I.

INTRODUCTION

a. Current Trends
b. Reasons for choosing such case for presentation
c. Objectives
• Student – centered
• Client – centered

II. NURSING ASSESSMENT

a. Personal History
i. Demographic Data
ii. Socio – economic and Cultural Factors

b. Pertinent Family History (Schematic Diagram)

c. History of Past Illness

d. History of Present Illness

e. Physical Examination (per visit)

f. Diagnostic and Laboratory Procedures

Diagnostic & Date Ordered Indications or Results Normal Analysis and Nursing
Laboratory Results in purposes Values Interpretation Responsibilities
Procedures
Ultrasound 08-25-09 Sonogram of Consider
guided the right loculated
thoracentesis hemithorax pleural
shows a effusion with
septated fluid septations..
measuring 8.9
x 9.0 x 8.2 cm.
with an
approximate
volume of 343
cc.

Diagnostic & Date Ordered Indications or Results Normal Analysis and Nursing
Laboratory Results in purposes Values Interpretation Responsibilities
Procedures
Chest 09-08-09 Chest Consider
Ultrasound sonogram organizing
shows a pleural
pleural effusion
efuusion with minimal to
septations and moderate.
medium level
echoes with an
approximate
volume of
 100cc, seen in
the right
pleural cavity.

Diagnostic & Date Ordered Indications or Results Normal Analysis and Nursing
Laboratory Results in purposes Values Interpretation Responsibilities
Procedures
Pleural Fluid 08-25-09 .Total volume: .
Analysis 3 ml
Appearrance:
Cloudy
Color: Light
yellow
Cell count
WBC: 1,500
cells/count
Diff. count:
Segmenters:
60

Diagnostic & Date Ordered Indications or Results Normal Analysis and Nursing
Laboratory Results in purposes Values Interpretation Responsibilities
Procedures
08-25-09 .

Diagnostic & Date Ordered Indications or Results Normal Analysis and Nursing
Laboratory Results in purposes Values Interpretation Responsibilities
Procedures
Pleural Fluid 08-25-09 .
Analysis

Diagnostic & Date Ordered Indications or Results Normal Analysis and Nursing
Laboratory Results in purposes Values Interpretation Responsibilities
Procedures
Pleural Fluid 08-25-09 .
Analysis

III. ANATOMY AND PHYSIOLOGY

Cells require oxygen to break down nutrients to release energy and produce
ATP, and must excrete the carbon dioxide that results. Obtaining oxygen and
removing carbon dioxide are the primary functions of the respiratory system, which
includes tubes that remove particles from incoming air and transport air into and out
of the lungs, as well as microscopic air sacs where gases are exchanged. The
respiratory organs also entrap particles from incoming air. Help control the
temperature and water content of the air, produce vocal sounds and participate in the
sense of smell and the regulation of blood pH.
Respiration is the process of gas exchange between the individual and the
environment. The process of respiration involves three components: (1) the
movement of air between the atmosphere and the alveoli of the lungs as we inhale
and exhale – called pulmonary ventilation, (2) gas exchange which involves
diffusion of oxygen and carbon dioxide between the alveoli and pulmonary
capillaries, and (3) transport of oxygen from the lungs to the tissues and carbon
dioxide from the tissues to the lungs.
STRUCTURE OF THE RESPIRATORY SYSTEM
The respiratory system is divided structurally into the upper respiratory
system and the lower respiratory system. The mouth, nose, pharynx, and larynx
compose the upper respiratory system. The lower respiratory system includes the
trachea and lungs, with the bronchi, bronchioles, alveoli, pulmonary capillary
network, and pleural membranes.
Air enters through the nose, where it is warmed, humidified, and filtered.
Large particles in the air are trapped by the hair at the entrance of the nares, and
smaller particles are filtered and trapped as air changes direction on contact with the
nasal turbinate sans septum. The sneeze reflex is initiated by irritants in nasal
passages. A large volume of air rapidly exists through the nose and mouth during a
sneeze, helping to clear nasal passages.
Inspired air passes from the nose though the pharynx, The pharynx is a
shared pathway for air and food. It includes both the nasopharynx and the
oropharynx, which are richly supplied with lymphoid tissue that traps and destroys
pathogens entering with the air.
The larynx is a cartilaginous structure that can be identified externally as the
Adam’a apple. In addition to its role in providing for speech, the larynx is important
for maintaining airway patency and protecting the lower airways from swallowed
food and fluids. During swallowing, the inlet to the pharynx (the epiglottis) closes,
routing to the esophagus. The epiglottis is open during breathing, allowing air to
move freely into the lower airways. Below the larynx, the trachea leads to the right
and left bronchi (primary bronchi) and the other conducting airways of the lungs.
Within the lungs, the primary bronchi divide repeatedly into smaller and smaller
bronchi, ending with the terminal bronchioles. Together these airways are known as
bronchial tree. The trachea and bronchi are lined with mucous epithelium. These
cells produce a thin layer of mucus, the “mucous blanket”, that traps pathogens and
microscopic particulate matter. These foreign particles are then swept upward toward
the larynx and throat by cilia, tiny hairlike projections on the epithelial cells. The
cough reflex is triggered by irritants in the larynx, trachea, or bronchi.
Until air passes through the terminal bronchioles and enters the respiratory
bronchioles and alveoli, no gas exchange occurs. The respiratory zone of the lungs
includes the respiratory bronchioles (which have scattered air sacs in their walls), the
alveolar ducts and the alveoli. Alveoli have very thin walls, composed of a single
layer of epithelial cells covered by a thick mesh of pulmonary capillaries. The
alveolar and capillary walls form the respiratory membrane (also known as the
alveolar capillary membrane), where gas exchange occurs between the air on the
alveolar side and the blood on the capillary side. The airways move air to and from
the alveoli; the right ventricle and pulmonary vascular system transport blood to the
capillary side of the membrane.
The outer surface of the lungs is covered by a thin, double layer of tissue
known as the pleura. The parietal pleura lines the thorax and the surface of the
diaphragm. It doubles back to form the visceral pleura, covering the external surface
of the lungs. Between these pleural layers is a potential space that contains a small
amount of pleural fluid, a serous lubricating solution. This fluid prevents friction
 during the movements of breathing and serves to keep the layers adherent through its
surface tension.

IV. THE PATIENT AND HER ILLNESS (Patient – based)

a. Schematic Diagram of Pathophysiology

b. Synthesis of the Disease
i. Definition of the Disease

ii. Predisposing and Precipitating Factors

iii. Signs and Symptoms
iv. Health Promotion and Preventive Aspects of the disease

V. THE PATIENT AND HER CARE

a. Medical Management
i. IVF
Medical Date Ordered General Indication(s) Client’s Initial Client’s Nursing
Management Date Description or Purposes Reaction to the Response to Responsibilities
Treatment Performed Treatment the Treatment
Date Changed
D5 0.3 NaCl

ii. Medications/Drugs
Generic Name Date Ordered Route of Indications or Specific Foods Client’s Nursing
Brand Name Date Administration, Purposes Taken Response to Responsibilities
Performed Dosage and the Treatment
Date Changed Frequency
;
iii. Diet
Diet Date Ordered General Indications or Specific Foods Client’s Nursing
Date Description Purposes Taken Response to Responsibilities
Performed the Treatment
Date Changed
NPO

iv. Activities
Activity Date Ordered General Indications or Specific Foods Client’s Nursing
Date Description Purposes Taken Response to Responsibilities
Performed the Treatment
Date Changed
Complete Bed
Rest
Deep
Breathing
Exercise

b. Nursing Management (Actual SOAPIER’s)

VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

a. Client’s Daily Progress Chart

DAYS ADMISSION DISCHARGE
Nursing Problems:
Vital Signs:
Diagnostic and
Laboratory
Procedures
Medical
Management:
IVF
Medications/Drugs
Diet
Activities

b. Planning
i. General Condition of the Client upon discharge

c. Method ( Medication, Exercise, Treatment, Health Teaching, OPD, Diet)

VII. LEARNING DERIVED (End)

VIII. CONCLUSIONS AND RECOMMENDATIONS
IX. SOCIOGRAM
X. BIBLIOGRAPHY