3.

Synthesis of the disease

3.1. Definition of the disease

Pneumothorax, or collapsed lung, is a potential medical emergency caused by

accumulation of air or gas in the pleural cavity, occurring as a result of disease or

injury, or spontaneously.

Classification of Pneumothorax

Spontaneous

 Cause is “Unknown”

 Could be result of another disease such as COPD, PTB and Cancer

 Chest wall is intact; blebs/bulla is rapture causing collapse lungs.

(a bladder-like structure more than 5 mm in diameter with thin walls that may be full of

fluid)

38
Tension

 Site of Pleural rapture acts as one way valve, permitting air to enter on inspiration but

preventing its escape by closing up during expiration.

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

 Air enters pleural space to the hole in chest wall or diaphragm.

 Cause of surgery on the chest or trauma to the chest wall. (e.g. stab wound)

(it allows air to enter the pleural space)

Close Pneumothorax

 Air escapes in pleural space from a puncture or tear in an internal respiratory structure

such as bronchus, bronchioles, and alveoli.

 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

 Sudden shortness of breath

 Dry coughs

39
 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

indicate pneumothorax, hence the term "sucking" chest wound.

 If untreated hypoxia may lead to loss of consciousness and coma.

 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.

 Untreated, a severe pneumothorax can lead to death within several minutes.

Spontaneous

 Pleural pain

 Tachypnea

 Mild Dyspnea

 P.E.

o Reveal Absent / decreased breath sound

o Hyperesonance (percussion) on the affected side.

Tension

 Severe hypoxemia

 Dyspnea

 Hypotension

 Venous return is decreased (result of compression by the increasing pressure)

 Shock

40
 Bradycardia

Assessment and Diagnostic findings

 Dyspnea

 Tachycardia

 Tachypnea

 Sharp chest pain

 Pleural Pain

 Absent of breath sound

 Decreased expansion unilaterally

 Cyanosis

 Hypotension

 Sucking Wound

 Tracheal deviation to the unaffected

side with tension pneumothorax

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

side because of a collapsed lung.

 Electrocardiogram (ECG)

Will be performed to record the electrical impulses that control the heart's activity.

 Arterial Blood Gases (ABGs)

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

decompress it until a chest tube can be placed

 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.

44
 After the pneumothorax is evacuated and the pleural rupture is healed, the chest tube is

removed.

Chest Thoracostomy Tube

 Returns (-) pressure to the internal pleural space

 Remove abnormal accumulation of air

 Serves as lung while healing is ongoing.

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

flow to the bottom of the pleural space.

45
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

46
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

47
V. PATIENT AND HIS CARE

1.Medical Management

48
 DATE
ORDERED
MEDICAL
DATE GENERAL
MANAGEMENT
PERFORMED DESCRIPTION
TREATMENT
DATE
CHANGED D/C
> These chemicals helps to > given to patients who have
D5 0.3NaCl 500cc x 53- DO : 08-24-09 maintain or give sufficient
54 ugtts/min DP: 08-24-09 level of sodium and
chloride which are needed
for normal body function.
>Oxygen therapy is used
to relieved patient from
hypoxemia.
>Administration of
oxygen helps to improve
Oxygen inhalation at 2- DO : 08-24-09 gas exchange between
3 LPM DP: 08-24-09 the alveoli and the blood
to increase concentration
of inspired air and to
assist the patient to meet
metabolic demands.
>a NGT may be inserted
NGT DO: 08-24-09 to take samples of
DP: 08-24-09 stomach contents for
D/C : 08-27-09 laboratory studies and to
test for pressure or motor
activity of the
gastrointestinal tract.
>Placing a NGT helps
prevent nausea and
vomiting by removing
stomach contents and
preventing distention of
the stomach when a
patient has a bleeding
ulcer, bowel obstruction
or other gastrointestinal
diseases.
CLIENT’S
INDICATION AND
RESPONSE TO THE
PURPOSE
TREATMENT
> The patient experience
low levels of pain on the venipuncture
sodium or chloride. site.
> may also be used for the
dilution of other medicines
before injecting into the body.
>To deliver low
concentration of
oxygen when only minimal
oxygen support is required. > The patient did not
>Used to increase manifest signs and
concentration of inspired air symptoms of respiratory
in order to assist the patient distress.
to meet cellular demand.
>To allow an uninterrupted
delivery of oxygen while the
client ingests food or fluids.
> to deliver substances > The patient becomes
directly into the stomach, irritable.
remove substances from the
stomach or as a means of
testing stomach function or
contents.
49
50
2.NURSING RESPONSIBILITIES:

i. INTRAVENOUS FLUID (IVF)

Prior:

 Verify the doctor’s order.

 Explain the procedure to the SO.

 Obtain the necessary materials. Acquaint the SO with the requirements needed for

IV infusion.

During:

 Check IV level.

 Check for the patency of the tubing.

 Check if the IVF is infusing well

 Select a suitable vein for vernipuncture

 Practice aseptic technique.

After:

 Adjust rate of flow of fluids appropriate to needs of patient as prescribed.

 Monitor IVF flow and patient’s response.

 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.

 Record all procedures done.

ii.NASOGASTRIC TUBE (NGT)

Prior:

51
 Check physician’s order for irrigation. Explain procedure to patient.

 Gather necessary equipment. Check expiration dates on irrigating saline solution

and irrigation set.

 Perform hand hygiene.

 Assist patient to semi-Fowler’s position, unless contraindicated.

 Check placement of nasogastric tube.

 Pour irrigating solution into container. Draw up 30 mL of saline solution (or

amount ordered by physician) into syringe. Don nonsterile gloves.

 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

agency or physician indicates). Do not force solution into tube.

 If unable to irrigate tube, reposition patient and attempt irrigation again. Check

with physician if repeated attempts to irrigate tube fail.

 Withdraw or aspirate fluid into syringe. If no return, inject 20 cc of air and

aspirate again.

 Reconnect tube to suction. Observe movement of solution or drainage. Remove

gloves.

 Measure and record amount and description of irrigant and returned solution.

 Raise equipment if it will be reused.

52
 Perform hand hygiene.

 Record irrigation procedure, description of drainage, and patient’s response.

During:

 Check physician’s order for insertion of nasogastric tube.

 Explain procedure to patient.

 Gather equipment.

 If nasogastric tube is rubber, place it in a basin with ice for 5 to 10 minutes or

place a plastic tube in a basin of warm water if needed.

 Assess patient’s abdomen.

 Perform hand hygiene. Don disposable gloves.

 Assist patient to high Fowler’s position or to 45 degrees if unable to maintain

upright position and drape his or her chest with bath towel or disposable pad.

Have emesis basin and tissues handy.

 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

or her mouth for several minutes (according to physician’s preference).

53
 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

ever if no fluids are permitted. Advance tube in a downward-and-backward

direction when patient swallows. Stop when patient breathes. Provide tissues for

tearing or watering eyes. If gagging and coughing persist, check placement of

tube with a tongue blade and flashlight. Keep advancing tube until tape marking is

reached. Do not use force. Rotate tube if it meets resistance.

 Discontinue procedure and remove tube if there are signs of distress, such as

gasping, coughing, cyanosis, and inability to speak or hum.

 Determine that tube is in patient’s stomach. Hold tube in place to keep it from

withdrawing while placement is checked.

o Attach syringe to end of tube and aspirate a small amount of stomach

contents.

o Measure pH of paper or a meter.

o Visualize aspirated contents, checking for color and consistency.

o Obtain radiograph of placement of tube (as ordered by physician).

 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

tape nasogastric tubes.

o Place unsplit end over bridge of patient’s nose.

o Warp split ends under tubing and up and over onto nose.

54
 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.

 Assist or provide patient with oral hygiene at regular intervals.

 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

used and patient’s response.

After:

 Check physician’s order for removal of nasogastric tube.

 Explain procedure to patient and assist to semi-Fowler’s position.

 Gather equipment.

 Perform hand hygiene. Don clean disposable gloves.

 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

gown and carefully remove adhesive tape from patient’s nose.

 Attach syringe and flush with 10 mL normal saline solution or clean with 30 to 50

cc of air. (optional).

 Instruct patient to take a deep breath and hold it.

 Clamp tube with fingers by doubling tube on itself. Quickly and carefully remove

tube while patient holds breath.

55
  Place tube in disposable plastic bag. Remove gloves and place in bag.

 Offer mouth care to patient and facial tissues to blow nose.

 Measure nasogastric drainage. Remove all equipment and dispose according to

agency policy. Perform hand hygiene.

 Record removal of tube, patient’s response, and measure of drainage. Continue to

monitor patient for 2 to 4 hours after tube removal for gastric distention, nausea,

or vomiting.

iii.CHEST THORACOSTOMY TUBE (CTT)

Prior:

 Elevate the head of the bed to ease the work of breathing and to prevent fluid

collection in upper body (from superior vena cava syndrome).

 Teach breathing retraining exercises to increase diaphragmatic excursion and

reduce work of breathing.

 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.

 Provide humidifier or vaporizer to provide moisture to loosen secretions.

 Teach relaxation techniques to reduce anxiety associated with dyspnea. Allow the

severely dyspneic patient to sleep in reclining chair.

 Encourage the patient to conserve energy by decreasing activities.

56
 Ensure adequate protein intake such as milk, eggs, oral nutritional supplements;

and chicken, fowl, and fish if other treatments are not tolerated – to promote

healing and prevent edema.

 Advise the patient to eat small amounts of high-calorie and high-protein foods

frequently, rather than three daily meals.

 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.

 Consider alternative pain control methods, such as biofeedback and relaxation

methods, to increase the patient’s sense of control.

 Teach the patient to use prescribed medications as needed for pain without being

overly concerned about addiction.

During:

 Check for the tube’s patency

 Monitor patient’s vital signs

 Note for any signs of respiratory distress

After:

 Monitor patient’s vital signs

 Assess patient’s condition after procedure

 Provide safety measures

 Give analgesics as ordered

57
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

>Antibiotic. Interferes with >Treatment of > The patient

Cefotaxime DO:08-24-09 215mg IV every 6 bacterial cell wall synthesis by
DG:08-24-09 hours (-)ANST inhibiting the cross linking of the
peptidoglycan. Peptidoglycans
make cell membranes rigid and
protective. Without it, bacterial
cells rupture and die.
infections due to experienced pain
susceptible organisms in the iv site.
that is serious & life-
threatening. Also used
as prophylaxis for
surgical infections.

>Dilates bronchial airways by >To loosen mucus >The patient

Salbutamol DO:08-24-09 1 nebulization triggering beta2 receptors. secretions for easy demonstrated
(Ventolin) DG: 08-24-09 every 2 hours drainage. relief of DOB and
easy
expectoration of
secretions.

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

59
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.

60
 >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.

61
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:

62
  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.

63
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:

64
  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:

65
  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

TYPE OF DIET DATE ORDERED GENERAL INDICATIONS SPECIFIC CLIENTS

DATE DESCRIPTION AND PURPOSES FOODS TAKEN RESPONSE OR
STARTED/CHANGED REACTION TO
THE DIET
>To avoid
This kind of diet aspiration of gastric
includes nothing by content due to
NPO DO:08-24-09 mouth meaning the vomiting >NONE >Patient looks
DS:08-24-09 patient is ordered >To undergo a hungry.
not to take any kind specific diagnostic
of food or liquid. procedure that may
require an NPO
order.

66
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.

67
VI. NURSING CARE PLAN and SOAPIER
First Nursing-Patient Interaction (August 27, 2009)

68
 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

-assist in -to clear airway

nebulization

-demostrate -to mobilize

bronchial tapping secretions
after nebulization
71
-give - to maintain
bronchodilators airway
(salbutamol neb) as
72
SOAPIE
August 27, 2009
S: Ø
O: Receive patient lying on crib, awake; c an IVF of D5 3NaCl at the level of 120 cc x
53-54 ugtts/min; infusing well at the R hand, c an O2 inhalation via NC regulated at 2-3
lmp, c a chest thoracostomy tube on the R connected to a bedside bottle. c a diminished
breathe sound on the R lung c nasal flaring; c dry lips; v/s recorded as: RR=96, PR=103,
Temp.=37˚C
A: Ineffective Breathing Pattern r/t presence of air in pleural cavity 2˚ Pneumothorax
AEB diminished breath sounds, RR=96.
P: After 4˚ of nsg. Interventions, the mother will be able to verbalize understanding about
the interventions to be implemented on how to improve breathing pattern.
I:
• Established rapport
• Am care given
• Monitored and recorded v/s
• Auscultated breath sounds
• Provided safety measure
• Instructed mother to elevate heat 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
• Regulated O2 inhalation
• @11:15am pt. is out on pass for fluoroscopy in Calcutta.
E: Goal met AEB verbalized understanding of the mother about the interventions and
health teachings given.
August 28, 2009
S: Ø
O: Receive patient lying on crib, asleep; c an ongoing IVF of D5 3NaCl at the level of
200 cc x 53-54 ugtts/min; infusing well at the R hand, c an O2 inhalation via NC
regulated at 2-3 lmp, c a chest thoracostomy tube on the R connected to a bedside bottle.

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.

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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

Respiration is the act of inhaling and exhaling air in order to exchange

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

factors, such as pollutants, harmful microorganisms, and weak immune

system, our respiratory functioning can be jeopardized, leading to mortality if

not treated. Pneumothorax for instance, can cause our respiratory system at

risk.

Pneumothorax, or collapsed lung, is a potential medical emergency caused

by accumulation of air or gas in the pleural cavity, occurring as a result of

disease or injury, or spontaneously. There are two kinds of pneumothorax: (1)

open pnemuthorax and (2) close pneumothorax. If it is not treated early, it

could make other complications and may lead to death.

Treatment can help a client feel better, stay more active, and slow the

progress of the disease. Treatments may include medicines, vaccines, oxygen

therapy, surgery, and managing complications. And as nurses, being 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

Based on the case presented, the following recommendations are given;

To the health care providers:

1. To broaden their knowledge and further prioritize concern and action

regarding Pneumothorax.

2. To give additional information regarding the disorder that would help them to

take extra effort in treating their clients.

3. To inform them of the latest updates in taking care of the client’s health

conditions.

To the Public:

1. To make them aware of the possibility of having Pneumothorax and what to

do in case they experience having such disorder.

2. To encourage them to be involved on campaigns and programs made by the

government towards preventing the disease.

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

the academe in terms of teaching this topic to the students.

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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

when they apply the knowledge in the clinical setting

To the government and other health groups:

1. To make the government take appropriate actions in handling this kind of

disorder that can threaten the lives of the public.

2. To enhance their perspectives and ideas on how to protect the public against

the disorder by means of information dissemination.

To the future researchers:

1. To help them in their future researches as this study will serve as a reference

for them to achieve their goal.

2. To use this study as their reference in improving their own study.

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X. BIBLIOGRAPHY

BOOK SOURCE:

 Black and Hawks. (2005) Medical-Surgical Nursing 7th edition. Elsevier Inc.

USA.

 Ray A. Hargrove- Huttel. (2005) Medical-Surgical Nursing 4th edition. Lippincott

Williams and Wilkins

 Carol Mattson Porth (2002). Pathophysiology: Concepts of Altered Health States

6th edition

 Ignatavius, Workman (2006).Medical Surgical Nursing: Critical thinking for

collaborative care 5th edition

INTERNET SOURCE:

 DOH, (2009). Health indicators. Statistics and Research, Retrieved August 6,

2009, from

http://www.doh.gov.ph/kp/statistics/morbidity

 US Census Bureau, Population.estimates, 2004

http://www. curesearch.com

 Healthday. (2008).Health, Healthy lifestyle, Retrieved August 6, 2009 from

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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