CHAPTER I

PRELIMINARY
1.1. Background
Pneumothorax is defined as the presence of air in the pleural cavity. Pressure in the
pleural cavities in healthy people is always negative in order to maintain the lungs in the
developing state (inflation). Pressure in the pleural cavity at the end of inspiration 4 s / d 8 cm
H2O and at the end of expiration 2 s / d 4 cm H2O.
Damage to the parietal pleura and / or visceral pleura can cause external air into the
pleural space, thus the lungs collapse. Most often spontaneous without any history of trauma; can
also be the result of thoracic trauma and due to various diagnostic and therapeutic procedures.
In the past, pneumothorax was used as a therapeutic modality in pulmonary tuberculosis
before the discovery of anti-tuberculosis drugs and surgery and was known as artificial
pneumothorax. Advances in engineering and medical equipment also have a role in improving
pneumothorax cases such as diagnostic procedures such as pleural biopsy, TTB, TBLB; as well as
some therapeutic measures such as pleural function, mechanical ventilation, IPPB, CVP can also
be the cause of pneumothorax (iatrogenic pneumothorax). There are three ways to get air into the
pleural space:
1) Perforation of the visceral pleura and the entry of air and in the lungs.
2) Penetration of the chest wall (in less rare cases of esophageal or abdominal perforation) and
parietal pleura, so that air and outside the body enter the pleural space.
3) The formation of gas in the pleural cavity by the gaseous microorganisms for example in
empyema.
The incidence of pneumothorax is generally difficult to determine because many cases
are not diagnosed as pneumothorax for various reasons. (Johnston & Dovnarsky) estimated the
incidence of pneumothorax ranged from 2.4 to 17.8 per 100,000 per year. Some characteristics of
pneumothorax include men more often than women (4: 1); most often at the age of 20-30 years.
Spontaneous pneumothorax arising at age 40 and 40 is often caused by chronic bronchitis and
empyema. More often on people with a thin and tall figure (astenikus) especially in those who
have a smoking habit. Right pneumonotoraks are more common and on the left.

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1.2. Purpose of Writing
The purpose of writing is as follows:
1) General Purpose
Students and college students get a real picture and experience in carrying out nursing care to
clients. K who suffered from pneumothorax in RSCM Public Wings Room VI.
2) Special Purpose
The specific purpose of this paper is that students can do and determine:
a. Assessment to clients Recommend to your friends Company Contact Name: K who suffer from
pneumothorax
b. Nursing Diagnosis on client Recommend to your friends Company Contact Name: K who suffer
from pneumothorax
c. Action plan on clients Recommend to your friends Company Contact Name: K who suffer from
pneumothorax
d. Implementation of nursing actions on clients Recommend to your friends Company Contact
Name: K who suffer from pneumothorax
e. Evaluation of nursing on clients Recommend to your friends Company Contact Name: K who
suffer from pneumothorax
f. Identify the supporting and inhibiting factors in performing nursing care to clients. K who suffer
from pneumothorax
g. Problem solving in nursing care found barriers to clients Recommend to your friends Company
Contact Name: K who suffer from pneumothorax

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 CHAPTER II
THEORY REVIEW
2.1. Basic concepts
2.1.1. Anatomy and Lung Physiology
The lung is an elastic structure enclosed in a thoracic cage, which is a strong air chamber with a
pressure-resistant wall. Ventilation requires the movement of the thoracic cage wall and its base,
the diaphragm. The effect of this movement is to alternately increase and decrease the chest
capacity. As the capacity in the chest rises, air enters through the trachea (inspiration), due to
internal pressure drops, and lung development. When the chest wall and the diaphragm return to
their original size (expiration), the elastic lungs deflate and push the air out through the bronchus
and trachea. The inspiratory phase of breathing normally requires energy; the expiratory phase is
normally passive. Inspiration occupies one-third of the breathing cycle, expiration occupies two-
thirds.

a. Pleura
The outer portion of the lung is surrounded by a smooth, slick, pleural membrane, which also
extends to enclose the interior walls of the thorax and the superior surface of the diaphragm. The
parietal pleura lining the thorax, and the visceral pleura lining the lungs. Between these two
pleuraes there is a space, called the pleural spasium, which contains a small amount of liquid that
lubricates the surface and allows both to shift freely during ventilation.

b. Mediastinum
Mediatinum is a wall that divides the thoracic cavity into two parts dividing the thoracic cavity
into two parts. Mediastinum is formed from two pleural layers. All thoracic structures except lungs
lie between the two pleural layers.
Lobes. Each lung is divided into lobes. The left lung consists of the lower and upper lobes, while
the right lung has the upper, middle, and lower lobes. Each of the further lobes is subdivided into
two segments separated by fissures, which are the extension of the pleura.

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c. Bronchus and Bronchiolus
There are several bronchial divisions within each lobe. First is the bronchus lobaris (three on the
right lung and two on the left lung). The lobar bronchus is divided into the segmental bronchus (10
in the right lung and 8 in the left lung), which is the structure sought when selecting the most
effective postural drainage position for a particular patient. The segmental bronchus is subdivided
into subsegmental bronchus. This bronchus is surrounded by connective tissue that has arteries,
lymphatics, and nerves.
The subsegmental bronchus then forms the branching into bronchioles, which have no cartilage
within the walls. The patency of the bronchioles is entirely dependent on the elastic recoil of
smooth muscle around it and at the alveolar pressure. Brokiolus contains submucosal glands,
which produce mucus that forms an unbroken blanket for the inner lining of the airway.
Bronchials and bronchioles are also coated by cells whose surfaces are coated by short "hairs"
called cilia. This cilia creates a constant sweeping action that serves to remove mucus and foreign
objects away from the lungs to the larynx.

The bronchioles then form the branching into the terminalis bronchioles, which have no
mucus glands and cilia. The terminal bronchioles then become bronchiolus respiratori, which is
considered to be a transitional channel between the airway conduction and the gas exchange air
path. Up to this point, the conduction air path contains about 150 ml of air in tracheobronchial
branches that do not participate in gas exchange. This is known as a physiological loss space. The
respiratory bronchioles then lead into the alveolar ducts and alveolar sac then the alveoli. The
exchange of oxygen and carbon dioxide occurs in the alveoli.

d. Alveoli
The lungs are formed by about 300 million alveoli, which are arranged in clusters between 15 and
20 alveoli. So many of these alveoli that if they unite to form a single sheet, it will cover an area
of 70 square meters (the size of a tennis court). There are three types of alveolar cells. Type I
alveolar cells are epithelial cells that form alveolar walls. Type II alveolar cells, metabolically
active cells, secrete surfactants, a phospholid coating the inner surface and preventing the alveolar
from collapsing. Type III alveolar cells are macrophages that are large phagocytic cells that feed
on foreign objects (eg, lenders, bacteria) and work as important defense mechanisms.

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 During inspiration, air flows from the surrounding environment into the trachea, bronchi,
bronchioles, and alveoli. During expiration, the alveolar gas undergoes the same route in the
opposite direction.

Physical factors that regulate the flow of air entering and exiting the lungs
simultaneously are referred to as ventilation mechanisms and include air pressure variance, airflow
resistance, and lung compliens. Air pressure variance, air flows from a region of high pressure to a
region with lower pressure. During inspiration, diaphragm movements and other respiratory
muscles enlarge the thoracic cavity and thereby lower the pressure in the thorax to levels below
the atmosphere. Therefore, air is attracted through the trachea and bronchi into the alveoli. During
normal expiration, the diaphragm relaxes, and the lungs deflate, resulting in a decrease in the size
of the thoracic cavity. The alveolar pressure then exceeds atmospheric pressure, and air flows from
the lungs into the atmosphere.

Air road resistance, determined primarily by the diameter or size of the airways in which
air flows. Therefore any process that alters the bronchial diameter or width affects airway
resistance and changes the velocity of the airflow to a certain pressure gradient during respiration.
Common factors that may alter bronchial diameter include bronchial smooth muscle contraction,
such as in asthma; thickening of the bronchial mucosa, as in chronic bronchitis; or airway
obstruction due to lenders, tumors, or foreign bodies. Loss of pulmonary elasticity as seen in
emphysema, can also alter the bronchial diameter because the lung connective tissue surrounds the
airway and helps it remain open during inspiration and expiration. With increased resistance,
greater respiratory effort is required to achieve normal ventilation levels.

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 Compliens, the pressure gradient between the thoracic cavity and the atmosphere causes
air to flow in and out of the lungs. If pressure changes are applied in a normal lung, there is a
porposional change in lung volume. Elasticity, expansion, and distensibility of the lungs and
thoracic strata are called compliens. Factors that determine pulmonary compensation are alveolar
surface resistance (normally low in presence of surfactants) and connective tissue, (eg, collagen
and elastin) of the lung.
Compliens are determined by examining the relationships of the volumes in the lungs
and thorax. In the normal compliens, the lungs and thorax can stretch and dilate easily when
pressurized. High or increased compatibility occurs when pressured. High or increased
compatibility occurs when the lungs lose their elasticity and the thorax is too depressed (eg,
emphysema). When the lungs and thorax are "stiff", there is low or downward compli- ance.
Conditions associated with this include pneumotorak, hemotorak, pleural effusion, pulmonary
edema, atelectasis, pulmonary fibrosis. The lungs with decreased compliens require the use of
more energy than normal to reach normal ventilation levels.

2.2. Pneumothorax
2.2.1. Understanding
Pneumothorax is the collection of air within the potential space between visceral and
parietal pleura (Arif Mansjoer et al, 2000).
It is a state where there is an accumulation of extrapulmonary air in the visceral and parinteral
pleural space, which can lead to pulmonary clopas. In the normal state of the pleural space does
not contain air, so that the lungs freely expands to the chest cavity. (rahajoe, 2012)
Pneumothorax is the release of air from the injured lung, into the pleural space often caused by the
tearing of the pleura (Suzanne C. Smeltzer, 2001).

2.2.2. Etiology
Pneumothorax may be classified according to the cause:
- Spontaneous Pneumothorax (primary and secondary)
Primary spontaneous pneumothorax occurs without the underlying lung disease, whereas
secondary spontaneous pneumothorax is a complication of the lung disease that preceded it.

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- Traumatic Pneumothorax
Due to sharp trauma, lung infections, cardiopulmonary resuscitation.
Traumatic can be divided into:
1. iatroganic pneumothorax
Occurred because of complications of medical and jennies are divided into two, namely:
- accidental iathogenic pneumothorax is due to medical action due to errors / complications of
action, such as chest paracentesis, pleural biopsy, transbronchial biopsy, percutaneous lung
biopsy / aspiration.
- pneumothorax traumatic iatroganic, artificial (deliberate) is a deliberate pneumothorax by filling
air into the pleural cavity through a needle with a maxwelbox device. Usually for tuborkolosis
therapy (before the antibiotic era), or to assess the surface of the lungs.

2. Non iatroganic pneumothorax (accidental)

Spontaneous pneumothorax can be divided into primary (without underlying disease) or secondary
(complications and from acute or chronic lung disease).

2.2.3. Pathophysiology
a. Narrative Pathophysology:
Pneumothorax may be caused by a chest trauma that can lead to visceral pleural leakage /
laceration. So that the lungs collapse part / complete relate to air / fluid into the pleural space. The
volume in the pleural space becomes increased and results in an increase in intra thoracic pressure.
If an increase in intra thoracic pressure occurs, then respiratory distress and gas exchange
disorders and cause pressure on the mediastinum that can trigger cardiac disturbances and
systemic circulation.

2.2.4. Clinical Manifestations

Almost all patients complained of mild to severe chest pain on either side of the chest and
dyspnea. Symptoms usually start at rest and end within 24 hours.
Pneumothorax with life-threatening respiratory failure may also occur if the underlying asthma
and COPD appear, this is completely irrespective of the size of the pneumothorax.

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The presence of tension pneumothorax should be suspected in case of severe tachycardia,
hypotension, and mediastinal / tracheal shifts, as well as high resonance sounds.
a. Shortness of breath
b. Tachypnea, superficial, uses additional breathing muscles
c. Unilateral chest pain, especially exacerbated during deep breathing and coughing
d. Development of the chest is not symmetrical
e. Cyanosis

2.2.5. Physical examination

• The presence / absence of dyspnea (if extensive)
• The presence or absence of severe pleuritic pain
• The presence / absence of the trachea shifts away from the side of the pneumothorax
• The presence or absence of tachycardia
• The presence or absence of cyanosis
• The chest shift is reduced and retarded on the affected part
• Hypersonar percussion over collapsing lungs
• Decreased breath sounds on the affected side
• Fremitus vowels and touches decreases.

2.2.6. Diagnostic Checkup

Arterial blood gas analysis results in hypoxemia and acute respiratory alkalosis in most
patients, but this is not an important issue. On ECG examination, the left primary pneumothorax
can cause QRS axis and T waves to alter to allow for an interpretation error as acute myocardial
infarction.
Diagnosis is supported by visceral pleural lines seen in conventional radiological
examination with the patient supine positioned to give an overview of the abnormal radiolucent
cirophrenic cycle. Diagnostic checks include:

a. Chest X-ray: states the accumulation of air / fluid in the pleural area; may indicate deviations of
mediastinal structures.

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b. GDA: the variable depends on the degree of lung function that is affected, the respiratory
mechanical disorders and the ability to compensate.
c. Torasentesis: declares blood / sero sanguinosa fluid
d. Hb: may decrease, indicate blood loss

2.2.7. Complications
Tension pneumothorax may be caused by mechanical respiration and this may be life-
threatening. Pneumo - mediastinum and subcutaneous emphysema may occur as a complication of
spontaneous pneumothorax. If pneumo - mediastinum is detected it should be considered that
there is esophageal / bronchial rupture.

2.2.8. Medical Management

1) Pharmacology
• Oxygen therapy can improve air reabsorption of the pleural space.
• Simple drainage for pleural air aspiration using a small diameter catheter (such as 16 gauge
angio-chateter / larger drainage catheter)
• Placement of a small pipe fitted one lane on the helmic valve to provide protection against
tension pneumothorax attacks
• Symptomatic drug for complaints of cough and chest pain

2) Radiological examination
The role of radiological examination include:
- Key diagnosis.
- Assessment of the extent of pneumothorax.
- Evaluate the underlying diseases.

On moderate to severe conventional photo pneumothorax (in an inspiratory state) may

indicate a hyperplain region with a pleural line on the medial side; but in minimal pneumotonax,
conventional photographs sometimes can not show the presence of air in the pleural space; for it
takes a maximum expiratory photo, sometimes a lateral decubitus photo. Hinshaw recommends

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making photos in 2 phases of inspiration and expiration, as it will provide more complete
information about:
- Degree / extent of pneumothorax.
- The presence or absence of mediastinal shifts.
- Indicates the presence of cysts and pleural attachments more clearly than conventional
photographs.

2.2.9. Cause
a. Chest trauma due to puncture wounds (eg, knives, bullets) that cause open chest wounds.
b. Chest trauma due to blunt object collisions that suppress the chest cavity
c. Complications of lung-aspiration biopsy procedures, pulmonary pleural function
d. Complications of infusion in the central vein
e. Spontaneous causes, asthma, conditions leading to pleural inflammation, increased subpleural
capillary pressure (eg, CHF), chronic obstructive pulmonary disease (COPD), and ARDS

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 CHAPTER III
CASE REVIEW

In this chapter will be described about the client's biography, history of the disease, and
implementation of nursing care that has been done to clients in the 6th floor Public Wings RSCM
from December 9-13, 2008.

3.1. Case Description

Clients Tn. K 33 years old, male gender, Islam, Jakarta tribe, high school education, Indonesian
language, clients work as Hansip (Security Guard).
The client entered RSCM on 29-06-08 due to the increasingly severe client situation and
recommended for hospitalization. Previously clients have been treated to the nearest Puskesmas.
But because the Puskesmas is not enough tools and drugs then the client is referred to RSCM.
Client received amoxicyllin 3 x (gr IV for 7 days from 3-9 December 2008 (last today) as an
antibiotic, inhaled with ventolin: bisolvon: NaCl = 1: 1: 1 to reduce shortness and secretion easily
out. Streptomicyin plan 1 x 550 mg IM (waiting for THT evaluation) as antibiotics and TKTP
2300 KKal + extra egg whites 3 x 2 eggs / day to reduce edema.
• Physical Assessment
Clinical Data
DS: Client said before hospitalized, Our client had an accident and had in the left chest surgery.
The client never complains of pain, but suddenly the client suffers cough and tightness for ± 3
weeks.
DO: S: 36,10C, N: 84 x / mnt, RR: 22 x / mnt, TD: 110/70 mmHg, Awareness: CM there are
wound surgery on the left chest, thin client body, productive cough, breathing kausmul, chest
percussion: Right dim from the ribs 1-3: left, dimmed from the 1-6 sphere.

• Nutrition and Metabolism

DS: Client says
- Eat one serving runs out
- BB previously 45 Kg
- Foods that make allergies are fish

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DO: BBI: 54 - 66 Kg, Vomiting (-), tooth caries (+), Constipation (-), Diarrhea (-), Bowel sounds
21 x / mnt, liver is not palpable, tongue clean, bad skin turgor.
• Respiration / Circulation
DS: Cough since ± 3 weeks, weakness.
DO: There is ronhi, productive cough, bleeding cough (-), white thick sputum, use of respiratory
muscle (-), caulmaul breathing, shallow depth, left fremitus <>
• Elimination
DS: Client says
- Current, Complaints (-)
- Current BAK, complaint (-)
DO: Abdomen; Flower (-), bowel sounds 21 x / min. CHAPTER: CHAPTER 3 x / day,
consistency of faeces: semi-solid, characteristic odor (-) character (-), frequency 4-5 x / day,
Rectum: no abnormality.
• Activity / training
DS: Client says when first enter RSCM (date 27-11-08) his child can still walk alone.
DO: Continuity goes poorly, left & right foot shape is symmetrical, but there is swelling on the
soles of the feet, seizures (-).
• Perception Sensory
DS: Client says that hearing, sight, smell, taste pasiehn still good. And also can still feel a touch if
touched.
DO: Can respond well to light stimuli, good orientation, isokor pupils, conjunctival anemis,
normal hearing, normal vision.
• Self concept
DS: Although Clients are like this now, clients never complain or never say ill. If asked just
answer as needed only.
DO: Posture is good, behavior is much silent.
 Sleep / Rest
DS: Client says since sick just sleep and lie down.
DO: clients often sleep (due to illness or due to drowsiness less studied)

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• Impact of hospitalization
- On the client (Mr. K): not much to say, thought of hope for a speedy recovery.
- On client's family: Family income becomes disrupted due to illness of client.
Current level of development: can answer questions provided by the client, the client does not say
much. Socialization: The client says he belongs to a teenage member of the mosque around his
home.
•Supporting investigation.
Laboratory examination dated 9-12-08
• Microcytic anemia hipokrom
• Leukocytes: 11,600 (N: 5,000 - 10,000)
• Na: 132 mmol / l (N: 135 - 1147)
• Potassium: 2.9 mmo; / l (N: 3,10 - 5,10)
• Cl: 91 mmol / l (N: 95 - 108)
• Management
Client get therapy
- IVFD Nacl 0.9% 500 cc / S hour (20 ttr / min)
- Amoxicyllin 3 x / gr IV HT (Last day in)
- Ardan 3 x 2 gr (IV) Ventolin Inhalation: Bisolvon: NaCl 1: 1: 1
- Diet TKTP 2300 kcal + extra egg whites 3x2 grains / day
- Streptomicym Plan 1 x 550 mg (IM) waiting day / evaluation of THT.

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3.2. Diagnosis, Intervention, Implementation and Evaluation of Nursing.
From the above data the author finds and lifts 1 diagnosis, which is the actual diagnosis.
The author performs the implementation from 09-12-08 s / d date 11-12-08, because the date of
11-12-08 clients go home and referred for outpatient.
The nursing diagnoses are:
1. Ineffective airway clearance b.d increased production of thick secretions
DS: Client says limp, cough since ± 3 weeks, smoked 1 ½ packs / day and has been smoking since
grade 5 elementary school. DO: pale skin, productive cough, white viscous sputum and left
fremitus <> Purpose: after nursing care performed 1 x 24 hours effective client breath pattern. KH:
Clients will Show an effective breath pattern (no ronhi, viscous secret) spontaneous breath pattern,
ananemic conjunctival, fremitus, fermitus breath sound, if coughing, breath in keeping the position
as comfortable as possible for the client (fowler or semi fowler), Implementation conducted on 09-
12-08 s / d 11-06-08 namely: positioning, observation: fremitus, breath sounds. Provide
streptomicym (IM), replace the bandage on the left upper chest. Evaluation: S: Complaints and
Shortness (-). O: Spontaneous breath pattern, white sputum ± 10 cc, A: Problem solved, P:
Intervention terminated because client referred for outpatient.

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 CHAPTER IV
COVER

4.1. Conclusion
After Nursing Care done on Tn. K who suffered / suffered from penumotraks in Public
Wings Room 7th floor RSCM, got the following conclusion:
 Data found by. K who suffers from Pneumotraks is not much different from the theories that
have been discussed, namely with the main sign of the cough more than 3 weeks and the
presence of ronkhi.
 From the results of the assessment found 1 actual nursing diagnoses are: Ineffective breath
pattern b.d a thick secret and increased formation of secondary mucus due to smoking.
Intervention and implementation of nursing at An. R has been prepared in accordance with the
required client at this time, so when performing the implementation found no difficulty.
 Evaluation of an actual diagnosis on Tn. K has been resolved on December 11, 2008

4.2. Suggestions
Based on the formulation and obstacles encountered during the nursing care the authors
propose some suggestions to be made material considerations that may be useful for efforts to
improve the quality of nursing services in the future, suggestions that can the author put forward
are as follows:
1. Nurses and families can work together in the fulfillment of daily needs.
2. With limited nurses, nurses are expected to work professionally and be able to provide
appropriate nursing care as well as age-appropriate communication.
3. Students to better understand the concepts of nursing care in Pneumotrak patients

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 BIBLIOGRAPHY

Mansjoer, Arif, et al. 2000.Kapita Selekta Medicine. Jakarta: Media Aescutapius.

Smeltzer, Suzanne c. 2001. Medical Surgical Nursing Teachings Vol.1. Jakarta: EGC
Doenges, Marilynn E. 1999. Nursing Care Plan Guidelines for Planning and Documenting Patient
Care 3rd Edition Jakarta: EGC
Wartonah, Tarwoto. 2006. Basic Human Needs and Nursing Process. Jakarta: Salemba Medika

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