FACULTY OF NURSING

RAMA UNIVERSITY

MANDHANA, KANPUR
BATCH: 2024-25

SUBJECT: ADVANCE NURSING PRACTICE

CASE STUDY ON: PLEURAL EFFUSION

SUBMITTED TO- SUBMITTED BY-

MRS. SUMIYA S. MISS LAXMI YADAV
ASSOCIATE PROFESSOR M.Sc. NURSING 1ST YEAR
HOD OF FON DEPT. MSN SPECIALITY

DATE OF SUBMISSION-
PROFILE OF THE PATIENT
Name : Mr. Vishal Sahu
Age/sex : 35yr/male
Ip no : 1036745
Date of admission : 12-4-25
Unit/ward : general male medical ward
Religion : Hindu
Occupation : farmer
Income : 14000
Diagnosis : pleural effusion
Address : Raipur (C.G.)

CHIEF COMPLAINT: -
My patient chief complains of a chest pain, high grade fever, difficulty breathing, generalized
weakness.

HEALTH HISTORY: -
Past medical history: - patient is not having hypertension acute infection chronic disease and
hospitalization blood transfusion history.

Present medical history: Patient got admitted in general male medical ward with chief
complain of high-grade fever cough chest pain difficult breathing generalized weakness for
past 2week after admission blood test, chest x-ray, urine test, done doctor diagnosed his he is
having pleural effusion he is taking medication tablet ceftriaxone, diclofenac and
theophylline iv fluid normal saline metronidazole 100ml.
Past surgical history: - No any type of past surgical history of my patient.
Present surgical history: No any type of present surgical history of my patent.

FAMILY HISTORY: -
Family health history Mr. Vishal Sahu was suffered to plural effusion and my client other
family member are healthy, no any history of hereditary disease like systemic illness (DM,
hypertension, asthma, convulsion, malignancies), communicable disease, psychiatric disease,
cardiovascular disease and congenital disorder.
 Name Relation Age/sex Education Occupation Marital Health
with status status
patient
Mr Rajkumar Father 65yr/ M 10 Farmer Married Healthy
Mrs. Ravina Mother 62yr/ F 10 Housewife Married Healthy
Mr Vishal Self 35yr/ M 12 Shopkeepe Unmarried Unhealthy
Sahu r
Mr. Janmejay Brother 30yr/ M 10 Shopkeepe Unmarried Healthy
r

PERSONAL HISTORY:
HABITS: -
 Smoking: My client has no habit of smoking.
 Tobacco chewing: My client has no habit of tobacco chewing
 Alcohol: No habits of drinking alcohol.
 Drug addict (specify): No any harmful drug addiction of my client such a sedative
drug

DIET: -
 Vegetarian: My client is a vegetarian.
 No. of meals per day: normally 3 times take meal per day but now my client is on
liquid diet only I time.
 Any allergic to any food items: No any allergy.

SLEEP AND REST PATTERN: -

 Timing of sleep: - disturb sleeping pattern due to chest pain only 3hr. sleeping in night
time.
 Timing of rest only 2 hr rest in day time because of discomfort and pain in chest.

ACTIVITIES OF DAILY LIVING: -

 Taking care and himself herself: -unable to self-care and activities.
 Needs assistance: - require some assistance for daily activities and care.
  Any problem with ADL: my client unable to move self-activities.
 Bladder frequency: Bladder control is impaired decrease urine output.
 Bowel movement is impaired and my client not motion passed

RECREATIONAL AND HABITS: -

 Exercise activity and tolerance (specific): My client doing no exercise regular.
 Habits (specify): No habit of extra activity.
 Spiritual history: my client believes in God prayer.

SOCIOCCONOMIC STATUS:
 Social factors: Good relationship with other family member, my client belong to joint
family, monthly income is 14000/year my client house and own house, ventilation
facilities are adequate, electricity, draining, lighting, water, waste disposal and latrine
facilities available in own house, availability of hospital under 5km, clinic, health
centres, market, temple, school and transportation also present near house.
 Economic factor: - My client family income is own businessmen, financial status is
not adequate

PHYSICAL EXAMINATION
GENERAL APPEARANCE:
 Level of consciousness : My client is conscious.
 Orientation : My client is oriented to place/time and person.
 Activity : My client activity is impairment and dull
 Body built : My client is thin.
 General grooming : not maintain hygiene
 Posturing : no kyphosis, lordosis

ANTHEROPOMETRIC MEASURMENT
 Height - 162CM
 Weight-40 KG
 BMI - 15.26
VITAL SIGN: -
 Temperature: -100.6 F
 Pulse:86 beats/min
 Respiration: -30 breaths/minute
 BP: 130/80mmHg
 SPO2-96%
 RBS-119 mg/dl

SKIN INSPECTION AND PALPATION (Integumentary System):

 Colour and vascularise: My client skin colour is fair.
 Turgor and mobility: Decreased.
 Temperature and moisture: My client skins are warm and dry over all body due to
fever.
 Texture: My client skin texture is rough.
 Nails: My client nails are clean.

HEAD INSPECTION:
 Shape: no cephalic, no micro, macro, hydrocephalic.
 Face: symmetry no puffiness.
 Hair: normal hair distribution in all over the body.
 Condition of scalp: My client's scalps are clean, no dandruff seen.
 Masses and lumps: Not present any masses and lump in my client head.

EYES INSPECTION:
 Eyebrows: symmetrical equal distributed.
 Eyelids: eyelids normal, no oedema, no ptosis.
 Sclera: White and other abnormalities creamy, yellowish, infected sclera are absent.
 Conjunctiva: My client conjunctiva is pale pink.
 Iris: Black colour and round shape.
 Cornea: Clear.
 Pupils: Equal pupil size and round shape.

EARS INSPECTION:
  Pinna: normally placed.
 Canal: Ear canal is clean.
 Tympanic membrane: Pearly white and no any inflamed,
 Hearing: normal.

BONE CONDUCTION TEST: -

 Tuning fork test: Listen.
 Weber test: Lateralizes equally to left/right side.
 Rinne test: Air conduction is more than bone conduction.
 Hearing aids: No any type of hearing aids uses my client.

NOSE AND SINUSES:

 Nasal septum: Nasal septum normal located in midline.
 Nasal mucosa and turbinate: Nasal mucosa is dry and chia present.
 Patency of nares: Right patent no partial obstruction.
 Olfactory: My client correctly identifies the familiar odours.
 Sinuses: Normal and no any, inflammation and tenderness.

MOUTH AND PHARYNX INSPECTION:

 Lips: Slightly black, lips are symmetrical and thin and lips are dry and cracked.
 Teeth: My client's teeth colour is a yellowish.
 Breathe odour: Bad odour present due to no proper mouth wash.
 Gums: Colour in pink, moist gum and sensitivity is present.
 Tongue: My client tongue is pink colour and thin.
 Mucosa: Intact and dry.
 Palate: Moist and no any other abnormalities.
 Tonsils: Normal tonsil present.

NECK INSPECTION:
 Range of motion: possible, no pain.
 Thyroid: Thyroid palpable no any tenderness.
 Lymph nodes: not enlarged, painful.

ANUS AND RECTUM:

  No haemorrhoids no inflammation, no lesion.

EXTRIMITIES
 Size and symmetrical: no swollen, no oedema, no any deformities.
 Vertebrae: no any spinal cord deformities.
 Muscle tone and strength: firm, muscular, no atrophy.

SYSTEMIC EXAMINATION:
RESPIRATORY EXAMINATION
 Inspection: normal shape
 Respiration rate 130 Breaths per minute, regular
 Palpation trachea central, apex beat-5" intercostals space, symmetrical expansion.
 Tenderness at right side chest.
 Movement of chest wall: bilateral symmetrical chest movement.
 percussion; mild dullness over the right chest.
 Auscultation: crackle sound,

CARDIOVASCULAR EXAMINATION:
 Inspection: no any infection and redness of the chest
 Palpation: abnormal palpation S1 loudest at apex compares than S2 sound.
 Auscultation: S1, S2 sound heard, volume and rhythm are irregular beat, murmur
sound and present pulse rate 86b/m blood pressure is 130/80 mmHg

GASTROINTESTINAL EXAMINATION:
 Inspection: distended, dry, normal colour and intact. No any lesion.
 Palpation: absent tenderness of liver and spleen.
 Percussion: distended and dull
 Auscultation: bowel sound dullness,

MUSCULOSKELETAL EXAMINATION:
 Back: Normal shoulder level and not any lordosis, scoliosis and kyphosis are absent
 Vertebral column alignment: Straight no any lordosis, scoliosis and kyphosis are
absent.
 Joints: No any swelling redness, deformities and tenderness are absent.
URINARY SYSTEM:
 Inspection: normal
 Palpation: tenderness present.
 Urine output: 2000ml/day.

REPRODUCTIVE SYSTEM
 Male genitalia: normal

NEUROLOGICAL EXAMINATION:
 Mental status examination:
 General appearance- not good.
 Consciousness level-Unconscious.
 Dressing & grooming - Appropriate
 Personal hygiene Personal hygiene neat & appropriate
 Posturing & movement Not able to do movement
 Gesture & facial depression - No facial expression
 Cognitive function-Impaired
 Orientation-oriented for time place & person
 Memory responding

INVESTIGATIONS:
 Sr.no. Investigation Normal value Patient value Remarks

1 Haemoglobin 13-18g/dl 10.5g/dl Normal

2 RBC 4.5-6.0 mil/cumm 4.31 mil/cumm Normal
3 WBC 4.5-11.0/cub.um 18800/cub.mm Increased
4 Neutrophil 50-65% 82% Increased
5 Platelet count 1.5lac-4.5 lac 90,000 Low
6 Haematocrit 40-54% 33.7% Low
7 ESR 2-10mm/hr 72 mm/hr High
8 Urea nitrogen 20-40mg% 46% High
9 Serum creatinine 0.5-1.5mg/dl 0.6mg/dl Decreased
10 Sodium 135-145 mmol/L 146 mmol/L Normal
11 Glucose <140 mg/dl 140mg/dl High
12 Serum urea 10-45 mg/dl 69mg/dl High
13 Bilirubin total 1-1.2 mg/dl 3mg/dl High
14 Bilirubin direct 0-3 mg/dl 4 mg/dl High

Chest x-ray
Impression - Pleural effusion underlying atelectasis change in right the field trachea is
centrally placed.
USG THORAX - Pleural effusion is present.
Pleural aspiration done; 10 ml straw

Interference; Chest x-ray-

Impression - Pleural effusion underlying atelectasis change in right the field trachea is
centrally placed.
USG THORAX-pleural effusion is present.
BLOOD INVETIGATION; HB-10.5%, WBC-high, ESR-high.

MEDICATIONS
 S.no. Drug name Dose Rout Frequency Mode of action
e
1 Tab. Theophylline 8 mg P/O BD
2 Tab. Amoxicillin 250 mg P/O OD Antibiotic
3 Inj. Ceftriaxone 1 gm IV TID Antibiotic
4 Tab. Iron and folic 60mg P/O OD
5 Inj. Diclofenac 2ml IM BD

ANATOMY AND PHYSIOLOGY OF LUNGS

There are two lungs, one lying on each side of the midline in the thoracic cavity. They are
cone shaped and have an apex, a base, a tip, costal surface and medial surface.

The apex- This is rounded and rises into the root of the neck, about 25 mm above the level of
the middle third of the clavicle. It lies close to the first rib and the blood vessels and nerves in
the root of the neck. The base This is concave and semi lunar in shape, and lies on the upper
(thoracic) surface of the diaphragm.

The costal surface- This surface is convex and lies directly against the costal cartilages, the
ribs and the inter costal muscles. The medial surface This surface is concave and has a
roughly triangular-shaped area, called the hilum, at the level of the 5th, 6th and 7th thoracic
vertebrae. Structures forming the root of the lung enter and leave at the hilum. These include
the primary bronchus, the pulmonary artery supplying the lung and the two pulmonary veins
draining it, the bronchial artery and veins, and the lymphatic and nerve supply.

The area between the lungs is the mediastinum. It is occupied by the heart, great vessels,
trachea, right and left bronchi, oesophagus, lymph nodes, lymph vessels and nerves. The right
lung is divided into three distinct lobes: superior, middle and inferior. The left lung is smaller
because the heart occupies space left of the midline. It is divided into only two lobes: superior
and inferior. The divisions between the lobes are called fissures. Pleura and pleural cavity the
pleura consist of a closed sac of serous membrane (one for each lung) which contains a small
amount of serous fluid. The lung is invaginated (pushed into) into this sac so that it forms two
layers: one adheres to the lung and the other to the wall of the thoracic cavity.
The visceral pleura- This is adherent to the lung, covering each lobe and passing into the
fissures that separate them. The parietal pleura This is adherent to the inside of the chest wall
and the thoracic surface of the diaphragm. It is not attached to other structures in the
mediastinum and is continuous with the visceral pleura round the edges of the hilum.

Functions
 Control of air entry- The diameter of the respiratory passages is altered by
contraction or relaxation of the smooth muscle in their walls, thus regulating the speed
and volume of airflow into and within the lungs.
 These changes are controlled by the autonomic nerve supply: parasympathetic
stimulation causes constriction and sympathetic stimulation causes dilation.
 The following functions continue as in the upper airways warming and humidifying
support and patency.
 Removal of particulate matter cough reflex. Respiratory bronchioles and alveoli.

DISEASE CONDITION-
Definition:
Pleural effusion, a collection of fluid in the pleural space, is rarely a primary disease process
but is usually secondary to other diseases. Normally, the pleural space contains a small
amount of fluid (5 to 15 ml), which acts as a lubricant that allows the pleural surfaces to
move without friction.

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.
According to Brunner and Suddarth

Twenty to forty percent of hospitalized patients with bacterial pneumonia develop pleural
effusion. In India, unlike the western countries, tuberculous pleural effusion is common the
pleural cavity is involved in approximately 5% of all patients with tuberculosis, which is next
only to lymph node tuberculosis.

Causes of pleural effusion-

The most common causes of transudative (watery fluid) pleural effusions include:

BOOK PICTURE PATIENT PICTURE

Heart failure Absent
Pulmonary embolism Absent
Cirrhosis Absent
Post open heart surgery Absent

OTHERS

BOOK PICTURE PATIENT PICTURE

Pneumonia Absent
Cancer Absent
Pulmonary embolism Present
Kidney disease Absent
Inflammatory disease Absent

Pathophysiology-
In certain disorders fluid may accumulate in the pleural space to a point where it becomes
clinically evident. This almost always has pathologic significance. The effusion can be
composes of a relatively clear fluid, or it can be bloody or purulent. An effusion of clear fluid
may be a transudate or an exudate. A transudate (filtrates of plasma that move across intact
capillary walls) occurs when factors influencing the formation and reabsorption of pleural
fluid are altered, usually by imbalances in hydrostatic or oncotic pressures. The finding of a
transudative effusion generally implies that the pleural membranes are not diseased. The most
common cause of a transudative effusion is heart failure. An exudate (extravasation of fluid in
to tissues or a cavity) usually results from inflammation by bacterial products or tumours
involving the pleural surfaces.

Due to etiological factor

 Increase in hydrostatic pressure and decrease in oncotic pressure +

Unable to remain the fluid with in a intravascular space +

Fluid shift interstitial space

Effusion

CLINICAL MANIFESTATIONS

BOOK PICTURE PATIENT PICTURE

Fever Present 100% F
Chills Absent
Pleuritic chest pain Present
Dyspnoea Absent
Coughing Absent
Shortness of breath Present

BOOK PICTURE PATIENT

PICTURE
Chest x-ray- Not done
A chest X-ray is the most common radiology test. You may need
your chest X-rayed if you have chest pain, a persistent cough, a
heart or lung disorder, a pacemaker and more. Risks are very low
and you won't feel anything.
Computed tomography (CT) scan- Not done
Computed tomography (CT) scan is a useful diagnostic tool for
detecting diseases and injuries. It uses a series of X-rays and a
computer to produce a 3D image of soft tissues and bones. CT is a
painless, non-invasive way for your healthcare provider to
diagnose conditions.
Ultrasound of the chest- Not done
Ultrasound (sonography) is a safe, accurate medical imaging test
that uses sound waves. It can monitor how a baby develops in the
womb during pregnancy. This test can detect routine and
sometimes serious health concerns, including gallstones, blood
clots and cancer.
Thoracentesis- Not done
A needle is inserted between the ribs to remove a biopsy, or
sample of fluid.
Pleural fluid analysis- Done 10 ml straw in
An examination of the fluid removed from the pleura space. colour.
Ultrasound can be used for early detection and management of Pleural effusion
respiratory complications under mechanical ventilation, such as present
pneumothorax, ventilator-associated pneumonia, atelectasis and
pleural effusions.

BOOK PICTURE PATIENT

PICTURE
Tab. Theophylline- 8 MG oral BD is
It relaxes the smooth muscles Located in the bronchial airways given to my client
and pulmonary blood vessels. It also reduces the airway
 responsiveness to histamine, adenosine, methacholine, and
allergens.
Tab. Amoxicillin-It is similar to penicillin in its bactericidal action 250 mg BD per oral is
against susceptible bacteria during the stage of active given to my client
multiplication. It acts through the inhibition of cell wall
biosynthesis that leads to the death of the bacteria.
Inj. Ceftriaxone-It works by inhibiting the mucopeptide synthesis 1gm IV once a day is
in the bacterial cell wall. The beta-lactam moiety of ceftriaxone given
binds to carboxypeptidases, endopeptidases, and transpeptidases in
the bacterial cytoplasmic membrane.
Inj. Diclofenac- 2ml IV SOS
As with all NSAIDs, diclofenac exerts its action via inhibition of
prostaglandin synthesis by inhibiting cyclooxygenase-1 (COX-1)
and cyclooxygenase-2 (COX-2) with relative equipotency.

NURSING THEORY:
Lydia E. Hall the Aspects of Care, Core. Cure

As Hall (1965) says: "To look at and listen to self is often too difficult without the help of a
significant figure (nurturer) who has learned how to hold up a mirror and sounding board to
invite the behaviour to look and listen to himself If he accepts the invitation; he will explore
the concerns in his acts and as he listens to his exploration through the reflection of the nurse,
he may uncover in sequence his difficulties, the problem area, his problem, and eventually the
threat which is dictating his out-of-control behaviour."

Major paradigm Concepts:

Individual:
Mr. Vishal Sahu having-sinonasal polyps with the complaints of acute pain, breathing
difficulty, swelling and mass inside the nose. irritation of nose is the focus of nursing care in
Hall's work. The source of energy and motivation for healing is the nursing care recipient
Health:
Poor health inferred to be a state of self-awareness with conscious selection of behaviours
that are optimal for that patient. Hall stresses the need to help the patient explore the meaning
of his or her behaviour to identify and overcome problems with the effective nursing
management through developing self-identity and maturity

Environment:
It is dealt with in relation to the patient environment Hall is credited with effective
environment with give good hygienic, sanitation, calm and good environment and developing
the environment that is conducive to self-development and promotion of health.

Nursing:
Nurse is provided effective therapeutic care to the sinonasal polyps patient with effective
medication, effective nursing care and surgical procedure, psychological support give to the
patient and identified as consisting of participation in the care, core, and cure
aspects of patient care.
 Core patient having
chest pain, difficulty
in breathing,
weakness, sweating
vomiting

Cure after
Care assesses the
intervention pain
vital sign, provide
level was
inj. tramadol,
reducing patient,
provide semi
take proper
fowlers, position,
breathing,
provide
vomiting was
psychological.
reduced.

Care and Core Predominate

The Core Circle
 It is based in the patient complaint that he is having chest pain difficulty in breathing
weakness, sweating, and vomiting.
 Patient express the feeling of discomfort and his own actual condition

The Care Circle

 The professional nurse provides care nose assessment, observation, examination for
the patient.
 Helps the patient complete such basic daily biological functions as eating, bathing,
elimination, and dressing medication.
 When providing this care, the nurse's goal is the comfort measure given and minimize
the uncomforted feeling.

The Cure Circle

 It is based in the pathological and therapeutic sciences and implement the all planning
give comprehensive care During this aspect of nursing care, an active advocate role
done for the patient.
NURSING DIAGNOSIS
1. Impaired gas exchange related to alveolar capillary membrane and respiratory fatigue as
evidenced by take deep breathing.
2. Ineffective breathing pattern related to decreased lung volume capacity as evidenced by
tachypnoea, presence of crackles on both lung field and dyspnoea.
3. Pain in chest related to infection in lung as evidenced by dull facial expression.
4. Hyperthermia related to infection as evidenced by warm body 98.6f.
5. Anxiety related to hospital environment as evidenced by anxious facial expression.
6. Deficit knowledge regarding disease condition and treatment evidenced by questioning
answering.
7. Disturb body image related to insertion of chest thoracostomy tube
Assessment Nursing diagnosis Planning Implementation Evaluation
Subjective data: Impaired gas Asses the Provide semi After
My Patient exchange related patient flower position. intervention of
complain that I to alveolar condition, and Monitor vital plan of action
having capillary provide signs. slowly reduce
difficulty in membrane and comfortable pain
breathing. respiratory fatigue position. level 3 or less.
as evidenced by Change the Provide the
take deep position. client in to high
breathing. fowlers
Objective data: position.
on observation Provide Oxygen therapy
I found that oxygen is given.
vitals T-100 (R- therapy.
30 b/m. P- Encourage Encourage
60b/m. BP- diaphragmatic diaphragmatic
130/80 breathing. breathing and
Restlessness, coughing.
cough, Administer Administer
suffocation bronchodilator Theophylline as
as per order. per order.
Assessment Nursing Planning Implementation Evaluation
diagnosis
Subjective Acute chest Assess the Apply the After intervention plan
data: My pain related to patient pain rating scale of action my client
client is coughing facial for intensity 6/10 pain. report pain was reduce.
having sever expression and using a pain
pain in chest. respiratory rating scale.
pattern. Monitor
vital sign Check out the
especially temperature-
pulse and 100F, BP-
Objective blood 130/80
data: I found pressure resp. 22br/min
that facial and pulse- 86bt/min
expression respiration.
dull activity Provide Music therapy
pain scale mind is given.
6/10. diversional
therapy.
 Assessment Nursing diagnosis Planning Implementation Evaluation
Subjective data: Hyperthermia Assess the History taking. After
my client is related to infection patient intervention the
complaining as evidenced by condition patient body
that I am having body temperature Provide cold Cold sponging temperature
fever. 99F. sponging. with cold water. reduce 98.6F.
Encourage Extra cloth
the patient removed.
to remove
Objective data: extra cloth.
on observation Provide IV Provide IV fluid
found that fluid as per normal saline
health condition order. 500 ml.
anxious by Administer Administered
facial antipyretic Paracetamol
expression. drug as per 500 mg.
physician
order.

HEALTH EDUCATION
Self-care:
  Use pressure to decrease pain. Hold a pillow against chest when cough or take a deep
breath.
 Do not smoke, and do not allow others to smoke around.
 Drink liquids as directed and rest as needed.
 Deep breathing and coughing will decrease your risk for a lung infection.

EXERCISE
 Deep breathing and coughing will decrease risk for a lung infection. Take a deep
breath and hold it for as long as can.
 Let the air out and then cough strongly.
 Deep breaths help open airway. Use an incentive spirometer to help take deep breaths.
 Put the plastic piece in mouth and take a slow, deep breath.
 Then let the air out and cough. Repeat these steps 18 times every hour.

Avoid These Foods with Lung Disease-

 Cold Cuts. Most cured meats such as bacon, cold cuts, ham, and hotdogs contain
additives called nitrates.
 Excessive Salt. While a small pinch of salt cooked in a dish may be fine, a salt-heavy
diet
 can be a problem.
 Dairy Products.
 Cruciferous Vegetables.
 Fried Foods
 Carbonated Beverages.
 Acidic Foods and Drinks.

MEDICATION
Advice the client to take proper medicines on time.

HYGIENE
Advised the client maintain personal hygiene.
Advised the client for take daily bath.
Advised the client clean for perineal area.
Advised the client change for cloth.
REST AND SLEEP
Advised the client for proper take rest and sleep.

FOLLOW UP
Educate the patient follow up check-up.

SUMMARY
As I sum up, I have included the history collection, physical examination, disease condition
of the patient, its causes, pathophysiology, sign and symptoms, diagnostic evaluation, medical
management and nursing management with the help of the nursing theory application.

CONCLUSION
Plural effusion is the buildup of excess fluid in the pleural space the area between the lung
and the chest wall. This fluid accumulation can be done due to various underlying conditions
like heart failure, pneumonia or cancer symptoms often include shortness of breath, chest
pain and cough, treatment focuses on addressing the underlying cause and removing the
excess fluid potentially through thoracentesis or chest tube drainage.

BIBLIOGRAPHY
 Brunner' and Suddarth, textbook of medical surgical nursing, volume pg. no. 324-356.
 B. Venkatesan, textbook of medical surgical nursing, volume 1, Emmess Medical
Publisher page no:291-299.
 Javed Ansari, textbook of medical surgical nursing, page no. 300-353.
 Gerard J. Tortora, textbook of anatomy and physiology, edition 2014 pg. no.466-567.