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injury, or spontaneously.
Classification of Pneumothorax
Spontaneous
Cause is “Unknown”
(a bladder-like structure more than 5 mm in diameter with thin walls that may be full of
fluid)
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Tension
Site of Pleural rapture acts as one way valve, permitting air to enter on inspiration but
Traumatic
May lead to lung collapse resulting from either blunt form trauma to chest wall creating
of an open sucking chest wound cause either gun or knife wound, motor vehicle accident.
Kinds of Pneumothorax :
Open Pneumothorax
Cause of surgery on the chest or trauma to the chest wall. (e.g. stab wound)
Close Pneumothorax
Air escapes in pleural space from a puncture or tear in an internal respiratory structure
This condition over time results in a gradual accumulation of air to the degree that it
begins to put pressure on the Mediastinum, compressing the heart and decreasing
cardiac output due to the reduced amount of diastolic filling of the ventricles, leading
to circulatory problems.
Clinical Manifestation
Dry coughs
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Cyanosis (turning blue)
Pain felt in the chest, back and/or arms are the main symptoms.
In penetrating chest wounds, the sound of air flowing through the puncture hole may
In addition, shifting of the Mediastinum away from the site of the injury can obstruct
the superior and inferior vena cava resulting in reduced cardiac preload and decreased
cardiac output.
Spontaneous
Pleural pain
Tachypnea
Mild Dyspnea
P.E.
Tension
Severe hypoxemia
Dyspnea
Hypotension
Shock
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Bradycardia
Dyspnea
Tachycardia
Tachypnea
Pleural Pain
Cyanosis
Hypotension
Sucking Wound
41
To diagnose pneumothorax, it is necessary for the health care provider to:
Auscultation
Note the one part of the chest that doesn’t transmit the normal sounds of breathing.
Chest X-Ray
Will show the air pocket and the collapsed lung and show that the trachea is being pushed to one
Electrocardiogram (ECG)
Will be performed to record the electrical impulses that control the heart's activity.
Blood samples may be taken to check for the level of O2 and CO2 level
Treatment
A small pneumothorax may resolve on its own, but most require medical treatment. The
object of treatment is to remove air from the chest and allow the lung to re-expand. This is
done by inserting a needle and syringe (if the pneumothorax is small) or chest tube through
the chest wall. This allows the air to escape without allowing any air back in. The lung will
then re-expand itself within a few days. Surgery may be needed for repeat occurrences.
A chest tube is placed quickly or a large-bore needle is inserted into the pleural space to
An outward gush of air as the needle or chest tube is inserted confirms the presence of
tension pneumothorax
The chest tube is connected to water seal drainage and suction until the damage pleura is
healed.
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After the pneumothorax is evacuated and the pleural rupture is healed, the chest tube is
removed.
The insertion of chest tube permits removal of the air or bloody fluid and allows re-expansion
of the lungs and restoration of the normal negative pressure in the pleural space. Because air
rises, a chest tube inserted to remove air is usually placed anteriorly through the 2 nd ICS. A chest
tube inserted to remove fluids is placed posteriorly in the 8th and 9th ICS because fluid tends to
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3.2 Predisposing/ precipitating factors
Predisposing factors:
>Age especially infants
due to their immature or underdeveloped immune system
>Immunocompromised individuals
easily susceptible to such disease upon exposure to microorganisms
>Common colds
these conditions when unresolved could lead to Pneumonia
Precipitating factors:
>Aspiration of foods or fluids
provides a medium for growth of microorganisms.
>Exposure to air pollution and inhalation of noxious substances (Environment)
allergens in the environment can further aggravate the condition
>Exposure to pathologic microorganisms
due to the environment where the patient lives and due to immature immune system
>Smoking
Disease of the small airways related to smoking probably contributes to the condition
>Lung Disease
Trapping of gases and destruction of lung tissue could lead to secondary spontaneous
pneumothorax
>Injury/accidents
Penetrating/non penetrating injuries through accidents, injury,etc. through the chest could
lead to pneumothorax
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3.3. Signs and symptoms with rationale
Dyspnea or difficulty of breathing is the first manifestation, it may begin insidiously but
steadily progressive it. The bronchioles narrow during expiration, causing the air to be
trapped in the alveoli making it difficult for the person to exhale air containing high
levels of carbon dioxide and difficult to inhale additional air.
Nasal flaring, and use of accessory muscles of inspiration- due to interference in oxygen
and carbon dioxide exchange, that causes hypoxemia
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V. PATIENT AND HIS CARE
1.Medical Management
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DATE
ORDERED
MEDICAL CLIENT’S
DATE GENERAL INDICATION AND
MANAGEMENT RESPONSE TO THE
PERFORMED DESCRIPTION PURPOSE
TREATMENT TREATMENT
DATE
CHANGED D/C
> These chemicals helps to > given to patients who have > The patient experience
D5 0.3NaCl 500cc x 53- DO : 08-24-09 maintain or give sufficient low levels of pain on the venipuncture
54 ugtts/min DP: 08-24-09 level of sodium and sodium or chloride. site.
chloride which are needed > may also be used for the
for normal body function. dilution of other medicines
before injecting into the body.
>Oxygen therapy is used >To deliver low
to relieved patient from concentration of
hypoxemia. oxygen when only minimal
>Administration of oxygen support is required. > The patient did not
oxygen helps to improve >Used to increase manifest signs and
Oxygen inhalation at 2- DO : 08-24-09 gas exchange between concentration of inspired air symptoms of respiratory
3 LPM DP: 08-24-09 the alveoli and the blood in order to assist the patient distress.
to increase concentration to meet cellular demand.
of inspired air and to >To allow an uninterrupted
assist the patient to meet delivery of oxygen while the
metabolic demands. client ingests food or fluids.
>a NGT may be inserted > to deliver substances > The patient becomes
NGT DO: 08-24-09 to take samples of directly into the stomach, irritable.
DP: 08-24-09 stomach contents for remove substances from the
D/C : 08-27-09 laboratory studies and to stomach or as a means of
test for pressure or motor testing stomach function or
activity of the contents.
gastrointestinal tract.
Prior:
Obtain the necessary materials. Acquaint the SO with the requirements needed for
IV infusion.
During:
Check IV level.
After:
Monitor patient for evidence of local IV R/T complications, such as pain, swelling
& tenderness.
Check for the presence of air in tubing. If there is, remove it immediately.
Prior:
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Check physician’s order for irrigation. Explain procedure to patient.
Clamp suction tubing near connection site. Disconnect tube from suction
apparatus and lay on disposable pad or towel or hold both tubes upright in
nondominant hand.
Place tip of syringe in tube. If Salem sump or double-lumen tube is used, make
sure that syringe tip is placed in drainage port and not in air vent. Hold syringe
upright and gently insert the irrigant (or allow solution to flow in by gravity, if
If unable to irrigate tube, reposition patient and attempt irrigation again. Check
aspirate again.
gloves.
Measure and record amount and description of irrigant and returned solution.
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Perform hand hygiene.
During:
Gather equipment.
upright position and drape his or her chest with bath towel or disposable pad.
Check nares for patency by asking patient to occlude one nostril and breathe
normally through the other. Select nostril through which air passes more easily.
Measure distance to insert the tube by placing tip of tube at patient’s nostril and
extending to tip of earlobe and then to tip of xiphoid process. Mark tube with a
piece of tape.
Lubricate tip of tube (at least 1-2 inches) with water-soluble lubricant. Apply
topical analgesic to nostril and oropharynx or ask patient to hold ice chips in his
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After having the patient lift his or her head, insert tube into nostril while directing
tube downward and backward. Patient may gag when tube reaches the pharynx.
Instruct patient to touch his or her chin to chest. Encourage him or her to swallow
direction when patient swallows. Stop when patient breathes. Provide tissues for
tube with a tongue blade and flashlight. Keep advancing tube until tape marking is
Discontinue procedure and remove tube if there are signs of distress, such as
Determine that tube is in patient’s stomach. Hold tube in place to keep it from
contents.
Apply tincture of benzoin to tip of nose and allow to dry. Secure tube with tape to
patient’s nose. Be careful not to pull tube too tightly against nose.
o Cut a 4-inch piece of tape and split bottom 2 inches or use packaged nose
o Warp split ends under tubing and up and over onto nose.
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Attach tube to suction or clamp tube and cap it according to physician’s orders.
Secure tube to patient’s gown by using a rubber band or tape and a safety pin. If
double-lumen tube is used, secure vent above atomach level. Attach at shoulder
level.
Perform hand hygiene. Remove all equipment and make patient comfortable.
Record the insertion skill, type, and size of tube and measure tube from tip of
nose to end of tube. Also document description of gastric contents, which naris
After:
Gather equipment.
Place towel or disposable pad across patient’s chest. Give tissues to patient.
Discontinue suction and separate tube from suction. Unpin tube from patient’s
Attach syringe and flush with 10 mL normal saline solution or clean with 30 to 50
cc of air. (optional).
Clamp tube with fingers by doubling tube on itself. Quickly and carefully remove
monitor patient for 2 to 4 hours after tube removal for gastric distention, nausea,
or vomiting.
Prior:
Elevate the head of the bed to ease the work of breathing and to prevent fluid
Augment the patient’s ability to cough effectively by splinting the patient’s chest
manually.
Instruct the patient to inspire fully and cough two to three times in one breath.
Teach relaxation techniques to reduce anxiety associated with dyspnea. Allow the
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Ensure adequate protein intake such as milk, eggs, oral nutritional supplements;
and chicken, fowl, and fish if other treatments are not tolerated – to promote
Advise the patient to eat small amounts of high-calorie and high-protein foods
Suggest eating the major meal in the morning if rapid satiety is the problem.
Change the diet consistency to soft or liquid if patient has esophagitis from
radiation therapy.
Teach the patient to use prescribed medications as needed for pain without being
During:
After:
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58
iv. Drugs
CLIENT’S
ROUTE,
DATE RESPONSE TO
DOSAGE
NAME OF ORDERED CLASSIFICATION/MECHA THE
AND INDICATIONS
DRUGS DATE GIVEN NISM MEDICATION
FREQUENCY OF AND PURPOSES
DATE OF ACTION W/ ACTUAL
ADMINISTRATI
CHANGED SIDE EFFECTS
ON
Diazepam DO:08-24-09 1.7 mg stat dose An aminoglycoside that inhibits > Drug of choice for > The patient was
DG:08-24-09 protein synthesis by binding status epilepticus. relief to anxiety.
DC: 08-24-09 directly to the 30S ribosomal Management of
subunit, bactericidal. anxiety disorders, for
short-term relief of
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anxiety symptoms, to
allay anxiety and
tension prior to
surgery, cardioversion
and endoscopic
procedures, as an
amnesic, and
treatment for restless
legs. Also used to
alleviate acute
withdrawal symptoms
of alcoholism, voiding
problems in older
adults, and
adjunctively for relief
of skeletal muscle
spasm associated with
cerebral palsy,
paraplegia, athetosis,
stiff-man syndrome,
tetanus.
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>An aminoglycoside >To treat serious >The patient
that inhibits protein infections caused experienced pain as
Penicillin G DO:08-24-09 215 u every 6 synthesis by binding by pseudomonas evidenced by his
DG:08-24-09 hours directly to the 30S aeruginosa, crying and facial
ribosomal subunit, Escherichia coli, grimacing.
bactericidal. proteus,
klebsiella, or
staphylococcus.
>To treat active
tuberculosis, with
other
antituberculosis.
85 mg every 4 > Antipyretic. The drug > Relief of fever. > The patient’s
Paracetamol DO:08-24-09 hours PRN for may relieve fever temperature was
DG:08-24-09 fever through central action lowered to normal
in the hypothalamic rage.
heat-regulating center.
I.
> Histamine-2 blockers. > used to treat and > The patient’s heart
Ranitidine DO: 08-25-09 8.5 mg every 8 Ranitidine works by prevent ulcers in the rate gets fast.
reducing the amount of stomach and
DG:08-25-09 hours. acid your stomach intestines
produces.
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NURSING RESPONSIBILITIES
Cefotaxime
Prior:
Explain the action of the drug to the client.
Check doctor’s order for the time, dosage and route of the drug.
Perform skin testing before administration.
During:
Re-check doctor’s order.
Observe sterile technique.
Slowly push the medication to avoid irritation and pain.
After:
Educate SO about the possible side effects.
Document the action done.
Observe for signs and symptoms of adverse or allergic reactions.
Paracetamol
Prior:
Check doctor’s order.
Assess patient’s temperature.
During:
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Check doctor’s order; confirm the dosage, route and frequency of drug.
Observe sterile technique.
After:
Monitor patient’s temperature after 4 hours or as necessary.
Document the administration of the drug correctly.
Ranitidine
Prior:
Check the doctor’s order.
Check the vital signs especially the blood pressure
During:
Re-check the doctor’s order.
Observe sterile technique
After:
Document the administration of the drug correctly.
Observe client for adverse effects.
Salbutamol
Before:
Explain the purpose of the drug prescribed.
Assess patient’s breath sounds during respiration.
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During:
Check doctor’s order.
Observe proper sterile technique.
Put medication into the nebulization equipment.
Shake the nebulization equipment to properly distribute the medication evenly.
After:
Perform bronchial tapping.
Document the action done.
Observe client for adverse reactions.
Penicillin G
Prior:
Check the doctor’s order.
Test for hypersensitivity.
Check the vital signs.
During:
Re-check the doctor’s order.
Monitor vital signs.
After:
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Document the action done.
Observe client for adverse reactions.
Diazepam
Prior:
Check doctor’s order.
Monitor BP, PR, and RR throughout therapy.
Assess IV site frequently during administration, diazepam may cause phlebitis and venous thrombosis.
During:
Re-check doctor’s order
Monitor frequently BP, PR, and RR.
Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient.
Observe depressed patients closely for suicidal tendencies.
After:
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Observe and record intensity, duration and location of seizure activity. The initial dose of diazepam offers seizure control for
15-20 min after administration.
v.Diet
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NURSING RESPONSIBILITIES
Before:
Check the doctor’s order
Explain the diet to the patient and the SO.
During:
Provide ice chips or moist cotton to moisten lips of the patient.
Observe patient for vomiting.
After:
Lift the prescribed diet according to doctor’s order.
Give foods slowly.
Document as appropriately.
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VI. NURSING CARE PLAN and SOAPIER
First Nursing-Patient Interaction (August 27, 2009)
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NURSING SCIENTIFIC NURSING
CUES DIAGNOSIS EXPLANATIO OBJECTIVES INTERVENTION RATIONALE EVALUATION
N S
-establish rapport -to gain pt.’s
S- Ø Ineffective Normally, the After 4˚ of nsg. trust and Goal met AEB
Breathing lungs are free of Interventions, cooperation verbalization of
O- c an O2 pattern r/t secretions. But the mother will understanding of
inhalation via presence of air when there is be able to -monitor vital signs - to indicate if the mother about
NC regulated at in pleural cavity pneumonia, verbalize particularly there is an the said
2-3 lmp AEB bacteria tend to understanding respirations accumulation of intervention.
c a chest diminished invade the about the secretions
thoracostomy breath sounds respiratory tract interventions on
tube on the R and RR=96 resulting to an how to improve -auscultate breath - to ascertain
connected to a inflammatory breathing sounds status and note
bedside bottle, c process in the pattern of the pt. complications
a diminished lungs. This
breath sounds response then -position pt.’s head - to maintain
on the R chest, leads to filling of in an elevated adequate and
c dry lips, c the alveolar sacs manner open airway to
nasal flaring with exudates different lung
RR=96 which cause segments
consolidation.
Due to
consolidation, - provide - to prevent
the airway is opportunities for fatigue
being narrowed rest
resulting to an
ineffective -assist in -to clear airway
airway. nebulization
-demostrate -to mobilize
bronchial tapping secretions
after nebulization
-give - to maintain
bronchodilators airway 69
(salbutamol neb) as
ordered
Second Nursing-Patient Interaction (August 28, 2009)
70
NURSING SCIENTIFIC NURSING
CUES DIAGNOSIS EXPLANATIO OBJECTIVES INTERVENTION RATIONALE EVALUATION
N S
S- Ø Ineffective Normally, the After 4˚ of nsg. -establish rapport -to gain pt.’s Goal met AEB
Breathing lungs are free of Interventions, trust and verbalization of
O- c an O2 pattern r/t secretions. But the mother will cooperation understanding of
inhalation via presence of air when there is be able to the mother about
NC regulated at in pleural cavity pneumonia, verbalize -monitor vital signs - to indicate if the said
2-3l mp 2˚ bacteria tend to understanding particularly there is an intervention
,c a chest pneumothorax invade the about the respirations accumulation of
thoracostomy AEB RR=92, respiratory tract interventions on secretions
tube on the R diminished resulting to an how to improve
connected to a breath sound on inflammatory breathing -auscultate breath - to ascertain
bedside bottle, c R lung field and process in the pattern of the sounds status and note
an intact NGT nasal flaring. lungs. This complications
on the L nostril response then
c a diminished leads to filling of -position pt.’s head - to maintain
breath sounds the alveolar sacs in an elevated adequate and
on the L lung, with exudates manner open airway to
irritable c nasal which cause different lung
flaring, c dry consolidation. segments
lips Due to
RR=96 consolidation, - instruct pt.'s S.O. -to liquefy
the airway is to increase oral viscous
being narrowed fluid intake of the secretions and
resulting to an pt. improve
ineffective secretion
airway. clearance
- provide - to prevent
opportunities for fatigue
rest
73
c an intact NGT on the L nostril; c a diminished breathe sound on the R lung; irritable, c
nasal flaring; c dry lips; v/s recorded as: RR=92, PR=94, Temp.=36.5˚C
A: Ineffective Breathing Pattern r/t presence of air in pleural cavity 2˚ Pneumothorax
AEB: RR=92, diminished breath sounds on the R lung side and nasal flaring.
P: After 4˚ of nsg. Interventions, the mother will be able to verbalize understanding
about the interventions on how to improve the breathing pattern pt.
I:
• Established rapport
• Am care given
• Assisted in giving neb. Meds.
• Monitored and recorded v/s
• Auscultated breath sounds
• Provided safety measure
• Instructed mother to elevate head of the pt.
• Position the pt. appropriately every 1-2 hrs(elevated head or side lying position)
• Instructed mother to wet lips of the pt. using clean wet cotton balls
• @6:35am, seen on rounds by Dra. Yap orders made and carried out:
o Ff: up referral to surgery
o Keep on NPO > instructed
o Maintain O2 @same rate
o Cont. IVF
o Cont. Meds
o For referral to pulmonary
o VS q 9˚
E: Goal met AEB verbalized understanding of the mother about the interventions on how
to improve breathing pattern.
74
VII. PATIENT’S DAILY PROGRESS
75
Drugs: DAYS ADMISSION 2 3 4 5 DISCHARGE
• Paracetamol (August
+ 24, (August
+ 25, (August
+ 26, (August
+ 27, (August
+ 28,
• Cefotaxime 2009)
+ 2009)
+ 2009)
+ 2009)
+ 2009)
+
Nursing Problems:
• Salbutamol + + + + +
1. Ineffective breathing
• Ranitidine ++ ++ ++ ++ ++
pattern
• Diazepam +
• Penicillin G + + + + +
Vital Signs:
• Temperature 37.4 ºC 36.9 ºC 37.6 ºC 37 ºC 37.8 ºC
Diet:• Pulse rate 102 bpm 97 bpm 105 bpm 104 bpm 96 bpm
•• NPO
Respiratory rate +
84 bpm +
82 bpm +
89 bpm +
96 bpm +
92 bpm
Lab Procedures:
• CBC +
• Chest X-ray +
Medical
Management: + + + + +
• IVF D5.03NaCl
x 53-54
ugtts/min
• O2 inhalation at + + + + +
2-3 Lpm
• NGT + + + +
• Chest + + + + +
Thotocostomy + + + + +
tube
76
77
VIII. CONCLUSION
oxygen for carbon dioxide. The process of respiration occurs in our lungs. Our
life depends on the proper functioning of our lungs but with the presence of
not treated. Pneumothorax for instance, can cause our respiratory system at
risk.
Treatment can help a client feel better, stay more active, and slow the
patient’s advocate, our role doesn’t end-up with our interventions and health
teachings but it only just begun. Our real mission is to help our clients toward
the full acceptance of their condition and be able to live an honorable life
accordingly.
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IX. RECOMMENDATIONS
regarding Pneumothorax.
2. To give additional information regarding the disorder that would help them to
3. To inform them of the latest updates in taking care of the client’s health
conditions.
To the Public:
3. To impart additional knowledge to make them aware of the danger the disease
may cause.
To the Academe:
1. To convey to them our knowledge and effort in researching this study to further
develop knowledge and widen their ideas about the disorder. This will also help
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2. To inform them on the latest trends and facts about the disease which will
enhance the theories learned by the students in school and will also help them
2. To enhance their perspectives and ideas on how to protect the public against
1. To help them in their future researches as this study will serve as a reference
80
X. BIBLIOGRAPHY
BOOK SOURCE:
Black and Hawks. (2005) Medical-Surgical Nursing 7th edition. Elsevier Inc.
USA.
6th edition
INTERNET SOURCE:
2009, from
http://www.doh.gov.ph/kp/statistics/morbidity
http://www. curesearch.com
http://www.healthday.com/view.
http://www.scribd.com/doc/6774377/Drug-Study
http://knol.google.com/k/ehowknol/how-to-write-a-book-
acknowledgement/3a9e8hggiw4cz/152#
http://www.drugs.com/pro/penicillin-g-procaine.html
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