MISSION

VISION MABINI COLLEGES provides quality instruction,

MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
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EDUCATION
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CASE STUDY
ON
PULMONARY TUBERCULOSIS
PLEURAL EFFUSION

Submitted By:
MELANIE M. TARDECILLA
BSN III – A (Group 4)

Submitted to:
Mr. Wenceslao Abogado RN
Clinical Instructor – Clinical/RLE
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.
EDUCATION
Daet, Camarines, Norte into:
Specifically, it transforms students

College of Nursing and Midwifery 1.

2.
God-fearing
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3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

INTRODUCTION

Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up

of excess fluid between the layers of the pleura outside the lungs. The pleura are
thin membranes that line the lungs and the inside of the chest cavity and act to
lubricate and facilitate breathing. Normally, a small amount of fluid is present in the
pleura. The seriousness of the condition depends on the primary cause of pleural
effusion, whether breathing is affected, and whether it can be treated effectively.
Causes of pleural effusion that can be effectively treated or controlled include an
infection due to a virus, pneumonia or heart failure. Two factors that must be
considered are treatment for associated mechanical problems as well as treatment
of the underlying cause of the pleural effusion.

A pleural effusion, is an excessive accumulation of fluid in the pleural space,

indicates an imbalance between pleural fluid formation and removal. Accumulation of
pleural fluid is not a specific disease, but rather a reflection of underlying pathology.
Pleural effusions accompany a wide variety of disorders of the lung, pleura, and
systemic disorders. Therefore, a patient with pleural effusion may present not only to
a pulmonologist but to a general internist, rheumatologist, gastroenterologist,
nephrologist, or surgeon. To treat pleural effusion appropriately, it is important to
determine its cause. With knowledge of the pleural fluid cytology, biochemistry, and
clinical presentation, an etiological diagnosis can be established in approximately
75% of patients.

Pleural effusion is the accumulation of fluid in between the parietal and

visceral pleura, called pleural cavity. It can occur by itself or can be the result of
surrounding parenchymal disease like infection, malignancy or inflammatory
conditions. Pleural effusion is one of the major causes of pulmonary mortality and
morbidity.
All healthy humans have a small amount of pleural fluid that lubricates the
space and facilitates normal lung movements during respiration. This delicate
balance of fluid is maintained by the oncotic and hydrostatic pressure and the
lymphatic drainage; disturbances in any one of these systems can lead to a build-up
of pleural fluid.

Mycobacterium tuberculosis (M. tuberculosis) is a pathogenic bacterial

species in the family Mycobacteriaceae and the causative agent of most cases of
tuberculosis (TB). Despite being isolated by Robert Koch in 1882, as well as the
availability of effective treatment and the use of a live attenuated vaccine in many
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parts of the world, TB remains one of the deadliest communicable diseases. In 2013,
an estimated 9 million people developed active TB, with 1.5 million deaths attributed
to the disease. According to the World Health Organisation the incidence of
pulmonary TB in some regions is as high as 1,000 cases per 100,000 persons.
Although TB affects the lungs in the majority of patients, extrapulmonary TB serves
as the initial presentation in about 25% of adults, and primarily involves the lymph
nodes and pleura. This review gives an overview of the pathogenesis, clinical
presentation, diagnosis and treatment of TB pleural effusions, highlighting recent
advances and controversies.

CAUSES
Pleural effusions are very common, with approximately 100,000 cases
diagnosed in the United States each year, according to the National Cancer Institute.
Depending on the cause, the excess fluid may be either protein-poor
(transudative) or protein-rich (exudative). These two categories help physicians
determine the cause of the pleural effusion.
The most common causes of transudative (watery fluid) pleural effusions
include: Heart failure, Pulmonary embolism, Cirrhosis, and Post open-heart surgery.
In Exudative (protein-rich fluid) pleural effusions are most commonly caused by
Pneumonia, Cancer, Pulmonary embolism, Kidney disease, and Inflammatory
disease. The other less common causes of pleural effusion include a Tuberculosis,
Autoimmune disease, Bleeding (due to chest trauma), Chylothorax (due to trauma),
Rare chest and abdominal infections, Asbestos pleural effusion (due to exposure to
asbestos), Meig’s syndrome (due to a benign ovarian tumor), and Ovarian
hyperstimulation syndrome.
Certain medications, abdominal surgery and radiation therapy may also cause
pleural effusions. Pleural effusion may occur with several types of cancer including
lung cancer, breast cancer and lymphoma. In some cases, the fluid itself may be
malignant (cancerous), or may be a direct result of chemotherapy.

SIGNS AND SYMPTOMS

Some people show no symptoms of pleural effusion. They usually find out the
condition through chest X-rays or physical examinations done for another reason.
Common symptoms of pleural effusion include; chest pain, dry cough, fever,
difficulty breathing when lying down, shortness of breath, difficulty taking deep
breaths, persistent hiccups, and difficulty with physical activity.

WORLWIDE EPIDEMIOLOGY OF PLEURAL EFFUSION

In the United States, up to one million patients develop parapneumonic
effusions annually, and approximately 100,000 patients undergo pleurodesis for
 MISSION
VISION MABINI COLLEGES provides quality instruction,
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recurrent pleural effusions per year. Pleural effusion is reported to have an incidence
of 0.32% in a study among the general population in central Bohemia. Congestive
heart failure accounts for nearly 50% of cases, with malignancy, pneumonia and
pulmonary emboli as the next three leading causes. However, the distribution of
causes is largely dependent on the population being studied. For example, the
incidence of pleural effusion among ICU patients is estimated to be 22.19 ± 17%,
whereas the prevalence of tuberculous pleural effusion remains steady with respect
to the total number of TB cases (14.3%-19.3%). The incidence of parapneumonic
effusions is constantly increasing, although, the microbial epidemiology of these
effusions differs from pneumonia with a higher prevalence of anaerobic bacteria. The
incidence of pediatric empyema increased from 1 per 100,000 children aged 0 to 14
years in 1998 to 10 per 100,000 in 2012, with a peak incidence of 13 per 100,000 in
2009 with Staphylococcus aureus as the most frequent cause followed by S.
pneumoniae. The age predominace of pleural effusion varies depending on the
underlying cause. Greater than 60% of tuberculous pleural effusion commonly
affects individuals between 15-44 years. Pleural effusions are the most common
thoracic involvement findings in patients with POEMS syndrome, affecting more than
40% of cases with median age at the time of diagnosis of POEMS syndrome as 45.1
years. HIV infection, pleural empyema, and complicated parapneumonic effusion is
mostly seen in middle-aged patients (53 ± 17 years). Males are more commonly
affected with tuberculous pleural effusion than females. The male to female ratio is
approximately 3:2. Males are more commonly affected with pleural empyema and
complicated parapneumonic pleural effusion than females. The male to female ratio
is approximately 2:1. There is no racial predilection to pleural effusion. Development
of tuberculous pleural effusion is common on endemic developing countries with TB
infection.
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.
EDUCATION
Daet, Camarines, Norte into:
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2.
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3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

Patient X is a 50 years old man and He is admitted in Camarines Norte

Provincial Hospital because of complaint in difficulty of breathing 2 days. PTA. On
July 30, 2020 at 7:00 PM, He was admitted in Camarines Norte Provincial Hospital.
He was directed to emergency room to be examined and treated. Vital signs taken
as follows: Temperature –37.8; Pulse Rate –30 beats per minute; cardiac Rate – 100
breaths per minute; Blood Pressure – 140/90mmHg.

Demographic Data
Name: Mr. X* Age: 61y/o Ward: medical ward
Permanent Address: P5 Borabod Daet Camarines Norte
Sex: Male Civil Status: married
Nationality: Religion:
Birthday: Birthplace:

Chief Complaint: The chief complaint of the client is difficulty of breathing in

2days.
DATE OF ADMISSION: July 30 2020
TIME OF ADMISSION: 7:00 PM
CHIEF COMPLAINT: difficuty of breathing 2days
ADMITTING DIAGNOSIS: PTB, Pleural effusiion Right

HISTORY OF PRESENT ILLNESS

Two weeks prior to admission patient experience of cough and easy
fatiguebility with episode of difficulty of breating. He also experiences of DOB when
dying flat on bed which relieve of using 2 pillows on moderate high back rest
position. He consulted private physician CXR was done with findings of PTB, pleural
effusion right. He reffered to CNPH.
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
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PATIENT PHYSICAL ASSESSMENT

Patient X has no allergies found.
 Pale conjunctiva
 Ictera sclerea
HEENT

 BP: 140/90 mmHg

 PR: 30 beats per minutes
VITAL SIGNS  CR: 100 beats per minutes
 TEMP: 37.8
 O2Sat: 93%
 Lower chest expansion
 Nrgative breath sound
CHEST/LUNGS  Positive chest pain

 Soft and non tender

ABDOMEN
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EDUCATION
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PATHOPHYSIOLOGY
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persons

PATHOPYSIOLOGY

In the normal healthy adult, the pleural cavity has minimal fluid which acts a
lubricant for the two pleural surfaces. The amount of pleural fluid is around at
0.1 ml/kg to 0.3 ml/kg and is constantly exchanged. Pleural fluid originates from the
vasculature of parietal pleura surfaces and is absorbed back by lymphatics in the
dependent diaphragmatic and mediastinal surfaces of parietal pleura. Hydrostatic
pressure from the systemic vessels that supply the parietal pleura is thought to drive
the interstitial fluid into the pleural space and hence has a lower protein content than
serum. Accumulation of excess fluid can occur if there is excessive production or
decreased absorption or both overwhelming the normal homeostatic mechanism. If
pleural effusion is mainly due to Mechanisms that lead to pleural effusion mainly due
to increased hydrostatic pressure are usually transudative, and leading to pleural
effusion have altered the balance between hydrostatic and oncotic pressures
(usually transudates), increased mesothelial and capillary permeability (usually
exudates) or impaired lymphatic drainage.
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
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persons

LABORATORY TESTS
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LABORATORY TEST
ECG
A line graph that shows changes in the electrical activity of the heart over
time. It is made by an instrument called an electrocardiograph. The graph can show
that there are abnormal conditions, such as blocked arteries, changes in electrolytes
(particles with electrical charges), and changes in the way electrical currents pass
through the heart tissue. Also called EKG and electrocardiogram.
An electrocardiogram (ECG or EKG) is a test that checks how your heart is
functioning by measuring the electrical activity of the heart. With each heart beat, an
electrical impulse (or wave) travels through your heart. This wave causes the muscle
to squeeze and pump blood from the heart.
An ECG measures and records the electrical activity that passes through the
heart. A doctor can determine if this electrical activity is normal or irregular.
An ECG may be recommended if you are experiencing arrhythmia, chest pain, or
palpitations and an abnormal ECG result can be a signal of a number of different
heart conditions.

CHEST X-RAY
An X-ray is an imaging test that uses small amounts of radiation to produce
pictures of the organs, tissues, and bones of the body. When focused on the chest, it
can help spot abnormalities or diseases of the airways, blood vessels, bones, heart,
and lungs. Chest X-rays can also determine if you have fluid in your lungs, or fluid or
air surrounding your lungs.
A chest X-ray is an easy, quick, and effective test that has been useful for
decades to help doctors view some of your most vital organs.

CREATININE TEST
A creatinine test reveals important information about your kidneys.
Creatinine is a chemical waste product that's produced by your muscle metabolism
and to a smaller extent by eating meat. Healthy kidneys filter creatinine and other
waste products from your blood. The filtered waste products leave your body in your
urine.

RANDOM BLOOD SUGAR

Random blood sugar test checks your blood glucose at a random time of day.
A level of 200 mg/dL or higher is a sign that you have diabetes.
A random blood glucose test is used to diagnose diabetes. The test measures
the level of glucose (a type of sugar) in your blood. If your blood glucose level is 200
mg/dL or higher and you have the classic symptoms of high blood sugar (excessive
thirst, urination at night, blurred vision and, in some cases, weight loss) your doctor
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VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
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EDUCATION
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may diagnose you with diabetes. If you do not have any symptoms of high blood
sugar, your doctor will probably have you take another test for further evidence of
diabetes.
Usually, having high blood glucose can be a sign that your body is not functioning
normally and that you may have diabetes. If you have high blood glucose and it is
not treated, it can lead to serious health complications. However, finding out that
your blood glucose is elevated is powerful information that you can use to keep
yourself healthy. If you know that your blood glucose is high, you can take steps to
lower it, by losing weight (if you are overweight or obese), getting regular moderate
physical activity, and taking a medication that lowers blood glucose.

BLOOD UREA NITROGEN

Blood urea nitrogen (BUN) is a medical test that measures the amount of urea
nitrogen found in blood. The liver produces urea in the urea cycle as a waste product
of the digestion of protein. Normal human adult blood should contain 6 to 20 mg/dL
(2.1 to 7.1 mmol/L) of urea nitrogen. Individual laboratories will have different
reference ranges as the assay used can vary between laboratories.[2][3][4] The test
is used to detect renal problems. It is not considered as reliable as creatinine or
BUN/creatinine ratio blood studies.

POTASIUM BLOOD TEST

A potassium blood test measures the amount of potassium in your blood.
Potassium is a type of electrolyte. Electrolytes are electrically charged minerals in
your body that help control muscle and nerve activity, maintain fluid levels, and
perform other important functions. Your body needs potassium to help your heart
and muscles work properly. Potassium levels that are too high or too low may
indicate a medical problem.

TREATMENT
The medical treatment for TB pleural effusion is the same as for pulmonary
TB, and is consistent with the theory that the majority of pleural TB cases develop
from pulmonary disease. The expected resolution of TB pleural effusion is variable,
and assuming appropriate therapy, fever usually resolves within 2 weeks with
reabsorption of the pleural fluid within 6 weeks. Naturally this will depend on the
burden of disease in the individual, and size of the effusion and resorption may take
up to 2-4 months.
Once the etiology of pleural effusion is determined, management involves
addressing the underlying cause. In cases of complex parapneumonic effusions or
empyema, (pleural fluid pH less than 7.2 or presence of organisms) chest tube
drainage is usually indicated along with antibiotics. Small-bore drains (10 G to 14 G)
 MISSION
VISION MABINI COLLEGES provides quality instruction,
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are equally effective as large-bore drains for this purpose. If patients do not respond
to appropriate antibiotics and adequate drainage, then thoracoscopic decortication or
debridement may be necessary. Instillation of intrapleural fibrinolytics and DNAse
may be used to improve drainage and in those who do not respond to sufficient
antibiotic therapy and those who are not candidates for surgical intervention. If a
patient with malignant pleural effusion is not symptomatic, drainage is not always
indicated unless an underlying infection is suspected. For malignant pleural effusions
that require frequent drainage, options for management are pleurodesis (where the
pleural space is obliterated either mechanically or chemically by inducing irritants
into the pleural space) and tunneled pleural catheter placement.

MEDICATIONS
Pharmacologic management of pleural effusion depends on the condition’s
etiology. For example, medical management includes nitrates and diuretics for
congestive heart failure and pulmonary edema, antibiotics for parapneumonic
effusion and empyema, and anticoagulation for pulmonary embolism.
In patients with parapneumonic effusions, empyemas, and effusions associated with
esophageal perforation and intra-abdominal abscesses, antibiotics should be
administered early when these conditions are suspected.