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