OUR LADY OF FATIMA UNIVERSITY

San Fernando, Pampanga

NCMB 314: Case Study

Submitted by: Beatrice Nicoli I. Rivera Submitted to: Anthony Ramos

You are caring for a 34-year-old patient who experienced blunt chest trauma in a motor vehicle crash. A chest tube was inserted to treat
a simple pneumothorax and hemothorax. The chest drainage system has drained 400ml of light red fluid during the 1st 6 hours after
insertion. The patient has become increasingly short of breath during the past hour. What physical assessment skills and strategies
would you use to determine potential changes in the patient’s respiratory condition? What are potential causes of this increasing
shortness of breath? What would you do to prepare for an emergency situation with this patient?

Pneumothorax and hemothorax are conditions that affect the pleural space surrounding the lungs. The chest drainage system has drained an abnormally
increasing amount of light red fluid from the patient. It is important to put the patient in a semi to high fowler’s position in order to promote lung expansion.
The nurse should also observe the patient’s breathing, cyanosis, pressure in the chest, and significant changes in the patient’s vital signs. Thoracic CT, chest
x-rays, and ABG monitoring are strategies which will be crucial in identifying any potential changes in the patient's respiratory state.
The potential factors that increase the patient’s shortness of breath is pneumothorax and hemothorax. Blood can build up between the chest wall and the lungs,
which is known as a hemothorax. Blood may be collected in the pleural cavity. As the blood pushes on the outside of the lung, the accumulation of blood in
this area may eventually cause your lung to collapse and this may be one of the potential causes in the increase of shortness of breath that the patient is going
through.

It is important to closely watch the patient, especially his chest tube. Always check the suction control chamber, monitor fluid level in the water-seal chamber
and maintain it at the prescribed level,and always observe the water-seal chamber bubbling. Anatomical landmarks should be used to determine the site of
incision for pleural decompression within the 'triangle of safety' to reduce risk of harm. In case of persistent air leaks, immediately clamp the thoracic tube and
put a gauze pad with petroleum jelly on the insertion site, this will serve as an airtight seal to prevent the recurrence of pneumothorax.
Pathophysiology: Hemothorax
Pathophysiology: Simple Pneumothorax
F-DAR

Focus Data, Action, Response

Risk for Acute Respiratory Distress syndrome DATA:

● Increasing shortness of breath over the past hour
● Chest tube inserted for simple pneumothorax and hemothorax.

ACTION:
● Listen for any changes in breath sounds, decreased or absent
breath sounds on the affected side.
● Evaluate the chest wall movement and look for signs of
respiratory distress.
● Administer supplemental oxygen to maintain oxygen
saturation.
● Hooked to cardiac monitor.
● Adequate rest provided.

RESPONSE:
● No signs of distress noted.

NCP

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective airway Short-term goal: 1. Assessment Regular assessments Short-term Goal
clearance related to After 4 hours of Conduct a thorough provide crucial Evaluation:
lung impairment nursing intervention, physical assessment, information about the After 4 hours of
the patient will be able including: patient's respiratory nursing intervention,
Objective: to improve ventilation ● Respiratory status and help in the patient has shown
Shortness of breath and have adequate rate and pattern detecting early signs of significant
400 ml of light red oxygenation. ● Chest complications. improvement in
fluid drained in the last symmetry and ventilation and
6 hours Long-term goal: movement Monitoring the chest oxygenation. The goals
After 24 hours of ● Breath sounds drainage system for this time frame have
nursing intervention the (auscultate for ensures that there are been met, and the
patient will be able to decreased or no obstructions or leaks patient's respiratory
improve respiratory absent breath that could affect lung status has improved.
function and will be sounds on the re-expansion.
free from symptoms of affected side) Long-term Goal
respiratory distress. ● Heart rate and Chest X-rays provide a Evaluation:
rhythm visual confirmation of After 24 hours of
● Blood pressure lung expansion and any nursing intervention,
Oxygen potential issues, such as the patient has made
saturation reaccumulation of substantial progress
(SpO2) pneumothorax or toward improving
● Level of hemothorax. respiratory function and
consciousness is no longer
● Skin color and experiencing symptoms
temperature of respiratory distress.
2. Monitor chest The long-term goal has
drainage been achieved, and the
system. patient is on a positive
Examine the chest trajectory toward
drainage system, recovery. Continued
ensuring that it's monitoring and
functioning correctly, appropriate care will be
and record the amount, essential to maintain
color, and
 characteristics of the and further enhance
fluid drained. Pay respiratory health.
attention to any sudden
increase in drainage.

3. Review chest
x-ray.
If available, review the
initial and most recent
chest X-rays to assess
for changes in lung
expansion and the
position of the chest
tube.

PHARMACOTHERAPEUTIC/MEDICATION
Drug Mechanism of Action Indication Adverse Effects Nursing Responsibility
Precaution

Generic Name: Sterile Talc Powder is a Indicated to prevent ● Fever and pain ● May preclude
Talc sclerosing agent for recurrence of malignant ● Dyspnea subsequent diagnostic
● Arrhythmia procedures of the
intrapleural administration. pleural effusions in pleura on the treated
Brand Name: Talc instilled into the pleural symptomatic patients during ● Empyema
side, including
Sclerosol, Steritalc ● Acute Respiratory
cavity is thought to result in thoracoscopy or open ipsilateral lung
Distress resective surgery and
Class: Sclerosing Agents an inflammatory reaction. thoracotomy.
pneumonectomy for
This reaction can promote Contraindications: transplantation
Dosage: adherence of the visceral and ● Hypersensitivity purposes
Aerosol Powder parietal pleura, which may ● No known
● 4g antineoplastic activity
prevent reaccumulation of
and should not be used
Suspension Reconstituted pleural fluid. alone for potentially
 ● 5g curable malignancies
where systemic
therapy would before
appropriate; does not
exhibit antineoplastic
therapy
● May cause pulmonary
complications (e.g.,
acute pneumonitis,
ARDS)
● Keep Sclerosol
(aerosol) away from
any heat source that
could cause it to
explode

Case Study: Community Acquired Pneumonia

Teresa, a 20 year old college student, lives in a small dormitory with 30 other students. Four weeks after the start of classes, she was diagnosed
as having bacterial pneumonia and was admitted to the hospital.

A. What intervention can the nurse provide to decrease the viscosity of secretions?

❖ Increasing fluid intake should take precedence because it will liquefy secretions and make expectoration easier for the patient. The nurse should
position the patient in a semi to high-fowler position in order to facilitate breathing and promote lung expansion and encourage the patient to cough or
suction the patient’s airway.
B. The nurse is assessing Teresa during the admission process. What manifestations of bacterial pneumonia does the nurse expect to
find?

❖ The nurse should expect to find a cough with thick yellow, green, or blood-tinged mucus. The patient articulates stabbing chest pain that worsens
when coughing or breathing and sudden onset of severe chills.

C. The nurse assesses Teresa for arterial hypoxemia. What does the nurse understand is the reason why this complication develops?

❖ The patient has been diagnosed with bacterial pneumonia and in its initial stages the intrapulmonary oxygen consumption by the lung during the acute
phase and ventilation-perfusion mismatch later on are both to some extent responsible for arterial hypoxemia. The main cause of this is the
persistence of pulmonary artery blood flow to consolidated lungs, which results in an intrapulmonary shunt. A relative failure of the hypoxic
pulmonary vasoconstriction (HPV) mechanism during acute pneumonia, which is at least caused by endogenous vasodilator prostaglandins associated
with the inflammatory process but also by other as of yet undefined mechanisms, appears to be the cause of the persistence of pulmonary blood flow
to consolidated lung.

D. The nurse is assessing vital signs and lung sounds every 4 hours. What complications should the nurse monitor for?

❖ The nurse should observe and immediately report the patient’s rapid or shallow breathing, cyanosis, pressure in the chest, subcutaneous emphysema,
symptoms of hemorrhage or significant changes in vital signs especially the patient’s respiratory rate and oxygen saturation.
Pathophysiology: Community Acquired Pneumonia
 F-DAR

Focus Data, Action, Response

Ineffective Airway Clearance DATA:

● Patient is diagnosed with bacterial pneumonia.

● Viscous secretions

ACTION:
● Place the patient in a semi to high-Fowler’s position to
promote lung expansion.
● Instruct the patient to perform deep breathing exercises.
● Assist the patient to perform incentive spirometry.
● Assist with chest physiotherapy.
● Adequate rest provided.

RESPONSE:
● Enhanced lung expansion and airway clearance.
 NCP

ASSESSMENT DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATION

S
Subjective: Short-term Goal: Independent: Independent: Short-term Goal:
● Shortnes Ineffective After 6 hours of 1. Assess the patient’s respiratory rate, depth, To identify signs of respiratory After 6 hours of
s of airway nursing intervention pattern, and abnormal breath sounds such as distress, airway obstruction, or nursing intervention the
breathclearance the patient will be wheezing or crackles abnormal lung sounds that may patient was able to:
● Cough related to able to: indicate excessive mucus or ● Verbalize signs of
thick ● Verbalize 2. Assess the patient’s cough frequency, secretions. effective airway
Objective: secretions as signs of effectiveness, and any associated symptoms clearance
● Hypoxemi evidenced by effective like chest pain or shortness of breath determine the patient’s ability to ● Expectorate secretions
a dyspnea and airway clear their airways and identify readily and effectively
hypoxemia clearance 3. Monitor and note the patient’s oxygen any factors that may impair ● Demonstrate
V/S: ● Expectorate saturation levels using pulse oximetry and effective coughing, such as weak increased air
● HR: 102 secretions assess for signs of hypoxemia or hypoxia, such respiratory muscles or excessive exchange as
bpm readily and as cyanosis or altered mental status mucus production. evidenced by oxygen
● RR: 26 effectively saturation levels
bpm ● Demonstrate 4. Assess the airway for patency To determine the adequacy of within the normal
● BP: increased air oxygen exchange and guide range (above 95%)
120/80 exchange 5. If tolerated, position the patient in an optimal appropriate interventions. ● Maintain adequate
● O2Sat: ● Maintain upright or semi-to-high-fowler’s position to oxygen levels in the
93% adequate facilitate optimal lung expansion and improve Maintaining the patency of the blood
oxygen levels airflow. airway is always the first and
in the blood highest priority Long-term Goal:
6. Encourage the patient to increase hydration or After 24 hours of
Long-term Goal: fluid intake, if not contraindicated This position helps reduce the nursing intervention the
After 24 hours of compression of the diaphragm, patient was able to:
nursing intervention 7. Perform chest physiotherapy techniques such allowing for better lung expansion ● Maintain and improve
the patient will be as percussion, vibration, and postural drainage and ventilation, improving air clear, open airways as
able to: exchange, and promoting airway evidenced by a
clearance. respiratory rate within
the normal range (12
● Maintain and 8. Teach and encourage the patient to perform Adequate hydration thins to 20 breaths per
improve clear, deep breathing and coughing exercises and/or secretions, loosens and liquefy minute), a regular and
open airways incentive spirometry mucus, and prevents dehydration. adequate depth of
● Demonstrate respirations, and the
absence or 9. Educate the patient about proper deep To help dislodge and mobilize ability to effectively
reduction of breathing exercises, coughing techniques, and bronchial secretions, making it cough up secretions
congestion strategies to improve and promote airway easier for patients to cough and after treatments and
with breath clearance clear their airways effectively. deep breaths.
sounds clear, ● Demonstrate absence
improved 10. Perform suctioning as needed These exercises help improve or reduction of
oxygen cough effectiveness, increase congestion with
exchange, and Dependent: oxygenation, and enhance the breath sounds clear,
respiration 1. Administer medications (bronchodilators, mobilization and clearance of improved oxygen
noiseless. mucolytics, expectorants, antibiotics, secretions. exchange, and
● Demonstrate steroids) as prescribed respiration noiseless.
and practice Patient education enables ● Demonstrate and
deep 2. Administer supplemental oxygen (2-3L/min) individuals to actively manage practice deep
breathing and as ordered their conditions, encourages breathing and
coughing adherence to prescribed coughing exercises
exercises Collaborative: treatments, and allows for early independently
independently 1. Refer to or collaborate with pulmonary detection of deteriorating
clinical nurse specialists or respiratory symptoms.
therapists as indicated
Suctioning aids in clearing of
accumulated secretions in the
airways, enhancing airway
patency and promoting efficient
breathing.

Dependent:
These medications help improve
breathing by reducing airway
resistance, reducing mucus
thickness, and promoting
clearance of airway secretions.
 Supplemental oxygen helps
ensure sufficient oxygen supply to
the tissues, improving
oxygenation, and facilitating gas
exchange and perfusion

Collaborative:
Consultants can incorporate more
advanced interventions and can
recommend treatment changes.
They may also be helpful in
ensuring that proper treatments
are met.

PHARMACOTHERAPEUTIC/MEDICATION

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICAT ADVERSE NURSING

ACTION IONS EFFECT RESPONSIBILITY
PRECAUTION

Generic Name: Prototype of the Ibuprofen is a Patient in whom CNS: Headache,

Ibuprofen propionic acid nonsteroidal urticaria, severe dizziness, ● Monitor for
NSAIDs (cox-1) anti-inflammatory rhinitis, light-headedness, therapeutic
Brand Name: inhibitor with drug (NSAID) used bronchospasm, anxiety, emotional effectiveness.
Advil, Amersol, nonsteroidal to control mild to angioedema, nasal lability, fatigue, Optimum
Children's Motrin, antiinflammatory moderate pain for polyps are malaise, drowsiness, response
Ibuprin, Junior activity and patients with precipitated by anxiety, confusion, generally
Strength Motrin significant antipyretic hemothorax and aspirin or other depression, aseptic occurs within
Caplets, Medipren, and analgesic pneumothorax. NSAIDs; active meningitis. 2 wk.
Motrin, Nuprin, properties. Blocks peptic ulcer, bleeding ● Observe
Pediaprofen, prostaglandin abnormalities. Safe CV: Hypertension, patients with
Pamprin-IB, Rufen, synthesis. Ibuprofen use during pregnancy palpitation, history of
Trendar activity also includes (category B), congestive heart cardiac
modulation of T-cell lactation, or children failure (patient with decompensati
Classification: function, inhibition of <6 mo is not marginal cardiac on closely for
NSAID (COX-1) inflammatory cell established. function); peripheral evidence of
chemotaxis, edema. fluid retention
Route: Oral decreased release of and edema.
superoxide radicals, Special Senses: ● Lab tests:
or increased Amblyopia (blurred Baseline and
scavenging of these vision, decreased periodic
compounds at visual acuity, evaluations of
inflammatory sites. scotomas, changes in Hgb, renal
color vision); and hepatic
nystagmus, function, and
visual-field defects; auditory and
tinnitus, impaired ophthalmolog
hearing. GI: Dry ic
mouth, gingival examinations
ulcerations, are
dyspepsia, heartburn, recommended
nausea, vomiting, in patients
anorexia, diarrhea, receiving
constipation, prolonged or
bloating, flatulence, high-dose
epigastric or therapy.
abdominal discomfort ● Monitor for
or pain, GI GI distress
ulceration, occult and S&S of
blood loss. GI bleeding.
● Notify
Hematologic: physician
Thrombocytopenia, immediately
neutropenia, of passage of
hemolytic or aplastic dark tarry
anemia, leukopenia; stools, "coffee
decreased Hgb, Hct; ground"
transitory rise in emesis,
AST, ALT, serum frankly
alkaline phosphatase; bloody
rise in (Ivy) bleeding emesis, or
time. GU: Acute other GI
renal failure, distress, as
polyuria, azotemia, well as blood
cystitis, hematuria, or protein in
nephrotoxicity, urine, and
decreased creatinine onset of skin
clearance. rash, pruritus,
jaundice.
Skin: Maculopapular
and vesicobullous
skin eruptions,
erythema multiforme,
pruritus, rectal
itching, acne.

Body as a Whole:
Fluid retention with
edema,
Stevens-Johnson
syndrome, toxic
hepatitis,
hypersensitivity
reactions,
anaphylaxis,
bronchospasm, serum
sickness, SLE,
angioedema.