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A CASE STUDY OF
Empyema Thoracis, Left secondary to
BPN severe Community Acquired Pneumonia
s/p Chest Thoracostomy Tube
IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS IN
RLE/NCM 103
Presented to
Mr. Sajid S. Uy, RN
1
Presented by
May, 2009
INTRODUCTION
2
in the Philippines, thus, it remains an important cause of
morbidity and mortality in the country.
There are many kinds of pneumonia that range in
seriousness from mild to life-threatening. In infectious
pneumonia, bacteria, viruses, fungi or other organisms
attack the lungs, leading to inflammation that makes it hard
for an individual to breathe. Pneumonia can affect one or
both lungs. In young and healthy individual, early treatment
with antibiotics can cure bacterial pneumonia. The drugs
used to fight pneumonia are determined by the germ
causing pneumonia and the doctors findings.. It is best to
do everything we can to prevent pneumonia, but if one get
sick, recognizing and treating the disease early offers the
best chance for a full recovery.
3
pneumonia is necessary to prevent its spread to others and
make them as another victim of this illness.
Bronchopneumonia is an illness of the lungs which is
caused by different organism like bacteria, viruses, and
fungi and characterized by acute inflammation of the walls
of the bronchioles. It is also known as pneumonia. It is
common in women and causes 6% in mortality rate.
Streptococcus pneumoniae (pneumococcus) and
Mycoplasma pneumoniae both are the common bacterium
which causes bronchopneumonia in the adults and children.
4
Suddarth’s Medical-Surgical Textbook, pp
628/pneumonia).
In Philippines, the case of pneumonia is one of leading
cause of mortality and morbidity among Filipinos, 75-85%
of the population acquired the disease and the one affected
the disease are those who are in low income status and the
below poverty line individual. (www.DOH.org/pneumonia)
Our patient Baby C, was 1 year old, living at
Gravahan, Matina Proper, Davao City, was admitted at
Davao Medical Center last March 28, 2009, at 6:37pm,
with chief complain of difficulty of breathing.
According to her mother, she noticed that her baby is
having substernal retraction with rapid shallow breathing
while asleep.
The family immediately took the baby to Davao
Medical Center, and was diagnosed with BPN severe,
Community Acquired Pneumonia.
Weeks after, the doctors suggested for placement of
chest thoracostomy tube, due to the accumulation of pus in
the pleural space.
5
IDENTIFICATION OF THE CASE
A.PERSONAL PROFILE
Name : Baby C
Address : Gravahan, Matina Proper, Davao
City
Age : 1 year
Gender : Female
Civil status : Single
Occupation : none
Admitting Doctor : Dr. Veralou L. Sojor
Admitting Diagnosis : Empyema Thoracis,
Left secondary to
BPN severe Community Acquired
Pneumonia s/p Chest
Thoracostomy Tube
6
Chief Complaint : Difficulty of breathing,
Dyspnea
Date of admission : March 28, 2009; 6:37pm
B.Background/History
DM HPN CA ASTHMA
Maternal - - - -
Paternal - - - -
C. Medical History
7
episodic fever and cough due to environmental factor.
Baby C. was hospitalized due to persistent cough with
yellowish mucus secretion. Baby C had completed the
immunization process done in there Barangay Health
Center.
E. Socio-economic background
The family of baby C was very supportive, they
have provided all her medication. Specially her
medicine and payments for other diagnostic
procedures to be done for her early and faster recovery
8
DEFINITION OF TERMS
9
collection in the pleural space. (Brunner and Suddart’s
Medical-Surgical Textbook, Chpt 23,pp 625)
10
Substernal Retraction – indrawing beneath the
breastbone, commonly manifested to infant and neonate
with respiratory distress(Fundamentals of Nursing, Seventh
Edition, Vital Signs unit VII, pp 507)
11
ANATOMY AND PHYSIOLOGY
12
13
A respiratory system functions to allow gas
exchange. The gases that are exchanged, the anatomy or
structure of the exchange system and the precise
physiological uses of the exchanged gases vary depending
on the organism.
In humans and other mammals, for example, the
anatomical features of the respiratory system include
airways, lungs, and the respiratory muscles. Molecules of
oxygen and carbon dioxide are passively exchanged, by
diffusion, between the gaseous external environment and
the blood. This exchange process occurs in the alveolar
region of the lungs.
14
The respiratory system can be conveniently
subdivided into an upper respiratory tract (or conducting
zone) and lower respiratory tract (respiratory zone), trachea
and lungs.
The conducting zone starts with the nares (nostrils) of
the nose, which open into the nasopharynx (nasal cavity).
The primary functions of the nasal passages are to: 1) filter,
15
2) warm, 3) moisten, and 4) provide resonance in speech.
The nasopharnyx opens into the oropharynx (behind the
oral cavity).
The oropharynx leads to the laryngopharynx, and
empties into the larynx (voicebox), which contains the
vocal cords, passing through the glottis, connecting to the
trachea (wind pipe).
The trachea leads down to the thoracic cavity (chest)
where it divides into the right and left "main stem" bronchi.
The subdivision of the bronchus are: primary, secondary,
and tertiary divisions (first, second and third levels). In all,
they divide 16 more times into even smaller bronchioles.
The bronchioles lead to the respiratory zone of the
lungs which consists of respiratory bronchioles, alveolar
ducts and the alveoli, the multi-lobulated sacs in which
most of the gas exchange occurs.Ventilation of the lungs is
carried out by the muscles of respiration.
Ventilation occurs under the control of the autonomic
nervous system from the part of the brain stem, the medulla
oblongata and the pons. This area of the brain forms the
respiration regulatory center, a series of interconnected
16
neurons within the lower and middle brain stem which
coordinate respiratory movements.
The sections are the pneumotaxic center, the apneustic
center, and the dorsal and ventral respiratory groups. This
section is especially sensitive during infancy, and the
neurons can be destroyed if the infant is dropped or shaken
violently. The result can be death due to "shaken baby
syndrome.”
Inhalation is initiated by the diaphragm and supported
by the external intercostal muscles. Normal resting
respirations are 10 to 18 breaths per minute. Its time period
is 2 seconds. During vigorous inhalation (at rates exceeding
35 breaths per minute), or in approaching respiratory
failure, accessory muscles of respiration are recruited for
support. These consist of sternocleidomastoid, platysma,
and the strap muscles of the neck.
Inhalation is driven primarily by the diaphragm. When
the diaphragm contracts, the ribcage expands and the
contents of the abdomen are moved downward. This results
in a larger thoracic volume, which in turn causes a decrease
in intrathoracic pressure. As the pressure in the chest falls,
17
air moves into the conducting zone. Here, the air is filtered,
warmed, and humidified as it flows to the lungs.
During forced inhalation, as when taking a deep
breath, the external intercostal muscles and accessory
muscles further expand the thoracic cavity.
Exhalation is generally a passive process, however active
or forced exhalation is achieved by the abdominal and the
internal intercostal muscles.
The lungs have a natural elasticity; as they recoil from the
stretch of inhalation, air flows back out until the pressures
in the chest and the atmosphere reach equilibrium.
During forced exhalation, as when blowing out a
candle, expiratory muscles including the abdominal
muscles and internal intercostal muscles, generate
abdominal and thoracic pressure, which forces air out of the
lungs.
The right side of the heart pumps blood from the right
ventricle through the pulmonary semilunar valve into the
pulmonary trunk. The trunk branches into right and left
pulmonary arteries to the pulmonary blood vessels. The
vessels generally accompany the airways and also undergo
18
numerous branchings. Once the gas exchange process is
complete in the pulmonary capillaries, blood is returned to
the left side of the heart through four pulmonary veins, two
from each side.
19
occur: 1) respiratory acidosis, a life threatening condition,
and 2) respiratory alkalosis.
Upon inhalation, gas exchange occurs at the alveoli,
the tiny sacs which are the basic functional component of
the lungs. The alveolar walls are extremely thin (approx.
0.2 micrometres), and are permeable to gases. The alveoli
are lined with pulmonary capillaries, the walls of which are
also thin enough to permit gas exchange. All gases diffuse
from the alveolar air to the blood in the pulmonary
capillaries, as carbon dioxide diffuses in the opposite
direction, from capillary blood to alveolar air. At this point,
the pulmonary blood is oxygen-rich, and the lungs are
holding carbon dioxide. Exhalation follows, thereby ridding
the body of the carbon dioxide and completing the cycle of
respiration.
In an average resting adult, the lungs take up about
250ml of oxygen every minute while excreting about
200ml of carbon dioxide. During an average breath, an
adult will exchange from 500 ml to 700 ml of air. This
average breath capacity is called tidal volume.
20
The respiratory system lies dormant in the human
fetus during pregnancy. At birth, the respiratory system is
drained of fluid and cleaned to assure proper functioning of
the system. If an infant is born before forty weeks
gestational age, the newborn may experience respiratory
failure due to the under-developed lungs.
This is due to the incomplete development of the
alveoli type II cells in the lungs. The infant lungs do not
function due to the collapse of the alveoli caused by surface
tension of water remaining in the lungs. Surfactant is
lacking from the lungs, leading to the condition. This
condition may be avoided if the mother is given a series of
steroid shots in the final week prior to delivery. The
steriods accelerate the development of the type II cells.
21
A transverse section of the thorax, showing the contents of
the middle and the posterior mediastinum. The pleural and
pericardial cavities are exaggerated since normally there is
22
no space between parietal and visceral pleura and between
pericardium and heart
23
pleurae are coated with lubricating pleural fluid which
allows the pleurae to slide effortlessly against each other
during ventilation. Surface tension of the pleural fluid also
leads to close apposition of the lung surfaces with the chest
wall. This physical relationship allows for optimal inflation
of the alveoli during respiration. Movements of the chest
wall, particularly during heavy breathing, are coupled to
movements of the lungs since the closely opposed chest
wall transmits pressures to the visceral pleural surface and,
hence, to the lung itself.
24
ETIOLOGY AND SYMPTOMATOLOGY
Etiology
25
conscious of the
environment.
The patient common
food intake are rice,
Diet hotdogs, eggs, chocolates,
(+) candies, sometimes fruits
( banana ), combination of
breast and formula milk.
Such as exposure to
certain viruses and foods
early in life, may trigger the
autoimmune response.
Mycoplasma Our patient is living in
pneumonae a poor environment,
and (+) because they’ve live in a
environmental dusty place where near the
factors highway, where many
vehicle passed by.
Vehicular smoke and dust
particles can be the carrier
of the bacteria, viruses.
26
Symptomatology
27
lining of the
airway
Presence of
foreign
pathogens, and
fluid accumulation
Bradypnea (+) in the airway
lining may cause
slow breathing
pattern, depth and
rhythm
Accumulation on
the lining of
airway, presence
Shortness of
(+) of mucus secretion
breath
and pathogenic
bacteria invades in
the body
Due to
compensatory
mechanism such
Loss of appetite as low immune
(+) response, any
(poor feeding) infection due to a
disease will result
to the loss of
appetite
28
COMPLICATION
Empyema
is inflammatory fluid and debris in the pleural space.
It results from an untreated pleural-space infection that
progress from free-flowing pleural fluid to a complex
collection in the pleural space.
Empyema most commonly occurs in the setting of
bacterial pneumonia. About 20-60% of all cases of
pneumonia are associated with parapneumonic effusion.
With appropriate antibiotic therapy, parapneumonic
effusions most often resolve without complications, and
they are of little clinical significance. The resulting
infection and inflammatory response can proceed until
adhesive bands form. The infected fluid becomes loculated
pus in the pleural space.
29
Pleurisy
Lung abscess
30
Pericarditis
31
PATHOPHYSIOLOGY
32
Predisposing factors Precipitating factors
Age (very young) Daily Activities
Gender Environment
Exposure (living) Diet
Chest Thoracostomy
Tube
33
Etiologic agents gain entry into the respiratory tract
through either inhalation or aspiration of secretions. The
pathogen creates a localized inflammatory reaction on the
airway mucosa that results in swelling and increased mucus
production. Significant inflammation and obstruction may
result in wheezing.
As entering the pathogen in the body compensatory
mechanism: body line of defense such as cilia, whipping
motion that propels mucus and foreign substances away
from the lungs toward the lungs, for expectoration. As
more pathological microorganism into the respiratory tract,
cilia may injure in some way, the escalator or the whipping
mechanism may have less effective.
The bacteria or viruses as progressively entering into
the lungs, it may reach to alveolar cell, type II cells lose
their structural integrity and surfactant production is
diminished, a hyaline membrane forms, and pulmonary
edema develops.
Accumulation of mononuclear cells in the submucosa
and perivascular space, resulting in partial obstruction of
34
the airway. They clinically manifest as wheezing and
crackles.
Hematogenous spread of bacteria from an extra-
pulmonary infection site—bacteria from another infected
site can be carried in the blood to the lungs
Resulting from these infections causes the lungs to
become stiff and less distensible, thereby decreasing tidal
volume. The patient must increase his respiratory rate to
maintain adequate ventialtion
MEDICAL MANAGEMENT
03/28/09
35
Admit patient at IMCU transferred to SVIX
under blue level II
o v/s q 4hr, BF with SAP
o CBC, Pt. U/A
o CXR
IVF D5IMB at 20cc/hr
Meds:
o Chloramphenicol at IVTT q8hr
o Paracetamol, PRN
o Salbutamol Nebuli
03/29/09
Ff up CBC
Ff U/A
Ff up CXR
03/30/09
For ABG, CBC, PC and U/A
Continue IVF at same rate
Continue Meds
o Start chloramphenicol
o Cefuraxime 335mg IVTT q8hrs
o Amikaxin 75mg IVTT, OD
o Decrease Salbutamol Neb, q4
03/31/09
Still for Na+, K+, Ca+, Mg+
Still for LP
Review CXR-APL
36
Continue IVF at same rate as ordered
Continue Meds:
o Cefutaxime
o Amikacin
o Paracetamol
04/01/09
V/S q4 with O2 Sat
Still for NPO
LP done, place pt on bed flat x4hrs
04/02/09
Rpt CXR-APL today
Ff up CSF analysis, GS/CS
Ff up sugar and protein
Continue Meds:
o Cefutaxime
o Amikacin
o Paracetamol
o Cloxacilline
04/17-24/09
D5IMB at 45cc/hr
Meds:
o Cloxacilline (D12)
o Pencillin Mg (D9)
o V/S q4hr
04/18/09
Cloxalline (D12-13)
37
Pencillin Mg (D10)
04/19/09
Cloxalline (D13- 04/25/09
14) Cloxalline (D14)
Pencillin Mg Pencillin Mg
(D10) (D12)
04/20/09 Rpt CXR –APL
Cloxalline (D14) Insert CTT
Pencillin Mg
(D11) 04/26/09
04/22/09 Retained CTT
Cloxalline (D15) Drained every
Pencillin Mg shift
(D12) 04/27/09
04/23-24/09 D5IMB at
Cloxalline (D13) 45cc/hr
Pencillin Mg Meds:
(D11) o Pencillin
Mg (D13)
o Cloxacilline
(D15)
38
Laboratory
Hematology
Norma
Clinical
Test Result l Remarks
Significance
Values
CBC+Plt Hemoglobin F: Obstructive
– 1.86- Pulmonary dse,
H 3.5 2.48 Failure of -increased-
mmol/ oxygenation
L
Hematocrit – F: dehydrated
.50 0.37- -increased-
0.47
RBC – H F: 4.2- Pulmonary
-increased-
6.59 5.4 disease
WBC – H 5.0- Overwhelming -decreased-
4.52 10.0 viral infection
Neutrophil – 55-75 Viral infection -decreased-
L 48
Lymphocytes 20- - normal
–26 40% range-
Monocytes – 2-10 -normal
4 range-
Eosinophil – 1-8 -normal
4 range-
Basophil – 0 0-1 -normal
range-
Platelet -normal
39
count –
200,000/cu range-
mm
Laboratory
Chemistry
40
Laboratory
ABG
Clinical
Normal
Test Result significanc Remarks
Values
e
-normal
pH 7.42 7.35-7.45
range-
-normal
pCO2 41.6 35-45
range-
Depressed
HCO3 27.6 22.0-27.0 -increased-
respiration
-normal
O2 Sat 98.2% 80-100%
range-
-normal
Cf CO2 28.6 23.0-30.0
range-
Chronic
obstructive
PO2 74.0 80-100 -decreased-
lung
disease
41
MEDICAL MANAGEMENT
Ideal Management
42
• Antibiotics are prescribed based in Gram stain
results and antibiotic guidelines (resistance patterns,
risk factors, etiology must be considered).
Combination therapy may also be used.
• Supportive treatment includes hydration,
antipyretics, antihistamines, or nasal decongestants.
• Bed rest is recommended until infection shows
signs of clearing
• Oxygen therapy is given for hypoxemia
• Respiratory support includes endotracheal
intubation, high inspiratory oxygen concentrations,
and mechanical ventilation
• Treatment of atelectasis, pleural effusion, shock,
respiratory failure, or superinfection is instituted, if
needed
• For groups at high risk for community-acquired
pneumonia, pneumococcal vaccination is advised
• Increased fluid intake to thin viscous and tenacious
secretions
43
44
45
46
47
48
NURSING ASSESSMENT
Physical Assessment
Neurological
Eye/Vision
Ears/Hearing
Nose
49
Mouth/Tongue/Teeth/ Speech
Throat/Neck
Respiratory System
Circulatory/Cardiovascular
50
Patient has an O2 Sat of 98%, heart rate of 90bpm,
and and blood pressure reading of 80/50, pulse rate was
130bpm with skipping beats. No edema, swelling, good
capillary refill less than 3secs.
Gastrointestinal
Genitourinary
Muscoloskeletal
Integumentary
51
NURSING MANAGEMENT
52
• Changes in chest x-ray findings
• Assess the characteristic of drained pus from the lungs
of the patient.
• Assess for complication, including continuing or
recurring fever, failure to resolve, atelectasis, pleural
effusion, cardiac complication, and superinfection
• Encourage bronchial hygiene, such as increased fluid
intake and directed coughing to remove secretions.
• Put patient into moderate high back rest for lung
expansion and clearing, and to cough effectively and
prevent retention of mucopurulent sputum,
NURSING THEORIES
Florence Nightingale
53
Her Notes on Nursing emphasized that a clean
environment, warmth, ventilation, sunlight, and a quiet
environment lead to good health.
Virginia Henderson
Hildegard Peplau
problems
• Teaching Role - offering information and helping the
patient learn
54
Reaction: As a nursing student, we had many roles to
perform to our patient.
One of these roles is being a councilor. As a councilor, it is
our duty to lessen if not alleviate the client’s problem.
55
56
57
58
59
60
61
62
HEALTH TEACHINGS
PRIMARY
1. Instruct the SO to have patient an oxygen therapy for
continuous normal breathing, and or breathing exercise
63
SECONDARY
TERTIARY
DISCHARGE PLAN
64
breathing exercise for lung expansion and clearing for
progressive normal breathing pattern and have adequate
rest periods. It is also important to maintain proper hygiene
to prevent further infection.
The client must relax in order to recover her present
condition and instructed significant others for minimal
exposure, to an open environment such as dusty and smoky
area, which airborne microorganisms are present that can
be a high risk factor that may cause severity of her
condition. The diet of the patient is also a factor for fast
recovery. Encouraged to eat nutritious foods intended for
respiratory problem patient, the family of the patient plays
a big role for the fast recovery.
Regular consultation to the physician can be factor for
recovery to assess and monitor her condition
65
H- separate utensils for the patient and other personal
things that will be use for the whole family
PROGNOSIS
66
to sustain the needed
Medication laboratory exams and the
feasibility of having the
condition
Family The family members
Support supported the patient
-
both financially and
emotionally.
Environmen The hospital setting is
t not well ventilated and
- may promote for further
infection of the patient’s
current situation.
Age Patient is 1 year old
therefore she has a good
chance of recovering for
-
her immune system is
still generating in the
process of development.
Precipitating The patient manifested
Factors all the factors that may
lead to
Bronchopneumonia sev,
-
CAP which urged the
family and the health
provider to set-up the
proper action
Percentage
67
Good: 4/7x100=42.85/43%
Poor: 3/7x100= 57.14/57%
Overall Prognosis
The prognosis is good, because the duration of illness,
compliance of medication, family support and age are the
contributing factors that result to have a good prognosis
EVALUATION
research.
68
The patient’s condition is in recovery period as she
moral support.
69
IMPLICATION
Nursing Practice
Nursing Education
70
which will be a very useful guide when they
will be making their own Nursing Care Plans.
Nursing Research
REFERENCES
71
• Medical-Surgical, Brunner and Suddart 11th Ed,
pp 628-631
pp665-668
• www.americanthoracicsociety.com/ thoracostomy
• http://www.springerpub.com/prod.aspx?
prod_id=72628
• wikipedia.org/wiki/Pneumonia
• wikipedia.org/wiki/Pleural cavity
72
• www.medicinenet.com/Bronchopneumonia/article.ht
• www.who.int/topics/bronchopneumonia
• www.DOH.org/bronchopneumonia_prevalence
• www.vetmed.wsu.edu/ClientEd/diabetes
73