global city innovative college- pneumothorax
TRANSCRIPT
GLOBAL CITY INNOVATIVE COLLEGEAssociate in Health Science Education
Fort Bonifacio, Taguig City, Metro Manila
College of Nursing and Allied International Health Studies
A Study ofPneumohemothorax of a 22 year old male
In Partial Fulfillment of the RequirementsIn Related Learning Experience 103
Presented to:College of Nursing Faculty
Global City Innovative College
Presented by:
The Class of N-313
1St Semester SY 2010-2011
INTRODUCTION:
When we breath, you think it’s as simple as 1,2,3 and it is when you do it but when
there’s an illness involved it gets more complicated than that and then people realize that
there’s so much more than the process and its not 1,2,3 anymore its like some algebraic
expression that needs more understanding.
So what if air enters the pleural cavity what happens? Is that a good thing? When you
say air enters your body you think it’s a normal circumstance but then why do doctors fear this
instance so much? This situation is called Pneumothorax, this is a collection of air or gas in the
pleural cavity of the chest, and this is between the lung and the chest wall. These kinds of
things may occur spontaneously but usually these things happen because of trauma or it comes
as a secondary disease.
A pneumothorax is a collection of free air in the chest outside the lung that causes the
lung to collapse. Spontaneous pneumothorax is caused by a rupture of a cyst or a small sac
(bleb) on the surface of the lung. Pneumothorax may also occur following an injury to the chest
wall such as a fractured rib, any penetrating injury (gun shot or stabbing), surgical invasion of
the chest, or may be deliberately induced in order to collapse the lung. A pneumothorax can
also develop as a result of underlying lung diseases, including cystic fibrosis,chronic obstructive
pulmonary disease (COPD), lung cancer, asthma, and infections of the lungs. The symptoms of
pneumothorax are determined by the size of the air leak and the speed by which it occurs, they
may include chest pain and shortness of breath. Although there are cases that small
spontaneous pneumothoraces do not require treatment, it’s always best that you go for the
better path and have a check up once in a while.
The following statistics relate to the incidence of Pneumothorax:
1.011 per 1,000 hospitalised at risk patients developed pneumothorax in the Philippines
in 2006-2008
18% of the 1.011 patients die from pneumothorax
Objectives
1. To gain more knowledge and to further understand the nature and extent of the disease
so as to prepare and arm ourselves with knowledge whenever we encounter the same
case in the future.
2. To have a clear and better understanding of pneumothorax particularly on its disease
process, treatment, diagnostic exam, preventive measures and nursing management.
1. To know the latest facts and keep ourselves updated with the newest information about
pneumothorax.
2. To be familiar with the disease that may help us in doing health teachings with our
patient.
3. To make the student nurses aware of the manifestations and complications brought by
pneumothorax
4. To present the anatomy and physiology of pneumothorax related with our patient’s
condition
5. To discuss the medical and surgical interventions related to our patient.
Nursing History
History of Present Illness:
One hour prior to admission, the patient was walking on a sidewalk when an unknown
person stabbed him on his right chest. He was then rushed to the Cardinal Santos Medical
Center by the bystanders. The patient was experiencing ipsilateral pain with a pain scale of
10/10 and blood loss.
Past Medical History
The patient reported that he has a history of convulsion when he was a child he also had
a fracture on his right clavicle due to a fall accident and was hospitalized on De Ocampo, he was
treated and given medications for pain. He completed his vaccination such as BCG, OPV, DPT,
Measles and Hepa B when he was a child.
Family History
The patient has 3 siblings, who are in good condition, same as his mother and father. His
mother had breast cancer and undergone mastectomy of the right breast. His mother side has a
history of hypertension while his father side has a history of Lung cancer.
Legend:
- Father’s side: Lung cancer
- Mother’s side: Hypertension; Breast Cancer
- Patient: Pneumothorax
- Siblings
“Nursing Health History”
Pattern of health Prior to hospitalization During hospitalization Interpretation1. Health Perception & Health management pattern
-The patient does not experience any diseases before and he used to be athletic. He does not smoke and he is an occasional drinker. He does not use drugs & used to have regular check-ups.
-He cannot do some athletic activities and feels ill to be in the hospital.
-He can’t adjust well because he can’t do what he wants, but his condition is improving.
2. Nutritional and Metabolic pattern
-The patient is given a diet as tolerated. The client eats with no difficulty. He eats almost everything and eats 3 times a day. A 1 cup of rice in the morning with different kinds of meat or vegetables, same in the lunch time and dinner time. He takes vitamins and drinks plenty of water at least 2000 cc
-He takes multivitamins(Centrum Complete) 500mg/day, drinks 8 glasses of water, and eats mixed meat and vegetables at least three times a day
-Nothing changed.
per day. He has a big appetite and can’t easily recover from illnesses.
3. Elimination Pattern -He urinates 5-6 times a day. He described the urine as somewhat yellowish in color. The amount is around 250 cc per urination. The patient defecates with brown formed stools. The color is brown and as said by the mother. The patient stated that there is no problem in elimination.
-He eliminates every day, feces are slightly wet and soft and in brownish in color. He also urinates lesser than before.
-His feces changed from the normal to slightly wet and lesser than before may be because of hospitalization.
4. Activity-Exercise Pattern
- He has enough energy to do his tasks. He is very active. He used to jog every morning and do swimming activities. He does not easily get tired and he has lots of energy reserve. The mother of the patient stated that he is a very active person who easily gets bored when he just sits down.
- He can’t exercise that much and his exercise is just by merely walking around the area.
- He can’t do normal tasks because he is in the hospital
5. Sleep-Rest Pattern -He used to sleep 8 hours a day and used to have a nap every afternoon. He watches movies, do swimming and eat snacks when he feels tired. The patient stated that he doesn’t have any problems in falling asleep.
-He can’t sleep well and can’t do much activities. He just do social networking when he feels stress and tired
-He can’t sleep well because of the setting and being disturbed by the nurses.
6. Cognitive-Perceptual Pattern
-The patient doesn’t have any problem on eye vision, hearing acuity and in memory.
-The patient feels pain in his right lung & side of the stitches
-due to his operation done
He doesn’t feel any pain7. Self-Perception and Self-Concept Pattern
-The patient used to be calm and do daily tasks
-He become less patient and do facebook
-He feels bored because he already stayed in the hospital for a month already
8. Role-Relationship Pattern
-He lives with his brother with no problems. His family is used to be healthy and close to people. The mother added that the most common problem they have revolves around management of finances. Whenever they are short of money, the mother of the client mentioned that she borrows money from her friends or relatives.
-With his mom in the hospital and his friends visits him
-His happy because his friends visits him
9. Sexuality-Reproductive Pattern
-he is a bisexual and does not have any commitment.
-The patient is single and bisexual
Nothing is changed
10. Coping-Stress Tolerance Pattern
-He don’t feel nervous & just calm and used to hang out with his family and friends
-Can’t meet his friends and feel bored in hospital
-He can’t go where he wants because of hospitalization
11. Value-Belief Pattern
-He achieve his dreams and goals in life. He loves his religion so much.
-He can’t do what he wants. Don’t believe in superstitions
-He does not believe in superstitions
Physical Assessment:
Name of Patient: Patient JS
Unit/Ward: San Lorenzo Ruiz Ward/1H
Age: 22 y/o Sex: male Civil status: Single
Diagnosis: Pneumohemothorax in the right lung.
Physical Exam
Date: Sept. 9, 2010
Temp: 37.1oC per tympanic membrane
PR: 83bpm (regular, bounding)
RR: 27cpm (diaphragmatic, regular, deep and moderately labored breathing)
BP: 90/60 mmHg, lying
Height: 168cm
Weight: 48 kg BMI: 17.02 (Underweight)
Date of Admission: August 18, 2010 11:07pm
General Survey: Patient is conscious, coherent, oriented to time, place and person with mild
cardio-respiratory distress, endomorph, and calm. With oxygen support of 2L per minute via
nasal cannula and IVF of PNSS 1L x 16o at the right metacarpal.
Assessment Normal Findings Actual Findings Analysis/ interpretation
SKIN
Inspection, palpation
Color: depends on race, can be whitish pink, brown shade to black.
No cyanosis,
PaleRoughFair skin turgorWarm to touchDry skinNo lesions, masses
Pallor may be an indication of possible premature destruction of erythrocytes which results in the liberation of hemoglobin from the erythrocytes into the
erythema, jaundice, pallor, petechiae, rashes
Texture: smooth, soft, no lesions, ulcerations, scar, papule, mapule
Turgor: good skin turgor
Moisture: moistTemperature: warm to touch
plasma; which then causes the paleness on the skin.
Dry and rough skin is due to loss or deficiency of water in the body tissues. The condition results from inadequate fluid intake and/or from excessive removal of water in the body.
(Textbook on medical surgical nursing, 12th edition, p.910.)
NAILS Inspection, palpation
Color: PinkishShape: convex, curvature
Texture: smoothCapillary refill of 2-3 seconds
SmoothCapillary refill of < 3 seconds.Color: pale
Destruction of premature erythrocytes causes the paleness on skin.
(Textbook on medical surgical nursing, 12th edition, p.910.)
HAIR
InspectionColor: depends on race, can be black, brown, burgundyEvenly distributed, no signs of alopeciaTexture: thick or thin, coarse or smoothMoisture: neither brittle nor dryScalp: Clean no lesions nor masses
Coarse and cleanBlack hairEvenly distributedCoarseClean scalpNo lesions, masses
The patient is still maintaining his hygiene during his stay in the hospital that is why, abnormalities, are not detected in his hair.
Normocephalic, Normocephalic The patient’s condition
HEAD Inspection, Palpation
round, No palpable mass, nodules, depressionNo pain upon palpationFace is symmetrical
Symmetrical facial featuresSymmetrical facial movementsNo palpable mass
has nothing to do with his head physically, so abnormalities were not detected upon assessment.
EYES
Inspection
SymmetricalEyebrows: symmetrical, black, evenly distributedEye lashes: black, slightly curve upwardEyelids: covers small part of the eye when open, covers the whole eye when closeNo ptosisConjunctiva: pinkish and moistCornea: transparent and smoothSclera: white, no discoloration, no pigmentation, no foreign objectsIris: brownish, no visible foreign objectsPupil: equally round, reactive to light and accommodation (PERRLA)Clear visual acuityOcular movement: eye moves freely
Lids: symmetricalConjunctiva: paleSclera: anictericPupil size: 4mm; equally reactive to light and accommodation Gross vision normal
Paleness on palpebral conjunctiva may indicate the decreased hemoglobin level on the blood.
(Textbook on medical surgical nursing, 12th edition, p.910.)
EARSInspection,
Bean shaped, parallel, symmetricalSame color with the complexion
External pinnae: normosetExternal canal has no unusual
Pneumothorax is air in the pleural cavity; so therefore, it has no effect on the
Auricles has firm cartilageNo redness of earlobesNo lesionsNo tenderness upon palpation of auricles and mastoid processNo discharges and lesions on ear canalWith presence of cerumenTympanic membrane: pearly gray, flat, and translucentHearing acuity: able to hear clearly
dischargesTympanic membrane is intact and pink in colorGross hearing normal and symmetrical
patient’s ears because pleural cavity was located in the space between the visceral and parietal pleura in the lungs.
NOSE AND SINUSES Inspection,
palpation
Nose is in the midline and is symmetricalNo unusual dischargesNo nasal flaringBoth nares are patentNo bones and cartilage deviationNo tenderness upon palpationNasal septum is in the midlineNasal mucosa is pinkNo tenderness and swelling of paranasal sinuses
Septum is in midlineMucosa is pinkishBoth nares are patentGross smell are symmetrical, patentNo tenderness noted on frontal and maxillary sinusesNo unusual discharges
Inspection
Lips: symmetrical, pinkish, no edema, moistGums: pinkish, no gum bleeding, no receding gums, and
Lips are pale and mucosaTongue is in midline Has complete set of teeth (32)
Pallor on his lips and mucosa may indicate the presence of anemia; a condition in which the hemoglobin
MOUTH
no swellingTeeth: number of teeth must be 32, white to slight yellowish in color, no dental carriesBuccal mucosa: hard and soft palate are pinkish and moistTongue: must be on the midline, pinkish, no lesions, and must move freelyUvula: is in the midline, pinkish to red in color, no swelling, no lesionsTonsils: pinkish in color, no swellingMandible: moves smoothly, no pain and tenderness upon palpation
Speech is intactUvula is in the midlineTonsils not inflamedPink oral mucous membrane
concentration is lower than normal which results in decreased amount of oxygen delivered to body tissues.
(Textbook on medical surgical nursing, 12th edition, p.910.)
NECK
Inspection, palpation
In the midlineNo visible masses or lumpsNo tenderness upon palpationTrachea is in the midlineMoves freelyROM full range
Trachea is in midlineNo jugular vein engorgementThyroids non-palpableFull ROMCervical lymph nodes are not palpable and non-tender
THORAX AND LUNGS
Inspection, palpation,
auscultation, percussion
Same as skin colorSymmetricalSpine vertically alignedNo kyphosis, scoliosis, lordosisNo dyspnea, tachypnea, bradypnea
Breathing pattern is regular, deep, diaphragmatic and mildly labored.Lung expansion is symmetricalTactile fremitus is symmetricalPercussion:
No retractionNo adventitious breath sounds
resonant/ hyper resonantwith CTT located at 9th ICS Right anterior axillary line
HEART Auscultation No tachycardia and bradycardiaNo dysrhythmiaNo lift or heavesNo heart murmurs
Precordial area is flatHeart sounds are regular at 83 bpm(-) murmurs
BREAST Inspection, palpation
Same as skin colorNo edema, erythema, wrinkling, retraction or dimplingNo lesionNo mass and tenderness upon palpation
Pinkish to brownish in colorHas smooth surface
ABDOMEN
Inspection, auscultation, percussion, palpation
Same as skin colorNo lesionsFlat, soft and roundedNo pain and tenderness upon palpationAudible, soft gurgling sound (5-20 seconds)No bruit, friction frubs
Symmetrical, flat configurationNormoactive bowel sounds, 21 sounds per minute Tympanitic percussionMuscle guarding noted on the right upper quadrant of the abdomen.
Muscle guarding serves as the defense mechanism of the abdomen to alter the pressures being inserted upon palpation.
GENIO-URINARY SYSTEM
Genitalia: no itching, redness and lesionsRectum: no lesions, inflammation, hemorrhoids, and rectal prolapsedUrinary: no hematuria, nocturia,
Patient refused
urinary incontinence, and no difficulty in urinating.
EXTREMITIES Inspection, palpation
Color: whitish pink to brown shade to blackEqual on both sidesHair evenly distributedNo lesions, lump, masses, and no areas of tendernessROM full rangeNo crepitus
Peripheral pulses are symmetrical, strong, and regularMuscle tone are equal with muscle strengthSpine is in midlineGait: coordinated
Anatomy and Physiology
The respiratory system is situated in the thorax, and is responsible for gaseous exchange between the circulatory system and the outside world. Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue.
The lungs are divided into lobes; The left lung is composed of the upper lobe, the lower lobe and the lingula (a small remnant next to the apex of the heart), the right lung is composed of the upper, the middle and the lower lobes. One main-stem bronchus leads to the right lung and one to the left lung. In the lungs, the main-stem bronchi divides into smaller bronchi and then into even smaller tubes called bronchioles, bronchioles end in tiny air sacs called alveoli.
Mechanics of Breathing
To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways.
Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax).
Physiology of Gas Exchange
Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over.
Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.
Course in the Ward
Patient is 21 years old male, tall and lanky who came in due to sudden onset of right
sided chest pain. Consultation done and chest x-ray showed pneumothorax right
subsequent admission and chest tube thoracotomy done. Initial drain of 200 cc
1st day- tachycardia, pallor, hypotension and CTT output increased to 500 cc in 1 hour.
Repeat CBC showed Hgb 9 from baseline of 16.
Thoracotomy done with clipping of bleeders and plication of bullae and plural abrasion.
BP- 81/40,HR- 79 O2 saturation 100% intubated, sedated, arousable, follows commands,
no murmurs, good air entry, clear breath sounds.
Date/Time Interpretation September 9, 2010
2:00 PM
4:00 PM
Acute pain>patient on bed, conscious>with O2 at 2 liters per minute via nasal cannula>pain scale 4/10 as verbalized>due meds facilitated>encouraged to verbalized feelings>encourage deep breathing exercise>v/s taken and recorded>proper hand washing, including his relatives health teaching about infection
>with O2 support because of difficulty in breathing>hand washing to avoid infection
September 11, 20102:00 PM
4:00 PM
>CTT tube on the right bedside bottle at 300 cc with scanty blood dischargesSevere pain>pain scale 10/10>ketorolac 1 amp IV given as PRN meds>relaxation and DBE
>CTT tube due to pleural effusion > pain scale of 10/10 due to incision for CTT insertion>Ketorolac for acute pain
>pain scale 4/10>v/s taken and recorded>input and output done including CTT output.>needs attended>still with mild pain>chest x-ray done
September 16, 2010
2:00 PM
4:00 PM
>with O2 a 2 liters per min>with CTT right to bed side bottle>v/s taken and recorded> with fever (38.9c º)>given paracetamol >TSB done
>given paracetamol for fever at 38.9 P.O.>TSB done to alleviate fever
September 17, 2010
2:00 PM
4:00 PM
>still on O2 at 2 liters per min. >with CTT right to BSB>salbutamol neb: 1/2 neb + 2ml NSS given>Encourage deep breathing exercise
>v/s taken and recorded>intake and output done>CTT output done>due meds given
>Salbutamol for better breathing pattern>EDBE to expel plegm
Health Teaching
- Frequently assess the hole that has been inserted the tube that is affected to check if there is a sign of infection
- Advice patient to continue taking his prescribed medicines like:
Diclofenac Calcium Carbonate (Caltrate +) Multivitamins (Nutricap)
- Maintain a quiet, pleasant, environment to promote relaxation.
- Provide clean and comfortable environment
- Provide oral and written instructions about activity, diet recommendations, medications
and follow-up visits.
- Patient will be advised to go back in the hospital in a specific date to have a follow-up
check-up after discharge
- Consult doctor for any problems or complications encountered.
- Encourage patient to increase protein for tissue repair
- Encourage patient to ask for God’s guidance
References:
Retrieved on September 16, 2010 from : http://www.le.ac.uk/pa/teach/va/anatomy/case2/frmst2.html
http://erj.ersjournals.com/content/28/3/637.abstract http://answers.yahoo.com/question/index?qid=20080801131255AA0mcNo http://content.karger.com/produktedb/produkte.asp?
typ=pdf&file=MPP2006015005338 Smeltzer S, (2008). Textbook of Medical-Surgical Nursing 12th Edition. Lippincott
Williams and Wilkins: Philadelphia USA