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Parapneumonic Effusion Case Study Adult I
Parapneumonic Effusion Case Study Adult I
University
Caribbean
College of
Nursing
Department of
Nursing
NRSG343:
Adult Nursing I
Group Fuzeon
Devon Carter-
28090137
Talietha Williams 18051905
Tiphanie Smith 28100039
Shaneque Greaves 18075036
Melissa Doctor 18090451
Nickesha Bailey 28090077
Kadian Stewart 60080061
Sabrina Bugam 24075068
Theresa Williams 60090137
Sherika Taylor 16040223
Natalie Clarke-Boothe - 60090109
Introduction
This case study seeks to evaluate the collaborative managements that were put in place in
providing holistic care to the patient. However, it also goes in dept to explore other options that
would have been appropriate for the successful outcome of the patient;researching literature
centered on the diagnosis stated below.
To provide confidentialitythe patient being studied is termed asMr. R.S,a 72 years old elderly
male diagnosed as having left Empyema, and left Para- pneumonia effusion. In 1986 and he was
admitted at Kingston Public Hospital for the removal of haemorrhoid, and in 2004 he had four
(4) gun shots gun removed from his neck. He was also admitted at the health agency National
Chest Hospital on the 22/10/12 in a wheel chair with a chest tube insitu and an underwater seal
drainage bottle attached. Prior to admission, he was well until 2/52 ago when he noticed that he
was losing weight and had a loss of appetite that caused him to seek medical attention. At the
same time he began to experience shortness of breath (sob) on exertion relieved by rest,
productive cough of white oral yellow coloured sputum, he had one episode of haemoptysis, an
intermitted fever and swollen limbs. His vital signs on admission were, Temperature-100.3F,
Pulse-104 bpm, Respitation-28 b/m, SPo2-94% and Blood pressure- 128/80. His weight was 169
pounds and he is five (5) feet tall. On the 23/10/12 the patient had a HB of 9.8, WBC 12, Platelet
count 183 and CO2 -24. On the 27/10/11 he had a HB of 10.4 and WBC 6.8, Platelet count 339
and CO2-20.
According to Scott (1993), The lung is lined by two thin membranes of pleura (inner visceral
and outer parietal), which allows the lung to expand and shrink with each breath with minimal
friction. (pg 102). Clare (2000), states that, Empyema is the collection of pus in the pleural
Literature Review
Sahn (2007) defines a parapneumonic effusion (PPE) as a type of pleural effusion that
arises as a result of pneumonia. Before looking at the pathophysiology of parapneumonic
effusion background knowledge of how a pleural effusion develops need to be established. A
pleural effusion occurs when excess amounts of fluid collects in the pleural space. This is
commonly known as water on the lungs. Signs and symptom of a pleural effusion include:
SOB, chest pain, gastric discomfort (dyspepsia), and cough. Two thin membranes are located in
the chest cavity, the visceral pleura which line the lungs and the parietal pleura that cover the
inside of the chest wall (Sahn 2007, pg 1480-1486). Normally, small blood vessels in the pleural
linings produce a small amount of fluid that lubricates the opposed pleural membranes so that
they can glide smoothly against each other during respiration. Any extra fluid that is produced is
absorbed by blood and lymph vessels. When too much fluid forms or something prevents its
removal, the result is an excess of pleural fluidan effusion. The most common causes are
disease of the heart or lungs, and inflammation or infection of the pleura (Thompson 2011).
According to Weyant (2007) pleural effusion itself is not a disease as much as a result of
many different diseases. There are two types of pleural effusion that may occur: the transudate
and the exudate. These two types of fluid are very different. The type of fluid present points to
what sort of disease is likely to have produced the effusion. It also can suggest the best approach
to treatment (Limsukon, 2011). A patient with parapneumonic effusion has an exudative pleural
effusion. An exudate, which often is a cloudy fluid containing cells and much protein results
from disease of the pleura itself. The causes are many and varied. Among the most common are
infections such as bacterial pneumonia and tuberculosis; blood clots in the lungs; and connective
tissue diseases, such as rheumatoid arthritis. Cancer and disease in organs such as the pancreas
also may give rise to an exudative pleural effusion (Shawn, 1993).
Hamm (1997) states that the development of pneumonia begins with the aspiration of
organisms from the oropharynx. If the organism load is high and the patient's host defences are
impaired (e.g., as a result of cigarette smoking or alcohol ingestion), the patient is more likely to
develop pneumonia. The interval between aspiration of organisms and the development of
pneumonia varies from a few days up to 1 week. Pneumonia typically begins in dependent lobes
at the periphery of the lung and, if untreated, spreads centripetally towards the hilum (Thompson,
201). If left untreated for the subsequent 25 days, an UPPE will likely develop. The effusion
forms because of an increased capillary permeability secondary to endothelial injury induced by
activated neutrophils. The resultant extravascular lung water increases the interstitial-pleural
pressure gradient and promotes a pleural effusion as fluid moves between mesothelial cells into
the pleural space. If interstitial fluid formation exceeds the capacity of the lung and pleural
lymphatics, a pleural effusion will accumulate. If left untreated for the subsequent 510 days, the
PPE transitions to the fibrinopurulent stage, which is characterized by the development of
fibrinous adhesions, increased neutrophils, and the presence of bacteria (Beers 2003).
According to Weyant (2007), fibrin forms as intravascular clotting proteins enter the
pleural space, with concomitant inhibition of pleural space fibrinolysis. Fibroblasts enter the
pleural space by 2 possible mechanisms: (1) movement of bone marrow fibrocytes to the site of
inflammation, and (2) mesothelial cell transformation to fibroblasts by cytokines, such as basic
fibroblast growth factor2. Later in the fibrinopurulent stage, pus will be aspirated at
thoracentesis; however, the lung is typically still expandable. As the fibrinopurulent stage
progresses, it becomes increasingly unlikely that the patient can be successfully treated without
pleural space drainage. If left untreated for the subsequent 1021 days, the PPE will evolve into
the final organizational or empyema stage, with evidence of lung entrapment due to visceral
pleural fibrosis. Patients with empyema always require pleural space drainage for adequate
resolution of pleural sepsis and often require decortication.
Empyema is a condition in which pus and fluid from infected tissue collects in a body
cavity, especially in the pleural cavity (Johnson, 2012). This condition represents the end-stage
of a progressive process evolving from a small amount of free-flowing, non-infected pleural fluid
to a large amount of frank pus that can become loculated and result in thick pleural peel. It is
most often used to refer to collections of pus in the space around the lungs (pleural cavity), but
sometimes refers to similar collections in the gall bladder or the pelvic cavity (Johnson, 2012).
Empyema in the pleural cavity is sometimes called empyema thoracis, or empyema of the chest,
to distinguish it from empyema elsewhere in the body.
Limsukon (2011) states that empyema may have a number of causes (contamination of a
wound because of inadequate skin preparation during procedures such as needle decompression,
chest tube placement, thoracentesis, or lung surgery) but is most frequently a complication of
pneumonia. Its development can be divided into three phases: an acute phase in which the body
cavity fills with a thin fluid containing some pus; a second stage in which the fluid thickens and a
fibrous, coagulation protein (fibrin) begins to accumulate within the cavity; and a third or
chronic stage in which the lung or other organ is encased within a thick covering of fibrous
material (Beers, 2003). Empyema thoracis can be caused by a number of different organisms,
including bacteria, fungi, and amebas, in connection with pneumonia, chest wounds, chest
surgery, lung abscesses, or a ruptured esophagus. The infective organism can get into the pleural
cavity either through the bloodstream or other circulatory system, in secretions from lung tissue,
or on the surfaces of surgical instruments or objects that cause open chest wounds. The most
common organisms that cause empyema are the following bacteria: Streptococcus pneumoniae,
Haemophilusinfluenzae, and Staphylococcus aureus (Sahn, 2007). When the disease organisms
arrive in the cavity surrounding the lungs, they infect the tissues that cover the lungs and line the
chest wall. As the body attempts to fight off the infection, the cavity fills up with tissue fluid,
pus, and dead tissue cells (Weyant, 2007).
The key presenting symptoms of empyema are breathlessness (secondary to large pleural
effusion or pneumonia), fever, and pleuritic chest pain (pain worsened by deep breathing,
coughing, sneezing, and chest movement). Other associated symptoms include those of
pneumonia (productive cough, green or rust-coloured sputum, shortness of breath) and systemic
infection (anorexia, malaise, fatigue, rigors)(Sahn,1996, para. 5).
Patients tend to have a subacute history of illness, with a mean duration of symptoms
before admission of 2 weeks. Failure of patients with pneumonia to respond to antibiotics or a
deterioration in clinical condition suggests the development of a complicated parapneumonic
effusion or empyema(Sahn,1996, para. 5).
The majority of patients who develop empyema have a recent history of pneumonia,
thoracic trauma, or iatrogenic intervention in the pleural space such as thoracic surgery, or
medical procedures such as chest drain insertion (4%), thoracentesis (pleural aspiration), tube
thoracostomy (chest drain insertion), and aspiration of pneumothoraces or pleural effusions
(Johnson, 2012).
Patients may have a history of a medical condition predisposing them to the development
of pneumonia and hence empyema, such as pre-existing lung diseases (e.g., bronchiectasis,
chronic obstructive lung disease [COPD], lung cancer) or conditions associated with an
increased risk of aspiration (e.g., stroke, presence of a nasogastric or endotracheal tube).
Immunocompromised patients (e.g., due to haematological disease, chemotherapy, HIV, or
malnutrition) are also at increased risk of developing empyema (Sahn, 2007).
Social History
Alcohol abuse and drug addiction are additional risk factors for the development of
empyema.
Clinical examination
Examination reveals evidence of a pleural effusion with or without signs of systemic infection.
Septic shock presents with pyrexia, tachypnoea, tachycardia, and hypotension (BP
<90/60). Such patients require urgent resuscitation.
Blood tests
A complete blood count, C- reactive protein test (CRP), and blood cultures should be
undertaken in all patients with suspected empyema at presentation. In empyema, the WBC count
and the CRP will be raised as part of a systemic response to infection. Blood cultures may be
positive for specific pathogens even if the pleural fluid culture is negative. Ideally, blood cultures
should be taken before the initiation of antibiotics if the clinical state of the patient permits
(Sahn, 2007).
Sputum Culture
Sputum testing requires a sample of sputum, collected from a deep cough. Culture of
sputum is used to identify the bacteria that caused the PPE and can help determine which
antibiotic is best.Symptoms of a lung infection may include difficulty breathing, pain when
breathing, or a cough that produces bloody or greenish brown sputum. It is also used to monitor
the treatment of an infection (Thompson, 2011).
Initial imaging studies
The initial investigations of choice are chest x-ray (CXR) and thoracic ultrasound, and
should be undertaken in all patients with a suspected empyema at presentation.
An urgent CXR should be organised in all patients who present with respiratory symptoms and
evidence of sepsis, as it can demonstrate the presence of a pleural effusion.A lateral decubitus
CXR is more sensitive than a posteroanterior view for detecting an effusion, but its use has been
superseded by thoracic ultrasound (Shawn, 1993). The presence of a loculated effusion suggests
an empyema. Empyemas may have a pleurally based 'D'-shaped appearance which can be
mistaken for a lung mass. There may be associated pulmonary consolidation due to pneumonia
and, in ventilated supine patients, a pleural effusion will appear as a diffuse unilateral increase in
opacification. An effusion measuring >10 mm on a lateral decubitus CXR, in association with
evidence of infection, requires thoracentesis (pleural aspiration).
Thoracic ultrasound is more sensitive than a CXR for the detection of pleural
effusions.Features suggestive of an empyema on thoracic ultrasound include the presence of
echogenic fluid, loculations, and septations.As empyemas are often associated with a raised
hemidiaphragm or tethered lung, image guidance for all procedures is preferable (Sahn, 2007).
The use of ultrasound to guide thoracentesis (pleural aspiration) in order to reduce its associated
complication rate is advised.Ultrasonography is also recommended to guide chest drain insertion,
especially in small or loculated effusions.
Thoracentesis
All patients with evidence of infection and a significant pleural effusion should undergo
thoracentesis (pleural aspiration). Aspiration of frank pus is diagnostic of an empyema and no
other investigations are required to establish the diagnosis, with the exception of pleural fluid
microbiology to guide antibiotic therapy. If the aspirate does not reveal frank pus, further
analysis is required to assess whether it is a complicated parapneumonic effusion. This involves
measurement of the pleural fluid pH, total protein concentration, LDH level, glucose
concentration, and white cell differential (Sahn, 1990).
All samples should be sent for microscopy, culture, and sensitivity testing.Cytology may
be used in cases where the diagnosis is unclear (e.g., for the detection of malignant cells in a
malignant pleural effusion).
Pleural fluid pH: Samples should be stored anaerobically.Local anaesthetics can falsely
lower the pH. Physicians should have access to a blood gas analyser so that samples can be
tested immediately to enable immediate insertion of a chest drain if indicated. If the sample is
frank pus, the pH should not be tested as it can damage the analyser (Weyant, 2007).
Pleural fluid total protein concentration: If frank pus is aspirated, the protein
concentration does not require analysis.
Pleural fluid LDH level: If frank pus is aspirated, the LDH level does not require
analysis.
Pleural fluid glucose concentration: If frank pus is aspirated, glucose does not require
analysis. If an accurate pleural fluid pH is not available, low glucose levels can be used as an
alternative predictor of a complicated parapneumonic effusion requiring urgent chest drain
insertion. Pleural fluid glucose has shown to be a robust predictor in this circumstance (Suzanne,
2010).
Pleural fluid white cell differential: Polymorphonuclear leukocytes are the predominating
(>90%) cell type. The predominance of lymphocytes in the exudate raises the suspicion of
tuberculosis or malignancy.
Pleural fluid microscopy, culture, and sensitivity: A positive Gram stain or culture is
obtained in 60% to 70% of samples.This can be used to guide antibiotic treatment (Thompson,
2011).
Further imaging studies
Further imaging studies are performed when there is doubt about the diagnosis or to
confirm the correct position of the chest drain.
Contrast-enhanced thoracic CT can help to distinguish empyema from other pleural
effusions and lung abscesses, and should be done with tissue phase contrast.Enhancement of the
pleura with contrast is characteristic of empyema. The split pleura sign represents enhancement
of the visceral and parietal pleura with interposed fluid. Pleural thickening may be visible, but
this is also seen in malignancy. Contrast-enhanced thoracic CT is especially useful for
confirmation of the correct positioning of the chest drain and may help in the planning of surgery
(Sahn, 2007).
MRI is unable to accurately diagnose an empyema and is therefore generally reserved for
patients who are unable to undergo contrast-enhanced CT.It may show septations, loculated
pleural fluid, or chest wall invasion.A PET scan is another possible imaging technique, but its
use is limited by the fact that it is unable to distinguish between malignancy and empyema.
As the causative organism in 40% of pleural infections remains unidentified, pleural fluid
polymerase chain reaction (PCR) may aid pathogen identification, allowing specific antibiotics
to be chosen.However, further prospective evidence is required on this technique before it can be
routinely recommended (Sahn, 2007).
the peel removed, the lung is inflated(Tobler et al. 2004). It is essential that the lung occupy the
complete hemithorax upon inflation to minimize pleural space problems such as persistent
atelectesis and recurrent empyema. The pleural space is irrigated with antibiotic solution and a
chest tube is placed via a port site. A single chest tube usually suffices. As in open thoracotomy,
chest tubes are removed when there is cessation of air leak and minimal pleural drainage.
Summary
Early surgical intervention has showed to hasten recovery and reduce morbidity. The use
of video-assisted techniques in the management of pleural space disease not only reduces
surgical morbidity further, but also appeals to non-surgical providers thereby facilitating an
earlier referral. Early video-assisted decortication provides an effective, singular procedure that
combines characterization of the pleural space fluid, cessation of the progression of the
parapneumonic process, removes the infected pleural material, allows for maximal lung
expansion and function, all with reduced pain and morbidity to the patient and a shortened
hospital stay(Tobler et al. 2004).
Management of Parapneumonic Effusion
According to Dr.Steve A. Sahn, author of Diagnosis and Management of Parapneumonic
Effusions and Empyema written in the journal Clinical Infectious Diseases, Parapneumonic
effusions outcome is related to the interval between the onset of clinical symptoms and
presentation to the physician, comorbidities, and timely management. Early antibiotic treatment
usually prevents the development of a PPE and its progression to a complicated PPE and
empyema.
administering antibiotics includes administering the antibiotics on time and monitoring for signs
of side effects and adverse effects on the patient.
In 2004, The Cochrane Database Review stated that, although the evidence suggests that
intrapleural fibrinolysis can be considered an important adjunctive therapy to tube drainage on
the basis of evidence from randomized, controlled trials alone, routine use was not recommended
for the management of CPPE and empyema, because the number of cases was too small
(Cameron R, Davies HR 2004). Streptokinase (no longer available as a result of a lack of market
demand) and urokinase were equally efficacious and that life-threatening complications were not
reported in any of the randomized, controlled trials. Fibrinolytic agents would probably be most
effective in the early fibrinolytic stage in avoiding the need for surgical drainage (Sahn, S.,
2007).
Surgery
Surgical options include thoracoscopy, both medical and video-assisted thoracic surgery
(VATS), standard thoracotomy, and open drainage. The decision for surgery should be made as
soon as it is obvious that pleural space drainage by tube thoracostomy has been ineffective in
controlling the pleural infection. Patients with a PPE can be sent directly to surgery or treated
with a 72-h trial of fibrinolytics(Tobler et al. 2004). If fibrinolytics do not improve drainage,
decrease temperature, and lower the leukocyte count, surgery should be strongly considered.
However, it should be recognized that, with clinical improvement, despite an abnormal pleural
space, observation may be warranted. There are patients who refuse surgery, despite minimal
clinical improvement, who over several weeks to months have complete lung re-expansion
without pleural space squeal (Sahn, S., 2007).
Open thoracotomy for CPPE and empyema is recommended for persistent pleural sepsis
and failure of less invasive procedures to control the infection (Mackinlay TAA et al 1996).
Conversion to thoracotomy can be effective when VATS cannot adequately access the pleural
space and is the optimal method for successful debridement and decortications (Deslauriers J et
al 2002). However, decortication is a major operation and can often not be performed in
debilitated patients. Decortication (stripping of the visceral pleural peel) can be performed early
to control pleural sepsis and late (36 months after the onset of empyema or CPPE) to treat a
symptomatic, restrictive ventilatory defect. Open drainage for empyema is an alternative to
decortication in the debilitated patient who cannot undergo a standard thoracotomy (Deslauriers J
et al 2002).
Nursing Management for Parapneumonic effusion
Antipyretics should be given as ordered for fever. Administration of analgesia as ordered
is important to keep the patient comfortable, particularly in the presence of a chest drain.
Facilitate early mobilization and exercise after surgery(Tobler et al. 2004).
Medications in the management of pleural effusion and empyema
The goals of pharmacotherapy are to reduce morbidity and prevent complications.In
patients with parapneumonic effusions, empyemas, and effusions associated with esophageal
perforation and intra-abdominal abscesses. Antibiotics should be administered early when these
conditions are suspected (Rubins, J. 2012). Therapy must be comprehensive and cover all likely
pathogens in the context of this clinical setting. Initiate therapy with intravenous antibiotics and
transition to oral agents or equivalent agents based on clinical response. Oral antibiotics can be
used to transition from intravenous therapy. They allow completion of a full course of therapy
Patient Data
Biographic data:
Initials:
DOB: 28/11/39
Age: 72
Sex: M
Marital Status: Married
Address: South Rd Kencot P.O. HWT Rd
Family/Social History:
6 children
9bedroom house,
Pipe water,
Toilet flushing,
Light electricity,
Garbage collection via garbage truck,
Family history of SLE seizures
Present complaint/ History of present complaint:
Health agency National Chest Hospital
Date of admission 22/10/12 @ 3:30pm Ward H
Presented with difficulty breathing, SOB, chest pain, generalized weakness, mild cough, thick
white sputum, swollen lower extremities, lack of appetite, weight loss which caused him to seek
medical attention
-
Duration 3weeks,
Onset Sept 30, 2012
The third principle, the preservation or restoration of lung space, is highly subjective
patient to patient, and depends on the healing capacity of each patients individual body (Tobleret
al.2004). This is done in situations where lung collapse has occurred, or in cases in which
decotication, the peeling of the thick fibrotic layer present in third stage parapneumonic effusion
(Sahn 2007, pp1480-1486).
Other important areas of necessary management include antipyretic measures, necessary
both due to the infective and inflammatory raise of temperature present with parapneumoniac
effusions and pain management. Management of the patients pain is especially important, as
chest pain, will cause the patient to breathe improperly (i.e. shallow breaths) and thus be more
likely to experience atelectasis or lung collapse (Colice 2000, pp1158-71).
Evaluation Criteria
Antibiotic Therapy Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to
combat the bacteria present within the pleural space. This is in accordance with the use of
antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).
Evacuation of Supportive Fluid Patient R.S. was noted to have 420cc of hemopurulent
fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also,
although not seen, the lack of oscillations were noted, indicating that the nurse was monitoring
the status of the thoracotomy tube as necessary for proper evacuation (Sahn 2007, pp. 14801486) .
Analgesics The need for analgesia was indicated by the grimace of pain noted by the nurse
upon assessment.Voltaren and Panadol were both administered for the purpose of analgesia. This
is an important management, as the presence of pain not only leads to patient discomfort and
decreased compliance with treatment methods, but can lead to ineffective breathing and
complications such as atelectasis (Colice 2000, pp1158-71)..
Nursing-Specific Management Bilateral pedal edema was noted, but nothing was
indicated as having been done for this observation. Appropriate managements would have
included elevating the feet, and informing the doctor whereby diuretics could have been
administered. The diagnosis Risk for Infection is inaccurate, as infection has occurred (See
definition of Empyema, parapneumoniac effusion). In the assessment, the lung sounds of the
patient were not auscultated. In addition, no mention of coughing was made, yet the patient was
reported as admitted with a cough with the production of thick, yellow-white sputum. Also, no
mention of sputum collection was made, and the subsequent identification of the bacteria that
was present within R.S.s pleural space. This is further evidenced by the administration of Flagyl
and Zosyn, which are both broadspectrum antibiotics. This is contraindicated according to the
research put forth by Hughes (Sahn 2007, pp. 1480-1486) in which he states that the correct
antibiotic must be used to provide for the accurate treatment of the condition and the prevention
of further proliferation.
Final Evaluation For Day 1 The final evaluation for day 1 maintains that, although the
health care team, both medical and nursing responsible for this patients care did a good job,
important facets of the care plan as evidenced by the literature review were left out, foremost
was the lack of sputum culture by the nurse and the subsequent bacterial identification and
corresponding antibiotic proscription by the doctors.
Evaluation Criteria
Antibiotic Therapy Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to
combat the bacteria present within the pleural space. This is in accordance with the use of
antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).
Evacuation of Supportive Fluid Patient R.S. was noted to have 75cc of hemopurulent
fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also,
oscillations were noted, indicating that the nurse was monitoring the status of the thoracotomy
tube as necessary for proper evacuation (Sahn 2007, pp. 1480-1486).
Antipyretics Patient R.S. was constantly monitored to determine whether or not antipyretic
measures would be need. None were administered as the temperature was within acceptable
range (97.2F). In addition, the continuous administration of Panadol as ordered provided an
antipyretic effect. Monitoring for the presence of hyperthermia is important, as both the infection
and inflammation present in parapneumonic effusion with empyema will have a direct effect on
the temperature. Thus, if the temperature is within normal ranges, it indicates the
infection/inflammation is being adequately managed. This is in accordance with the information
presented in the literature review (Colice 2000, pp1158-71).
Final Evaluation for Day 2 The final evaluation for day two reports that not only does
the sputum culture remain undone, but the breath sounds were not auscultated to indicate the
level of exudate infiltration within the pleural space or whether or not atelectasis, an important
complication, had started to occur. In addition, there was no mention of the patients cough and
subsequent production of sputum, nor was there mention of any teaching methods designed to
enhance the patients cough reflex.
Evaluation Criteria
Antibiotic Therapy Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to
combat the bacteria present within the pleural space. This is in accordance with the use of
antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).
Evacuation of Supportive Fluid Patient R.S. was noted to have 150cc of hemopurulent
fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also,
oscillations were noted, indicating that the nurse was monitoring the status of the thoracotomy
tube as necessary for proper evacuation (Sahn 2007, pp. 1480-1486) .
Antipyretics Patient R.S. was constantly monitored to determine whether or not antipyretic
measures would be need. None were administered as the temperature was within acceptable
range (96 F). In addition, the continuous administration of Panadol as ordered provided an
antipyretic effect. Monitoring for the presence of hyperthermia is important, as both the infection
and inflammation present in parapneumonic effusion with empyema will have a direct effect on
the temperature. Thus, if the temperature is within normal ranges, it indicates the
infection/inflammation is being adequately managed. This is in accordance with the information
presented in the literature review (Colice 2000, pp1158-71).
Analgesics The need for analgesia is indicated not only by the presence of the chest tube in
situ (Sahn 2007, pp. 1480-1486) even though the client had no c/o of pain during the
nursesreceivalassessment. This is evidenced by the administration of Pethidine 75mg throughout
the day. Pethidine is a narcotic analgesic which can cause respiratory depressant effects, and thus
administration of this drug should have been followed by a thorough assessment of the patients
respiratory system, which was not noted. Voltaren and Panadol were both administered for the
purpose of analgesia. This is an important management, as the presence of pain not only leads to
patient discomfort and decreased compliance with treatment methods, but can lead to ineffective
breathing and complications such as atelectasis (Colice 2000, pp1158-71). Baralgin was also
administered, which is contraindicated in patients with infection as long term Baralgin use can
lead to agrannulocytosis, particularly with a reduction in bactericidal neutrophils. Thus, the
researcher does not agree with the prescription/administration of Baralgin.
Final Evaluation for Day 3 The final evaluation for day three reports that not only does
the sputum culture continue to remain undone, but the breath sounds were not auscultated to
indicate the level of exudate infiltration within the pleural space or whether or not atelectasis, an
important complication, had started to occur. In addition, there was no mention of the patients
cough and subsequent production of sputum, nor was there mention of any teaching methods
designed to enhance the patients cough reflex. There was also no mention of an assessment of the
wound site. Wound site assessment is important during dressing changes as it indicates the
presence or potential for reinfection/ super infection (Hughes 1991).
Evaluation Criteria
Antibiotic Therapy Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to
combat the bacteria present within the pleural space. This is in accordance with the use of
antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).
Evacuation of Supportive Fluid Patient R.S. was noted to have 200ml of hemopurulent
fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also,
oscillations were noted, indicating that the nurse was monitoring the status of the thoracotomy
tube as necessary for proper evacuation (Sahn 2007, pp. 1480-1486) .
Antipyretics Patient R.S. was constantly monitored to determine whether or not antipyretic
measures would be need. None were administered as the temperature was within acceptable
Final Evaluation for Day 4 The final evaluation for day four reports that the sputum
culture was not done. Also, the lack of auscultation of breath sounds indicates a deficiency in the
assessment performed by nurse, and constitutes an unacceptable practice, in accordance with the
literature review. In addition, there was no mention of the patients cough and subsequent
production of sputum, nor was there mention of any teaching methods designed to enhance the
patients cough reflex, both necessary in the removal of sputum from the patients airways.
Final Evaluation
it is interesting to note that only on day four was an assessment of the abdomen done, even
though the primary reason for seeking health care by the patient was loss of appetite and marked
weight loss. No mention of interventions whether medical or nursing to deal with this concern of
the client was made. Also, a note made in the patients record indicateds that an order for fluid
culture by the doctor was made on the 2/11, which was over a week after admission. Culture
collection and analysis should have been one of the first interventions done, as it is one of the
three primary principles of empyema care (Tobler et al. 2004).
Glossary
1.
2.
3.
4.
21. Thoracentesis-is a procedure to remove fluid from the space between the lining of
the outside of the lungs (pleura) and the wall of the chest.
22. Thoracostomy- is a flexible plastic tube that is inserted through the chest wall and
into the pleural space or mediastinum. It is used to remove air, fluid or pus from the
intrathoracic space.
23. Parapneumonic effusion- is a type of pleural effusion that arises as a result of a
pneumonia, lung abscess, or bronchiectasis.
24. Hemithorax- this is half of the thorax.
25. Comorbidity- this is two or more coexisting medical conditions or disease.
26. PPE-Parapneumonic Pleural effusion
27. CPPE- Chronic Parapneumonic Pleural effusion
Appendix
COMPLETE BLOOD COUNT
The complete blood count (CBC) is often used as a broad screening test to determine an
individual's general health status. According to (Complete, 2012), a CBC is a panel of tests
that evaluates the three types of cells that circulate in the blood; Evaluation of white blood cells,
the cells that are part of the body's defense system against infections and cancer and also play a
role in allergies and inflammation, evaluation of red blood cells, the cells that transport oxygen
throughout the body and the evaluation of platelets, cell fragments that are vital for normal blood
clotting. It can be used to:
Monitor treatment that is known to affect blood cells, such as chemotherapy or radiation
therapy
CHEST PHYSIOTHERAPY
Chest physiotherapy (CPT) is a technique used to mobilize or loose secretions in the lungs and
respiratory tract (Chest Physiotherapy, 2011). This is especially helpful for patients with large
amount of secretions or ineffective cough. Chest physiotherapy consists of external mechanical
maneuvers, such as chest percussion, postural drainage, vibration, to augment mobilization and
with substances that promote the growth of bacteria or fungi. If no bacteria or fungi grow, the
culture is negative. If organisms that can cause infection grow, the culture is positive. The type of
bacterium or fungus will be identified with a microscope or by chemical tests. If bacteria or fungi
that can cause infection grow in the culture, other tests may be done to determine which
antibiotic will be most effective in treating the infection. This is called susceptibility
or sensitivity testing.
This test is done on a sample of sputum that is usually collected by coughing. For people who
can't cough deeply enough to produce a sample, they can breathe in a mist solution to help them
cough. A sputum culture is done to:
Find and identify bacteria or fungi that are causing an infection (such as
pneumonia or tuberculosis) of the lungs or the airways leading to the lungs. Symptoms of
a lung infection may include difficulty breathing, pain when breathing, or a cough that
produces bloody or greenish brown sputum.
CHEST X-RAY
A chest x ray is a painless, noninvasive test that creates pictures of the structures inside the chest,
such as the heart, lungs, and blood vessels. This test is done to find the cause of symptoms such
as shortness of breath, chest pain, chronic cough (a cough that lasts a long time), and fever. Chest
x rays help doctors diagnose conditions such as pneumonia, heart failure, lung cancer, lung tissue
scarring, and sarcoidosis. Doctors also may use chest x rays to see how well treatments for
certain conditions are working. (Chest,2010)
CHEST TUBE THORACOSTOMY
According to (American Thoracic Society, 2012), a chest tube thoracostomy is done to drain
fluid, blood, or air from the space around the lungs. Some diseases, such as pneumonia and
cancer, can cause an excess amount of fluid or blood to build up in the space around the lungs
(called a pleural effusion). Also, some severe injuries of the chest wall can cause bleeding around
the lungs. Sometimes, the lung can be accidentally punctured allowing air to gather outside the
lung, causing its collapse (called a pneumothorax). Chest tube thoracostomy (commonly referred
to as "putting in a chest tubevm") involves placing a hollow plastic tube between the ribs and
into the chest to drain fluid or air from around the lungs.
THORACENTESIS
Thoracentesis is a procedure to remove fluid from the space between the lungs and the chest wall
called the pleural space. It is done with a needle (and sometimes a plastic catheter) inserted
through the chest wall. Ultrasound pictures are often used to guide the placement of the needle.
This pleural fluid may be sent to a lab to determine what may be causing the fluid to build up in
the pleural space.
On average only a small amount of pleural fluid is present in the pleural space. A buildup of
excess pleural fluid (pleural effusion ) may be caused by many conditions, such as infection,
inflammation, heart failure, or cancer. If a large amount of fluid is present, it may be hard to
breathe. Fluid inside the pleural space may be found during a physical examination and is usually
confirmed by a chest X-ray. (Thompson, 2011)
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