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ACKNOWLEDGEMENTS

The students are very grateful to the many people who have contributed for the
completion of this case study.
First of all, we thank our dear parents for their never ending support all
throughout the year as we pursue our aspiration to become professional and competent
nurses in the future. Thank you so much for providing us our needs.
Secondly, to our college, College of Nursing, Bukidnon State University for
allowing students to experience your academic proficiency and to our clinical instructors,
.for sharing their knowledge and expertise in the clinical field and in
theory.
Also, we thank the Bukidnon Provincial Medical Center (BPMC) clinical staff
and administration for allowing nursing students to be exposed at the Emergency Room,
Medical Ward and Surgical Ward for the first semester of SY 2013-2014. The clinical
exposures we have had will make us competent and confident student nurses.
We also would like to thank our patient, who with confidence allowed the
students to study and present her case to the third year students of Bukidnon State
University- College of Nursing and to all our very diverse patients in the Medical Ward,
Surgical Ward, and Emergency Room, we thank you for the learning experience.
Lastly, to our classmates, friends, duty mates, and mentors, thank you. Thank you
for always encouraging us to move out from our comfort zones and for allowing us to
challenge ourselves and for inspiring students to survive and excel in the many
endeavours. May we always keep learning and may we never forget to help each other.
May God bless us and guide us always! To God be all the glory!

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TABLE OF CONTENTS

ii

ACKNOWLEDGEMENT...3

iii

TABLE OF CONTENTS.4

iv

OBJECTIVES..5

I.

INTRODUCTION...6
I.1 Patients Profile ...7

Demographic Data...7, 8

History of Past Illness......9

History of Present Illness...9, 10

I.2 Anatomy and Physiology/ Etiology of Disease ....11-15

I.2 Pathophysiology...16, 17
II.

THEORETICAL FRAMEWORK....18-27

III.

ASSESSMENT.....28-32

IV.

NURSING CARE PLANS.......33-44

V.

DISCHARGE PLAN....45-46

VI.

BIBLIOGRAPHY....47-48

VII.

APPENDIX....49
VII.1 Consent Form...49
VII.2 Researchers...50

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OBJECTIVES

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

I.

INTRODUCTION

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The patient to be mentioned in this paper will be given a pseudo name Ms. X.
Ms X was one of the patients admitted to the BPMC Female Medical Ward last June 15,
2013 due to complaints of shortness of breath and was diagnosed with Pleural Effusion.
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, nonproductive 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.
DEMOGRAPHIC DATA

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Name of Patient

Ms. X

Age

57 Years Old

Sex

Female

Date of Birth

01-26-1956

Place of Birth

Malaybalay City

Address

P-4 Kalasungay, Malaybalay City Bukidnon

Religion

Baptist

Nationality

Filipino

Civil Status

Married

Occupation

Street Vendor

Informant

Mr X and Client

Relationship to Patient :

Husband (Mr. X)

Date of Admission

June 15, 2013

Time of Admission

4:11 PM

Attending Physician

Dr. Marie Alexis De Castro

Admitting Vital Signs

Temp.: 37oC

PR: 72 bpm

RR: 30 cpm

BR: 100/80 mmHg

Food Allergy

No known food allergies

Drug Allergy

No known drug allergies

Educational Attainment :

Elementary Level

Monthly Income

3,000-4,000

Source of Income

Gardening, Selling cakes

Chief Complaint

: Shortness of Breath

Diet

: On diet as tolerated with strict aspiration precaution

Admitting Diagnosis

: Right Pleural Effusion

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Baseline Data (July 10, 2013)

Height

: 157 cm

Weight

55 Kg

Body Mass Index

22 (Within normal range)

Vital Signs (July 10, 2013)

Blood Pressure

: 100/80 mmHg

Temperature

: 37 C

Pulse Rate

: 80 beats per minute

Respiratory Rate

: 30 breaths per minute (Tachypnea)

HISTORY OF PAST AND PRESENT ILLNESS

HISTORY OF PAST ILLNESS

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The patient experienced common illnesses during childhood such as fever,

common colds, coughs and abdominal pain. Patient denies having been given
vaccinations.
HISTORY OF PRESENT ILLNESS
The patient is a 57 years old married female presently residing at P-4 Kalasungay,
Malaybalay City with her husband. Ms X experienced dizziness and shortness of breath
last December 2012. On January 2013, which was her first BP measurement after many
years, her blood pressure reading was 200/100 mmHg taken by a Barangay Health
Worker and decided to have her check-up at Malaybalay Polymedic General Hospital.
She was discharged after five days of admission. She was given prescription medications
for hypertension by her physician but has difficulty complying due to financial
difficulties.
On February 13, 2013 Ms. X was admitted at Bethel Baptist Hospital and was
diagnosed with Cardiovascular Disease (CVD). Then on May 13, 2013 patient was again
admitted to BBH and was diagnosed with Hypertensive Cardiovascular Disease (HCVD)
and Cerebrovascular Accident (CVA) which led to right residual weakness of her body.
On June 6, 2013, she went to Bethel Baptist Hospital because she experienced shortness
of breath and was admitted. Thoracentesis was done to the patient on the same day. On
June 13, 2013, her physician suggested a Chest Tube Thoracostomy to be done at
whichever hospital they prefer.
A day after discharge from BBH, Ms. X experienced shortness of breath and was
admitted at Bukidnon Provincial Medical Center (BPMC) on June 15, 2013 at 4:11PM
and was for several diagnostic tests. X-ray was done on June 16, 2013 and revealed no
significant interval change in the right hemithorax from the previous result. On June 17,
2013, chest ultrasound revealed a right loculated pleural fluid of not less than 1000 cc.
On June 19, 2013, a final pathological report revealed a chronic inflammatory pattern
negative for malignant cells. On June 20, 2013, thoracentesis was done and two days
after, CTT was done. Chest CT scan, plain and contrast was done on July 22, 2013 and
revealed the following:
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There is 23 x 8.8 x 13.8 cms (1396.60 cc) thick walled loculated pleural

effusion which is slightly hyperdense in the right hemithorax

There is volume loss of the right lung with no definite mass lesion seen

and very minimal aerated lung at the upper lobe

There is minimal reticular and haze densities at the upper lobe
There is shift of mediastinal structure to left
The heart is not enlarged but there is minimal pericardial effusion
Aorta is normal in calibre with minimal calcification along the walls
No enlarged lymph nodes seen
There is minimal thoracic spondylosis
There is chest tube in place in the right side with tip at the medial aspect,
level of T8-9

The patient is still for sputum Acid-Fast Bacilli (AFB) 3x and medications were given
to her. She was discharged last July 25, 2013.

ANATOMY AND PHYSIOLOGY/ ETIOLOGY OF THE DISEASE

PLEURAL EFFUSION
The pleural space is a potential space between the visceral pleura, which covers
the outer surface of the lung, and the parietal pleura, which lines the inside of the chest
wall. In this space, there is a small amount of fluid present that functions to mechanically
couple the lung to the chest wall and lubricate the interface of the visceral and parietal
10 | P a g e

pleura. Pleural fluid normally

results from the filtration of
blood

through

high-pressure

systemic blood vessels, and is

drained from the pleural space
through lymphatic openings in
the parietal pleura that drain into
parietal lymphatic vessels, in
different disease states, fluid may
originate from the interstitial
spaces of the lungs, the intrathoracic lymphatics, the intrathoracic blood vessels, or the
peritoneal cavity.
A pleural effusion is defined as an abnormal collection of fluid in the pleural
space. Effusions occur when the rate of fluid formation exceeds the rate of fluid
absorption. Pleural effusions are commonly classified as being either exudative or
transudatice. An exudative pleural effusion implies that there is a disease process that is
affecting the pleura directly, causing the pleura and/or its vasculature 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).
SYSTEMS INVOLVED

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
11 | P a g e

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
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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
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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
14 | P a g e

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)

15 | P a g e

Predisposing
Factors:
Age: 57
Gender: F
Ethnicity: Lumad
(Higaonon)
Familial

Precipitating Factors:
Stress from noisy environment with poor sanitation, P3000P4000 monthly family income, inability to maintain
prescribed medications for HPN, children, nature of work:
street vendor, diet: High in Na (Dried fish, ginamos, etc.),
cardiovascular Disease (Feb 2013)

Increase peripheral vascular resistance

Hypertension (December 2012)

Increased
hydrostatic
pressure in
arterial end of
capillary

200/10
0
mmHg

Cerebrovascular
accident with right
residual weakness (May
2013)

Fluid movement
into tissue

Presence of +2
bipedal edema
Page | 16

Pleural Fluid Cytology:

Final pathological report:
Chronic Inflammatory
Pattern
Negative for Malignant
Cells.
Gross/Microscopic
Description:
Specimen consists of 1
liter blackish fluid for
cytology
Chest
Ultrasound:
Loculated fluid
of not less than
1,000 is seen
occupying the

Prevent forward flow of blood from left side

of the heart

WBC =
16.1/L
Hb =11.4
g/dL
Hct =34.4
vols%
Platelets
=329,000

Laboratory
and
Diagnostic
Examination
s
THEORETICAL FRAMEWORK

Backward pressure
Shortness of
breathing
Pulmonary
edema
Pleural effusion

Chest xray:
Shown progression of the
density in the right hemothorax
with very aerated lung seen at
NURSING
the outer aspect of right
upper
lobe, left lung is clear

Crackles,
dullness to
upon
percussion,
THEORIES
tactile
fremitus is
attenuated

Impaired
gas
exchange

tachypne
a
orthopne
a
dyspne
a

CT Scan
1. There is 23 x 8.8 x 13.8 cms (1396.60 cc) thick walled
loculated pleural
effusion which is slightly hyperdense
Theorist
Theory
in1.theFlorence
right hemithorax
Nightingale
Environmental Theory
2. There
is volume
loss of the right lung with no definite
2. Virginia
Henderson
14 Components Of Basic Nursing Care
mass
lesion seen
3. Dorothea
Oremand very minimal aerated lung at the Self Care Deficit Theory
upper lobe
Florence Nightingales Environmental Theory, Virginia Hendersons 14 Components of Basic Nursing Care and Dorothea Orems Self
3. There is minimal reticular and haze densities at the
lobe
Careupper
Deficit
Theory are the three theories the students have chosen as fundamental guide in providing care of patient X. As decided and
4. There is shift of mediastinal structure to left
observed
by theisstudents,
these but
theories
have
great impact to the patients condition by many ways. First is thru means of manipulating the
5.
The heart
not enlarged
there
is minimal
pericardial effuse
6. Aorta is normal in calibre with minimal calcification
Page | 17
along the walls
7. No enlarged lymph nodes seen

environment to support the patients healing and recovery. Second, by ensuring that the 14 basic needs (referring to Hendersons Theory) of a
person be met by being the substitute for the patient, by being a helper to the patient and by being a partner to the patient with emphasis that by
these actions, the patient/person will gain independence of himself as rapidly as possible. And lastly thru help from Dorothea Orems Theory,
students will be able to define their roles in maintaining universal requisites of self-care of the patient.

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.
Page | 18

Upon following the nursing process and thought suggested by Nightingale, these are the results gathered and the needed action to be done
NIGHTINGALES

NURSING PROCESS

ACTUAL

CANONS

AND THOUGHT

(BPMC-Female

NURSING ACTION PLAN

Medical Ward
Area)
Ventilation and

Check

Warmth

body
room

the

ventilation

patients Body temperature:

Since the Female Medical Ward

temperature,

36.0 C

upon our assessment is filled with

temperature,

Room Temp: Warm

other 19 in-patients, this number of

Room Odour: Foul

patients with their watchers/family

Room Ventilation:

care providers will add to the room

Accessible

congestion thus will affect room

windows

temperature, ventilation, and then

and

foul

odours.

finally affect the patients body

temperature and type of air she is
breathing.
Light

Check

room

for

Patient is placed in

Patient

receives

adequate

light

adequate light. Sunlight

bed #3 which is

without her being exposed to direct

is beneficial to patient.

located at the right

sunlight.

side of the room.

This side allows the
patient to witness
Page | 19

change

of

time

(day/night) via the

transparent
windows open at
the porch.
Cleanliness

Keep room free from

Since the Medical

Student

dust,

Ward is a huge area

maintaining or doing basic cleaning

for cleaning.

at the patients bedside.

Patients watcher is

Student nurse can remind watcher

and

well informed of

and

ensure clean water and

the proper disposal

disposal. Accessible windows with

fresh air.

of waste products

screens can be opened to allow air

and maintenance of

inside the room.

dampness

and

dirt.

Health of House

Remove
stagnant

garbage,
water,

nurse

patient

can

of

focus

proper

on

waste

health of patients
area.
The medical ward
Noise

Remind visitors and student nurses

Attempt to keep noise

tends to be noisy to maintain a peaceful and quiet

level in minimum

due to presence of

environment to allow patients to

visitors.

rest

and

sleep

without

any

interruption.
Student nurses are responsible in
Page | 20

Bed and Bedding

Keep

the

bed

dry, Sheets are available

wrinkle free.

upon request.

maintaining that patient is well

rested

in

any

position

(sitting/supine/etc) by doing bed

making and regular linen changing.
Patient

must
own

Personal

Attempt to keep the

provide

Cleanliness

patients skin dry and

paraphernalias

clean at all times.

maintaining

Attempt to accomplish

skin integrity.
Patient may also

By encouraging family members to

variety in the room and

feel well by making

engage with patient in stimulating

with the client

sure her bedside is

activities.

Variety

Assist patient in doing self-care.

in

good

kept clean and well

Chattering hopes
and advices

Avoid talking advice

maintained.
If patients

without a fact.

questions that need

Respect the patient as a person and

to be answered by a

avoid personal talk.

have

superior, then allow

the

superior

to

answer to prevent
misinterpretation
and
Taking Food

Check

the

diet

of

miscommunication.
Food is prepared by Note on the amount of food and
Page | 21

patient.
Observation of the

Observe

Sick

anything
patient.

and
about

record
the

BPMC.

fluid ingested by patient at every

The nurses notes

meal.
Continue

allow

to

patients environment and make

record and evaluate

changes in the plan of care if

the manipulation of

needed.

nurses

observation

in

the

environment.

The nursing diagnosis formulated by the students upon assessing the environment and its effect to the patient are as follows: Disturbed
sleep pattern related to noise; lack of sleep privacy; interruptions for therapeutics, monitoring, lab tests; unpleasant odours

14 COMPONENTS OF BASIC NURSING CARE

by Virginia Henderson
According to Virginia Henderson, a patient is an individual requiring help toward achieving independence. She states that The unique
function of the nurse is to assist individual, sick or well, in the performance of those activities contributing to health or its recovery (or peaceful
death) that she would perform unaided if he had the necessary strength, will, or knowledge and to do this in such a way to help him gain
independence as rapidly as possible. (Balita, Octavio. 2008)
Henderson conceptualized 14 Fundamental Needs of humans and herewith are the needs we have observed to our patient:
1. Breathing normally: patient has DOB due to presence of pleural effusion
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Patient must be given O2 as per doctors order and must be placed in a semi fowlers or sitting position.
2. Eating and drinking adequately
3. Eliminating body wastes
Patient must be given laxatives as per doctors order. And must be encouraged to increase fiber intake.
4. Moving and maintaining a desirable position: Patient is unable to move due to recent stroke.
Patient is assisted in changing positions and doing activities of daily living.
5. Sleeping and resting: Patient cannot sleep well due to environmental factors and physiologic factors such as difficulty in breathing.
Provide strategies that can deviate patients thoughts from the environmental stressors surrounding her.
6. Selecting suitable clothes
7. Maintaining normal body temperature by adjusting clothing and modifying the environment
8. Keeping the body clean and well groomed to promote integument (skin): Patient is unable to move due to recent stroke.
Patient is assisted in changing positions and doing activities of daily living
9. Avoiding dangers in the environment and avoiding injuring others: By making sure bedrails are up and teaching patient of situations that are
risky for her to acquire injuries
Use of bedrails, assistive device and health teaching
Page | 23

10. Communicating with others in expressing emotions, needs, fears or opinions: Patient uses native/binukid language and a little of vernacular
thus she is more comfortable of sharing her thoughts to her husband.
Allow the husband to the secondary/ follow-up speaker so that patient may understand the student nurse and vice versa.
11. Worshipping according to ones faith
12. Working in such a way that one feels a sense of accomplishment: Patient cannot feel sense of accomplishment due to impaired mobility.
Encourage and praise patient of her little improvements to allow sense of accomplishment.
13. Playing or participating in various forms of recreation: Patient remains rested at bed but is well entertained and cared for by family members.
One way of providing recreation is by conversing to the patient, this allows her to express her thoughts and emotions.
14. Learning, rediscovering or satisfying the curiosity that leads to normal development and health: Patient is not observed to be curious of health
development but significant others are.
Explain to the patient the procedures, nursing intervention, medication and health teachings she must know for her to gain knowledge
regarding her health thus she will be aware of her condition and may feel determined to improve herself.

Henderson also emphasized the need to view the patient and her family as one unit since in order for patient to achieve health. The patient
must be able to meet her need for support system (emotional needs) as provided by the family.
The nursing diagnoses formulated by the students upon assessing the patient are as follows:
Page | 24

1. Ineffective Breathing Pattern related to Decreased Lung Volume Capacity as evidenced by tachypnea, presence of crackles on both lung
fields and dyspnea
2. Impaired Gas Exchange related to Alveolar Capillary Membrane Changes
3. Disturbed Body Image related to Insertion of Chest Thoracostomy Tube
4.
5.
6.
7.

Self-Care Deficit related to musculoskeletal impairment secondary to CVA

Knowledge Deficit related to unfamiliarity with information resources, cognitive limitation, information misinterpretation, lack of recall
Risk for Impaired Swallowing related to neuromuscular/perceptual impairment
Self-Care Deficit related to neuromuscular impairment, decreased strength and endurance, loss of muscle control/coordination

SELF CARE DEFICIT THEORY

by Dorothea Orem
Dorothea Elizabeth Orem emphasized that nursing is helping clients to establish or identify ways to perform self-care activities and that
nursing actions are geared towards the independence of the client. If the patient is highly dependent, there is a need for the nurse to assist and
address the needs of the client. (Balita, Octavio. 2008).

Page | 25

In addition, Orem defined self-care as an activity that promotes a persons well-being. Concerning our patient, she is unable to provide
self-care due to her present condition and her recent case of infarction (as diagnosed by her last physician from Bethel Baptist Hospital last June
2013) of which she cannot move her right peripherals. It is another nursing task to assist in providing self-care to the partially unable patient.
There are eight universal self-care requisites according to Orem and these are the following:
UNIVERSAL SELF CARE REQUISITES
Maintenance of a sufficient intake of air

NURSING STUDENT ACTION

Patient must be given O2 as per doctors order and
must be placed in a semi fowlers or sitting position.

Maintenance of sufficient intake of food

Allow proper ventilation inside the room

Allow patient to use left hand when eating, drinking.
Praise patient whenever she does independent
activities even if its the basic to make her feel good
about herself and to prevent self-pity.

Maintenance of sufficient intake of water

Teach patient on good nutrition

Allow patient to use left hand when drinking,
instruct and remind constantly to take in small

Provision of care associated with elimination

Maintenance of balance between activity and rest

amount of fluid to prevent aspiration

Offer bedpan and clean patient afterwards. Also
allow patient to use left hand when necessary.
Since patient has hemiplegia, her activity is limited.
Offer stimulating conversations, activities that do
not need too much physical effort.
Page | 26

In terms of exercise, she can perform passive ROM

Maintenance of balance between solitude and
social interaction

at left peripherals, deep breathing exercise

Maintain balance between solitude and social
interaction. Converse with patient together with her
husband about how she feels. Allow her to express
herself.
Pts husband reports that patient is feeling kaguol regarding her present condition and worries
about her children through they are already mature
adults.
Remind family to show emotional support by
showing appreciation and value towards their

Prevention of hazards to human life, human

functioning and human well-being

mother.
Since patient is hemiplegic, PREVENTION of any
complication, illness, injury is very important.
Always provide safety measures to patient such as
raising bed rails, providing physical assistance
upon walking, turning to side, and sitting. Assist in

Promotion of human functioning and development

self-care activities.
According to Erik Erikson, during ages 40 to 65
Page | 27

(Generativity vs Stagnation/ Middle adulthood

Stage) adults need to create or nurture things that
will outlast them, often by having children or
creating a positive change that benefits other
people. Success leads to feelings of usefulness and
accomplishment, while failure results in shallow
involvement in the world.
It is important to remind the family of the
importance of making their mother feel the essence
of being productive/accomplished

CONCLUSION: All the nursing theories cited are fundamental guides for student nursing upon providing care/interventions to patient X. These
theories will help in identifying the patients problem, and alleviate or address the patients problem. Above all, these theories are aimed at
promoting patients well-being.

Page | 28

ASSESSMENT
DIGESTIVE/METABOLIC SYSTEM
SUBJECTIVE

OBJECTIVE

Page | 29

TULO NA SIYA KA ADLAW WALA

KALIBANG MAAM, AS
VERBALIZED BY PATIENTS
HUSBAND
IKA TULO SIYA MOKAON PERO
GAMAY RA IYANG GA KAN-ON , AS
VERBALIZED BY PATIENTS
HUSBAND
GA INOM SIYA UG TUBIG (1 BASO)
KADA HUMAN UG KAON UG GA
GATAS OG KAPE SIYA SA HAPON ,
AS VERBALIZED BY PATIENTS
HUSBAND

APATHETIC
DRY, WARM SKIN
SUNKEN EYEBALLS
MOIST TONGUE
NO OF TEETH: 28
T:37C
P: 80 BPM
R: 30 CPM BP: 100/80
MESOMORPH
LOSS OF APPETITE
WEIGHT 55 KG
BMI: 22

Page | 30

RESPIRATORY SYSTEM
SUBJECTIVE
DILI KO KAGINHAWA OG TARONG
SAUNA MAAM. PERO ADTONG GI
BUTANGAN UG TUBO NI ARANGARANG
AKONG GINHAWA AS VERBALIZED BY
THE PATIENT
BISAG MUHIGDA O MOLINGKOD DI
MAN GUHAPON SIYA MAKA GINHAWA
UG MAAYO, NIINGON MAN SIYA SA
AKOA ADTONG NAA PAMI SA BALAY AS
VERBALIZED BY THE PATIENTS
HUSBAND

OBJECTIVE
FINE CRACLES AT RIGHT LUNG FIELD
HYPORESONANCE AT RIGHT LUNG
FIELD
USE OF ACCESSORY MUSCLE
DYPNEA
RR-30CPM
CTT ATTACHED TO RIGHT
MIDAXILLARY RESGION DRAINING TO
WATER SEALED BOTTLE
DECREASED TACTILE FREMITUS
DIAGNOSTIC TEST
Multiple axial tomographic secretions of the chest with
and without contrast were obtained revealing the
following:
There is 23 x 8.8 x 13.8 cms (1396.60 cc)
thick walled loculated pleural effusion which
is slightly hyperdense in the right hemithorax
Page | 31

There is volume loss of the right lung with no

definite mass lesion seen and very minimal
aerated lung at the upper lobe
There is minimal reticular and haze densities
at the upper lobe
There is shift of mediastinal structure to left
The heart is not enlarged but there is minimal
pericardial effuse
Aorta is normal in calibre with minimal
calcification along the walls
No enlarged lymph nodes seen
There is minimal thoracic spondylosis
There is chest tube in place in the right side
with tip at the medial aspect, level of T8-9

CARDIOVASCULAR/ CIRCULATORY SYSTEM

SUBJECTIVE

OBJECTIVE

Page | 32

NABAL-AN NGAHIGHBLOOD SIYA

MAM NIADTONG PAG ADTO NAMO
SA MALAYBALY POLYMEDIC
GENERAL HOPITAL
GI-ADMIT PUD SIYA SA BETHEL
(DIAGNOSED WITH CVD, HCVD AND
CVA WITH RIGHT RESIDUAL
WEAKNESS)
AY SAUNA MAHILIG NI SIYA UG
KUBI-KUBI PERO KARUN DILI
NAGYUD NIYA MAKAYA. KUN MAG
CR SIYA, UBANAN GYUD SIYA, AS
VERBALIZED BY PATIENTS
HUSBAND
AKO NAMAN ANG GA PLASTAR
SAIYA MAAM. KUN MOHIGDA SIYA
O MO LINGCOD BA KAHA, AKO
SIYANG ALALAYAN, AS VERBALIZED
BY PATIENTS HUSBAND

TEMPERATURE OF 37 C
BLOOD PRESSURE: 100/80
REGULAR APICAL PULSE WITH A
RATE OF 84 BEATS PER MINUTE
REGULAR, STRONG RADIAL PULSE
WITH THE RATES OF
R: 84 L: 84
WEAK DORSALIS PEDIS
WEAK POSTERIOR TIBIA
REGULAR HEART RHYTHM: 80
BEATS PER MINUTE
PALE NAIL BEDS
BIPEDAL +2 PITTING EDEMA
INABILITY TO PERFORM BASIC
ROM AT RIGHT PERIPHERALS
DIAPHORESIS
WEIGHT 55KG

INTEGUMENTARY SYSTEM
SUBJECTIVE

OBJECTIVE

Page | 33

GI TAORAN SIYA UG TUBO

DIRI MAAM, AS VERBALIZED
BY PATIENTS HUSBAND
KATONG PAG TAOD AND
COLOR NGA AKONG
NAMATIKDAN KAY PULA, AS
VERBALIZED BY HUSBAND

DRY, WARM SKIN

POOR SKIN TURGOR
BIPEDAL +2 PITTING EDEMA
TEMPERATURE OF 37 C
NORMAL HAIR DISTRIBUTION
DIRTY, UNTRIMMED NAILS
PALE NAIL BEDS

ELIMINATION
SUBJECTIVE
TULO NA SIYA KA ADLAW
WALA KALIBANG MAAM, AS
VERBALIZED BY PATIENTS
HUSBAND
IKA TULO SIYA MOKAON PERO
GAMAY RA IYANG GA KAN-ON
, AS VERBALIZED BY PATIENTS
HUSBAND

OBJECTIVE
WITH ASSISTANCE
INTAKE AND OUTPUT
DATE
INTAKE
OUTPUT
July 10, 2013
315 cc
230 cc
July 11, 2013
390 cc
320 cc
July 12, 2013
630 cc
300 cc
BIPEDAL +2 PITTING EDEMA
DARK YELLOW, CLOUDY URINE
TEMPERATURE OF 37 C

GA INOM SIYA UG TUBIG (1

BASO) KADA HUMAN UG KAON
UG GA GATAS OG KAPE SIYA SA
HAPON , AS VERBALIZED BY
Page | 34

PATIENTS HUSBAND
GA TAGAAN SIYA UG TAMBAL
(SUPPOSITORY) PARA
MAKALIBANG SIYA , AS
VERBALIZED BY PATIENTS
HUSBAND
SIGE SIYA UG PANINGOT
KARUN , AS VERBALIZED BY
PATIENTS HUSBAND

MUSCULOSKELETAL SYSTEM
SUBJECTIVE
GAKAPOYAN KO UG LIHOK DALI RA
KO SINGTON AS VERBALIZED BY THE
PATIENT

OBJECTIVE
AVERAGE WEAKNESS
OBSERVED LIMITED RANGE OF MOTION
AT RIGHT PERIPHERALS
DIAPHORESIS
PREVIOUS DIAGNOSIS FROM BBH
S/P OR CEREBRAL VASCULAR ACCIDENT
INFARCT WITH RIGHT SIDED RESIDUAL
WEAKNESS

COGNITIVE AND PERCEPTUAL/ NEUROLOGIC

Page | 35

SUBJECTIVE
NABAL-AN NGAHIGHBLOOD SIYA
MAM NIADTONG PAG ADTO NAMO SA
MALAYBALY POLYMEDIC GENERAL
HOPITAL
GI-ADMIT PUD SIYA SA BETHEL
(DIAGNOSED WITH CVD, HCVD AND
CVA WITH RIGHT RESIDUAL
WEAKNESS)
NOTE: PATIENT COMMUNICATES WITH
US VIA HIS HUSBAND SINCE SHE IS
COMFORTABLE IN SPEAKING
BINUKID. PATIENT ALSO USES CUES
SUCH AS NODDING UP AND DOWN OR
LEFT AND RIGHT UPON ANSWERING
OUR QUESTIONS

OBJECTIVE
RESPONSIVE (VIA USE OF CUES)
DECREASED SENSATION AT RIGHT
PERIPHERALS
PUPILLARY SIZE: PERRLA
OREINTED TO PERSON, PLACE,
TIME/DATE AND PAIN
T:37C
P: 80 BPM
R: 30 CPM BP: 100/80
POSITIVE LEFT PATELLA, BICEPS,
TRICEPS, ACHILLES REFLEXES
NEGATIVE RIGHT PATELLA, BICEPS,
TRICEPS, ACHILLES REFLEXES
AGE: 57

Page | 36

IV. NURSING CARE PLANS

NCP #1
DATA

NURSING DX

SUBJECTIVE CUES:

Kasagara namo nga ga

kan-on kay bulad ug
ginamos, as
verbalized by patients
husband

OBJECTIVE CUES:

Bipedal edema
+2
RR-30cpm
Crackles at
right lung upon
auscultation
dyspnea
right pleural
effusion as

EXCESS FLUID
VOLUME
RELATED TO
EXCESSIVE
SODIUM
INTAKE

OBJECTIVE
S
SHORT
TERM:
After 30
minutes
patient will be
able to
verbalize
understanding
of individual
dietary
restrictions

LONG
TERM:
After 3 days
of nursing
intervention
patient will be

NURSING INTERVENTIONS

RATIONALE

INDEPENDENT:

Review dietary restrictions

and safe substitutes for salt

Elevate edematous
extremities, change position
frequently

To reduce tissue
pressure and risk of
skin breakdown

Encourage coughing/deepbreathing exercises.

Pulmonary fluid sh
ifts potentiate respi
ratory
complications

Encourage bedrest. Schedule

care to provide frequent
rest periods.

Limited cardiac res

erves result in fatig
ue/activity
intolerance. In
addition, lying
down favors
diuresis and
reduction of
edema.

This can decrease

extracellular fluid
retention

EVALUATIO
N
SHORT
TERM:
After nursing
intervention
patient was
able to
verbalize
understanding
of individual
dietary
restrictions

LONG
TERM:
After giving
nursing
intervention
patient was
Page | 37

evidenced by
an ultrasound
pallor
poor skin
turgor

able to
stabilize fluid
volume as
evidenced by
vital signs
within clients
normal limits
and reduced
signs of
edema

Provide safety precautions as

indicated, e.g., use of
siderails, bed in low position,
frequent observation, softrestr
aints (if required)

Fluid shifts may ca

use cerebral edema
or changes in
mentation,
especially in the
geriatric population

To facilitate
movement of
diaphragm, thus
improving
respiratory effort

To address ongoing
nutrition concerns
or dietary needs

Extracellular fluid
shifts, sodium
restriction affect
serum sodium
levels.

Place in semi-Fowlers
position, as appropriate

DEPENDENT:

Consult dietitian, as needed

Monitor laboratory studies as

indicated, e.g., electrolytes,
BUN. ABGs

able to
stabilize fluid
volume as
evidenced by
vital signs
within client;s
normal limits
and reduced
signs of
edema

NCP #2
Page | 38

DATA

NURSING DX

SUBJECTIVE CUES:
Galisod ko ug ginhawa
maam, as verbalized by the
patient

OBJECTIVE CUES:

Tachypnea
Presence of crackles
at right lung field
upon auscultation
Use of accessory
muscle
RR-30cpm
Orthopnea
Diaphoresis
Dypnea
Restlessness
Decreased Tactile
fremitus
Dull resonance

OBJECTIVES
SHORT TERM:

INEFFECTIVE
BREATHING
PATTERN
RELATED TO
DECREASED
LUNG VOLUME
CAPACITY AS
EVIDENCE BY
TACHYPNEA
AND PRESENCE
OF CRACLES ON
THE RIGHT SIDE
OF THE LUNG
FIELDS

After 30 minutes
of nursing
intervention,
patient will reveal
no abnormal
breath sounds
upon auscultation;
patient will
demonstrate
adequate
breathing pattern,
with easy,
unlabored
respirations;
Patient will
demonstrate
correct technique
in pursed-lip
breathing,
abdominal
breathing and
relaxation
techniques.

NURSING
INTERVENTIONS

RATIONALE

EVALUATION

INDEPENDENT:

Provide relaxing
environment

Elevate patient head

Assist patient in the

use of relaxation
techniques

Force Fluids

Teach patient on
pursed-lip breathing,
abdominal breathing
and relaxation
techniques

DEPENDENT:

Give oxygen as
prescribed

SHORT TERM:

To promote adequate
rest periods and to
limit fatigue

To promote lung
expansion

To maximize oxygen
available for cellular
uptake

To liquefy secretions

These activities allow

patient participate in
maintatinng health
status and ventilation

The patient shall

have demonstrated
appropriate coping
behaviors and
method to improve
breathing pattern

LONG TERM :
The patient shall
have applied
techniques that
improved breathing
pattern and be free
from signs and
symptom of
respiratory AEB
respiratory rate
within normal range
absence of
cyanosis, effective
breathing and

Page | 39

Chest thoracostomy
tube

Supplemention of
oxygen helps to
improve breathing
pattern and relieve
respiratory distress

To remove excess
fluid from pleural
space

minimal used of
accessory muscles
during breathing

NCP #3

DATA

NURSING DX

OBJECTIVES
SHORT TERM:

SUBJECTIVE CUES:
Risk for infection
related to surgical

After 30minutes of
nursing intervention
the patient will be
able to identify

NURSING INTERVENTIONS

RATIONALE

INDEPENDENT

Stress and model proper

hand washing techniques
to client and caregiver

EVALUATION
SHORT TERM:

Reduce
cross
contaminati
on and

The patient shall

identify
behaviour and
practice in

Page | 40

OBJECTIVE CUES:

Presence of
chest
thoracostomy
tube at the right
midaxilliary
area
Open
environment
Over crowded
area

procedure as
evidenced by
presence of right
midaxillary chest
thoracostomy tube

behaviour and
practice to prevent
and reduce the risk
for infection

Maintain aseptic technique

with any procedures.
Provide routine site care
and wound care as
appropriate

Inspect dressing not

characterized by drainage

LONG TERM:
After 3 days of
giving nursing
intervention the
client will achieved
timely wound
healing free of signs
of infection and
inflammation
purulent drainage
and fever

Encourage frequent
position changes and being
out of bed or early
ambulation as tolerated

bacterial
colonizatio
n
Prevent
entre of
bacteria
reducing
risk
nosocomial
infection

Early
detection of
developing
infection
provides
opportunity
for timely
intervention
and
prevention
and more
serious
complicatio
n
Limit stasis

preventing
infection

LONG TERM :
The patent shall
achieve wound
healing and free
from infection
and
inflammation

Page | 41

Monitor vital signs

DEPENDENT:

Administer antibiotics as
indicated

Ceftriaxone
1 mg/q8/IVTT

of body
fluids
promotes
optimal
functional
organ
system and
gastrointest
inal tract
To have
base line
data
specially
increase
temperature
Wide
spectrum
antibiotics
may be
used
prohylactic
ally or
antibiotic
therapy
may be
geared
toward
specific
Page | 42

organism

In inhibits the cell

wall synthesis
causing cell death

NCP #4

DATA
SUBJECTIVE CUES:
luya jud siya as
verbalized by the
significant others
OBJECTIVE CUES:

NURSING DX
Ineffective airway
clearance related to
weakness and poor
cough effort.

OBJECTIVES
SHORT TERM
GOAL:
At the end of 4 hours
in giving nursing
intervention patients
lung sounds will be

NURSING
INTERVENTIONS

RATIONALE

INDEPENDENT

Anterior
and
posterior
chest
auscultated

To determine the
decrease or absence of
ventilation and the
presence of sound
barriers.
Page | 43

EVALUATION

Slight weakness
Crackles at the right
lung field upon
auscultation
Tachypnea
RR: 30 cpm
Dyspnea
Used if accessory
muscle
Pallor

clear to auscultate;
Patient will be free
of dyspnea; Patient
will demonstrate
correct coughing and
deep breathing
techniques

LONGTERM
GOAL:
At the end of 1 day
of giving nursing
intervention patient
will maintain a
patent airway

Maintain adequate
hydration.

To reduce the viscosity

of secretions.

To avoid worsening
patients condition.

Inform
patients
and families that
smoking is an
activity that is
prohibited in the
treatment room.

Instruct
patients
about cough and
deep
breathing
techniques.

Encourage
physical activity

If the patient is
unable to perform
ambulation,
the
location of the
patient
sleeping
position changed
every 2 hours.

Inform

patients

To facilitate the release

of secretion.

To improve the
movement of
secretions.
To avoid pneumonia
and pressure ulcers.

To reduce anxiety and

increase self-control.
Controlled couching is
accomplished by
Page | 44

before starting the

procedure.

Encourage to take
a deep breath hold
for two second,
and cough two or
three times in
succession.

Elevate the head of

the patient in semi
high
fowlers
position.

DEPENDENT

closure of the glottis

and the explosive
expulsion of air from
the lungs by the work
by the abdominal and
chest muscle.
Promotes better lung
expansion and
improved gas
exchange.
Early supplemental
oxygen is essential
since early mortality is
associated with
inadequate delivery of
oxygenated blood to
the brain and vital
organs

Administer
supplemental
oxygen.

Page | 45

NCP #5

DATA
SUBJECTIVE CUES:
Ang sakit ra man gyud
na iyang gibati kay
dapit sa gibutangan ug
tubo, dili kayo siya
maglihok-lihok as
verbalized by the

NURSING DX
ACUTE PAIN
RELATED TO
PLACEMENT OF
CHEST
THORACOSTOMY
TUBE

OBJECTIVES
SHORT TERM:

After 3 hours of
nursing intervention
the patient will be
able to report a
decrease of pain.

NURSING
INTERVENTIONS

RATIONALE

Perform comfort
measures to
promote relaxation
such as
repositioning and
relaxation
techniques.

Provide patient

These measures
reduce muscle
tension or spasm,
and help patient
focus on non-pain
related subjects

EVALUATION
SHORT TERM:

The patient shall

have reported pain
is relieved from a
pain scale of 6/10
to 3/10

This educates
Page | 46

significant others
Patient verbalized pain
scale of 6 out of 10.
OBJECTIVE CUES:

Facial grimace
Guarded behaviour
on the CTT site
Tachypnea
RR: 30 cpm
Dyspnea
Use of accessory
muscle
Pallor
Loss of appetite

with information
to help increase
pain tolerance; for
example reasons
for pain and length
of time it will last

LONG TERM:
After 2 days of
nursing interventions
the patient will be
free from pain and
demonstrate
relaxational skills.

patient and
encourages
compliance in
trying alternative
pain relief measures

Manipulate the
environment to
promote periods of
uninterrupted rest

This promotes
health, well-being,
and increased
energy level
important to pain
relief.

Encourage and
assist client to do
deep breathing
exercises

Deep breathing
exercises contribute
to relief of pain

Encourage
verbalization and
feelings of pain

Only the client can

judge the level and
degree of pain; pain
management should
be a team approach
that includes the
client

LONG TERM :

The patient shall

be free from pain
as evidenced by
demonstration of
relaxation skills
and diversional
activities with the
help of the SO.

Page | 47

DEPENDENT:

Administer
medications,
particularly
analgesics, as
prescribed (e.g
Tramadol+PCM
(P-dol) 1 tab TID
PO)

To relieve pain

VII. DISCHARGE PLANS

Instruct patient to comply on the following medication regimen:

1. Moriamin Forte 1 cap twice a day for vitamins and minerals

Medications:

supplementation which is essential to the body.

2. Tramadol + Paracetamol to relieve pain discomfort.
3. Bisacodyl suppository per rectum to relieve constipation and
stimulate bowel movement.
4. Acetylcystein (Mucomyst) 30mg to liquefy or dissolve mucus so that
it maybe coughed up easily.
5. Multivitamins + Iron 1 tab at once daily to supplement vitamin and

mineral deficiency and iron to aid in the formation of haemoglobin.

Take medications on time.
Page | 48

Instruct patient to perform deep breathing exercise to help

strengthen the lungs, build lung capacity and prevent further

Exercise:

accumulation of fluid between the pleural cavities.

Advice patient to perform simple coughing exercise to allow
chest wall contraction and may help prevent excess fluid from
accumulating and help prevent condition such as pneumonia. To
decrease pain when coughing, hold a pillow over the chest where

the pain is located and take pain medications as directed.

Perform passive active exercise (e.g. bending, and moving) to
help joints and muscle become stable. It keeps the joint areas
flexible. Exercise also helps calf pump which promotes venous
return and thus presents further formation of edema. Without
these exercises, blood flow and flexibility of the joints can
decrease.

Position the patient to high fowlers position or elevate the head

of patient to promote optimal lung expansion.

Provide relaxing environment to promote adequate rest periods

and to limit fatigue.

Frequent position changes every two hours to prevent pressure

Treatment:

ulcers.
Page | 49

Maximize respiratory effort with good posture and effective use

of accessory muscle to promote wellness.

Stop smoking or avoid second hand smoke, because it can
exacerbate the condition.

Outpatient
(Check-up):

Instruct patient to return to the hospital 1 week after discharge or

as set by the doctor for updates of the patients condition. Or
when the following situations occur: Accidental expulsion of

Chest tube thoracostomy or Inability to breathe

Instruct patient if fever, increasing trouble breathing or rapid
breathing, coughing up blood, and worsening or continued chest
pain occur, she must seek medical attention immediately.

Limit foods rich in sodium (e.g. dried fish, junk foods, etc.).
Because it can exacerbate the condition and it retains fluid on the

Diet:

body adding more complication to the patient.

Eat a healthy diet (e.g. fruits, vegetables, and protein like meat);
good nutrition can help body fight illness and protein helps in

oncotic pressure/absorption mechanism of fluid.

Drink plenty of fluids at least 8 glasses per day or more within
patients tolerance to keep the air passage moist and better able to
get rid of germs and other irritants, and liquefy secretions.
Page | 50

BIBLIOGRAPHY

BOOKS/EBOOKS
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Black, J., Hawk, J. (2008). Medical Surgical Nursing: Clinical Management for Positive Outcomes, 8th Ed. Management of Clients
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Bouros, D., (2004). Pleural Disease. Boca Raton, FL: CRC Press
Khan, Daw (2011). Do the right thing:how to judge a good ward: ten standards for adult in-patientmental healthcare. London
King, C., & Henretig F. (2008). Textbook of Pediatric Emergency Procedures. Baltimore, MD: Lippincott Williams & Wilkins
Kollef, M., & Isakow, W. (2012). The Washington Manual of Critical Care. Baltimore, MD: Lippincott Williams & Wilkins
Rinzler, C. A., (2011). Nutrition for Dummies (5th edition). Hoboken, NJ: Wiley Publishing, Inc.
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http://my.clevelandclinic.org/anatomy/musculoskeletal_system/hic_normal_structure_and_function_of_the_musculoskeletal_system.aspx
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Page | 52

CONSENT FORM

Access to Health Information for Presentation and/or Publication

I,
. , hereby consent to allow Dioneflor Artana, Lyra Dain Lorca, Maria Vanessa Ronolo, Lucky Charm Rosos, and
Marvin Telin from Bukidnon State University College of Nursing to review my health information for the purpose of presenting my de-identified
information at a research conference and/or to publish as a case report in a scientific journal. I understand that my name will not be associated in
any way with the information presented or published. Any information that is obtained that can identify me will remain confidential and will be
disclosed only with my permission or as required by law.

If I have any questions about the above, I can contact: Lyra Dain Lorca at 09357400***.
I have read the information above. I have been given the opportunity to discuss it. All of my questions have been answered to my satisfaction. This
signature on this consent form means that I agree to allow access to my personal health information for the purposes of presentation and
publication.
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__________________________
Signature of Patient
__________________________
Signature of Patients

______________
Name (Printed)
______________
Name (Printed)

_____ / ______ / _____

Year Month

Day

_____ / ______ / _____

Year Month

Day

Authorized Legal Representative

__________________________

______________

Witness to Patients Signature

Name (Printed)

_____ / ______ / _____

Year Month

Day

I will be given a signed copy of this consent form

NCM 103 RLE

GROUP 1
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DIONEFLOR P. ARTANA

LUCKY CHARM D. ROSOS

BSN III, Student Nurse

BSN III, Student Nurse

MARVIN C. TELIN
BSN III, Student Nurse

LYRA DAIN O. LORCA

BSN III, Student Nurse

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BSN III, Student Nurse

MA. VANESSA RONOLO

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