GLOBAL CITY INNOVATIVE COLLEGE

Associate in Health Science Education

Fort Bonifacio, Taguig City, Metro Manila

College of Nursing and Allied International Health Studies

A Study of
Pneumohemothorax of a 22 year old male

In Partial Fulfillment of the Requirements

In Related Learning Experience 103

Presented to:
College of Nursing Faculty
Global City Innovative College

Presented by:

The Class of
N-313
1St Semester SY 2010-2011
INTRODUCTION:

When we breath, you think it’s as simple as 1,2,3 and it is when you do
it but when there’s an illness involved it gets more complicated than that
and then people realize that there’s so much more than the process and its
not 1,2,3 anymore its like some algebraic expression that needs more
understanding.

So what if air enters the pleural cavity what happens? Is that a good
thing? When you say air enters your body you think it’s a normal
circumstance but then why do doctors fear this instance so much? This
situation is called Pneumothorax, this is a collection of air or gas in the
pleural cavity of the chest, and this is between the lung and the chest wall.
These kinds of things may occur spontaneously but usually these things
happen because of trauma or it comes as a secondary disease.

A pneumothorax is a collection of free air in the chest outside the lung

that causes the lung to collapse. Spontaneous pneumothorax is caused by
a rupture of a cyst or a small sac (bleb) on the surface of the lung.
Pneumothorax may also occur following an injury to the chest wall such as a
fractured rib, any penetrating injury (gun shot or stabbing), surgical invasion
of the chest, or may be deliberately induced in order to collapse the lung. A
pneumothorax can also develop as a result of underlying lung diseases,
including cystic fibrosis,chronic obstructive pulmonary disease (COPD), lung
cancer, asthma, and infections of the lungs. The symptoms of pneumothorax
are determined by the size of the air leak and the speed by which it occurs,
they may include chest pain and shortness of breath. Although there are
cases that small spontaneous pneumothoraces do not require treatment, it’s
always best that you go for the better path and have a check up once in a
while.

The following statistics relate to the incidence of Pneumothorax:

• 1.011 per 1,000 hospitalised at risk patients developed

pneumothorax in the Philippines in 2006-2008
• 18% of the 1.011 patients die from pneumothorax

Objectives

1. To gain more knowledge and to further understand the nature and

extent of the disease so as to prepare and arm ourselves with
knowledge whenever we encounter the same case in the future.

2. To have a clear and better understanding of pneumothorax particularly

on its disease process, treatment, diagnostic exam, preventive
measures and nursing management.

1. To know the latest facts and keep ourselves updated with the newest
information about pneumothorax.

2. To be familiar with the disease that may help us in doing health

teachings with our patient.

3. To make the student nurses aware of the manifestations and

complications brought by pneumothorax
 4. To present the anatomy and physiology of pneumothorax related with
our patient’s condition

5. To discuss the medical and surgical interventions related to our

patient.

Nursing History

History of Present Illness:

One hour prior to admission, the patient was walking on a sidewalk

when an unknown person stabbed him on his right chest. He was then
rushed to the Cardinal Santos Medical Center by the bystanders. The patient
was experiencing ipsilateral pain with a pain scale of 10/10 and blood loss.

Past Medical History

The patient reported that he has a history of convulsion when he was a

child he also had a fracture on his right clavicle due to a fall accident and
was hospitalized on De Ocampo, he was treated and given medications for
pain. He completed his vaccination such as BCG, OPV, DPT, Measles and
Hepa B when he was a child.

Family History

The patient has 3 siblings, who are in good condition, same as his
mother and father. His mother had breast cancer and undergone
mastectomy of the right breast. His mother side has a history of
hypertension while his father side has a history of Lung cancer.
 Legend:

- Father’s side: Lung cancer

- Mother’s side: Hypertension; Breast Cancer

- Patient: Pneumothorax

- Siblings

“Nursing Health History”

Pattern of health Prior to During Interpretation

hospitalization hospitalization
1. Health -The patient does -He cannot do -He can’t adjust
Perception & not experience any some athletic well because he
Health diseases before activities and feels can’t do what he
management and he used to be ill to be in the wants, but his
pattern athletic. He does hospital. condition is
not smoke and he improving.
is an occasional
drinker. He does
not use drugs &
used to have
regular check-ups.
2. Nutritional and -The patient is -He takes -Nothing changed.
Metabolic pattern given a diet as multivitamins(Cen
tolerated. The trum Complete)
client eats with no 500mg/day, drinks
difficulty. He eats 8 glasses of water,
almost everything and eats mixed
and eats 3 times a meat and
day. A 1 cup of rice vegetables at
in the morning with least three times
different kinds of a day
meat or
vegetables, same
in the lunch time
and dinner time.
He takes vitamins
and drinks plenty
of water at least
2000 cc per day.
He has a big
appetite and can’t
easily recover from
illnesses.
3. Elimination -He urinates 5-6 -He eliminates -His feces changed
Pattern times a day. He every day, feces from the normal to
described the urine are slightly wet slightly wet and
as somewhat and soft and in lesser than before
yellowish in color. brownish in color. may be because of
The amount is He also urinates hospitalization.
around 250 cc per lesser than before.
urination. The
patient defecates
with brown formed
stools. The color is
brown and as said
by the mother. The
patient stated that
there is no problem
in elimination.
4. Activity- - He has enough - He can’t exercise - He can’t do
Exercise Pattern energy to do his that much and his normal tasks
tasks. He is very exercise is just by because he is in
active. He used to merely walking the hospital
jog every morning around the area.
and do swimming
activities. He does
not easily get tired
 and he has lots of
energy reserve.
The mother of the
patient stated that
he is a very active
person who easily
gets bored when
he just sits down.
5. Sleep-Rest -He used to sleep 8 -He can’t sleep -He can’t sleep
Pattern hours a day and well and can’t do well because of
used to have a nap much activities. the setting and
every afternoon. He just do social being disturbed by
He watches networking when the nurses.
movies, do he feels stress
swimming and eat and tired
snacks when he
feels tired. The
patient stated that
he doesn’t have
any problems in
falling asleep.
6. Cognitive- -The patient -The patient feels -due to his
Perceptual doesn’t have any pain in his right operation done
Pattern problem on eye lung & side of the
vision, hearing stitches
acuity and in
memory. He
doesn’t feel any
pain
7. Self-Perception -The patient used -He become less -He feels bored
and Self-Concept to be calm and do patient and do because he
Pattern daily tasks facebook already stayed in
the hospital for a
month already
8. Role- -He lives with his -With his mom in -His happy
Relationship brother with no the hospital and because his
Pattern problems. His his friends visits friends visits him
family is used to be him
healthy and close
to people. The
mother added that
the most common
problem they have
revolves around
management of
finances.
 Whenever they are
short of money, the
mother of the
client mentioned
that she borrows
money from her
friends or relatives.

9. Sexuality- -he is a bisexual -The patient is Nothing is

Reproductive and does not have single and changed
Pattern any commitment. bisexual

10. Coping-Stress -He don’t feel -Can’t meet his -He can’t go where
Tolerance Pattern nervous & just friends and feel he wants because
calm and used to bored in hospital of hospitalization
hang out with his
family and friends
11. Value-Belief -He achieve his -He can’t do what -He does not
Pattern dreams and goals he wants. Don’t believe in
in life. He loves his believe in superstitions
religion so much. superstitions

Physical Assessment:

Name of Patient: Patient JS

Unit/Ward: San Lorenzo Ruiz Ward/1H

Age: 22 y/o Sex: male Civil status: Single

Diagnosis: Pneumohemothorax in the right lung.

Physical Exam

Date: Sept. 9, 2010

Temp: 37.1oC per tympanic membrane

PR: 83bpm (regular, bounding)

RR: 27cpm (diaphragmatic, regular, deep and moderately labored breathing)

BP: 90/60 mmHg, lying

Height: 168cm

Weight: 48 kg BMI: 17.02 (Underweight)

Date of Admission: August 18, 2010 11:07pm

General Survey: Patient is conscious, coherent, oriented to time, place and

person with mild cardio-respiratory distress, endomorph, and calm. With
oxygen support of 2L per minute via nasal cannula and IVF of PNSS 1L x 16o
at the right metacarpal.

Assessm Normal Actual Analysis/

ent Findings Findings interpretation

Inspection Color: depends Pale Pallor may be an

SKIN
, palpation on race, can be Rough indication of
whitish pink, Fair skin turgor possible premature
brown shade to Warm to touch destruction of
black. Dry skin erythrocytes which
No lesions, results in the
masses liberation of
No cyanosis, hemoglobin from
erythema, the erythrocytes
jaundice, pallor, into the plasma;
petechiae, which then causes
rashes the paleness on the
skin.
Texture:
smooth, soft, no Dry and rough skin
lesions, is due to loss or
ulcerations, deficiency of water
scar, papule, in the body tissues.
mapule The condition
results from
Turgor: good inadequate fluid
skin turgor intake and/or from
excessive removal
 Moisture: moist of water in the
Temperature: body.
warm to touch
(Textbook on
medical surgical
nursing, 12th
edition, p.910.)

Color: Pinkish Smooth Destruction of

NAILS
Inspection Shape: convex, Capillary refill premature
, palpation curvature of < 3 erythrocytes causes
seconds. the paleness on
Texture: smooth Color: pale skin.
Capillary refill of
2-3 seconds (Textbook on
medical surgical
nursing, 12th
edition, p.910.)

Color: depends Coarse and The patient is still

Inspection on race, can be clean maintaining his
black, brown, Black hair hygiene during his
HAIR burgundy Evenly stay in the hospital
Evenly distributed that is why,
distributed, no Coarse abnormalities, are
signs of alopecia Clean scalp not detected in his
Texture: thick or No lesions, hair.
thin, coarse or masses
smooth
Moisture:
neither brittle
nor dry
Scalp: Clean no
lesions nor
masses

Normocephalic, Normocephalic The patient’s

HEAD
Inspection round, No Symmetrical condition has
, Palpation palpable mass, facial features nothing to do with
nodules, Symmetrical his head physically,
depression facial so abnormalities
No pain upon movements were not detected
 palpation No palpable upon assessment.
Face is mass
symmetrical

Symmetrical Lids: Paleness on

Eyebrows: symmetrical palpebral
Inspection symmetrical, Conjunctiva: conjunctiva may
black, evenly pale indicate the
distributed Sclera: decreased
Eye lashes: anicteric hemoglobin level on
EYES
black, slightly Pupil size: the blood.
curve upward 4mm; equally
Eyelids: covers reactive to (Textbook on
small part of the light and medical surgical
eye when open, accommodatio nursing, 12th
covers the n edition, p.910.)
whole eye when Gross vision
close normal
No ptosis
Conjunctiva:
pinkish and
moist
Cornea:
transparent and
smooth
Sclera: white, no
discoloration, no
pigmentation,
no foreign
objects
Iris: brownish,
no visible
foreign objects
Pupil: equally
round, reactive
to light and
accommodation
(PERRLA)
Clear visual
acuity
Ocular
movement: eye
moves freely

Bean shaped, External Pneumothorax is

 parallel, pinnae: air in the pleural
symmetrical normoset cavity; so
EARS
Inspection Same color with External canal therefore, it has
, the complexion has no unusual no effect on the
Auricles has firm discharges patient’s ears
cartilage Tympanic because pleural
No redness of membrane is cavity was
earlobes intact and pink located in the
No lesions in color space between
No tenderness Gross hearing the visceral and
upon palpation normal and parietal pleura in
of auricles and symmetrical the lungs.
mastoid process
No discharges
and lesions on
ear canal
With presence
of cerumen
Tympanic
membrane:
pearly gray, flat,
and translucent
Hearing acuity:
able to hear
clearly

Nose is in the Septum is in

midline and is midline
symmetrical Mucosa is
No unusual pinkish
discharges Both nares are
No nasal flaring patent
NOSE Both nares are Gross smell
AND Inspection patent are
SINUSES , palpation No bones and symmetrical,
cartilage patent
deviation No tenderness
No tenderness noted on
upon palpation frontal and
Nasal septum is maxillary
in the midline sinuses
Nasal mucosa is No unusual
pink discharges
No tenderness
and swelling of
paranasal
 sinuses

Lips: Lips are pale Pallor on his lips

symmetrical, and mucosa and mucosa may
pinkish, no Tongue is in indicate the
edema, moist midline presence of
Inspection Gums: pinkish, Has complete anemia; a
no gum set of teeth condition in
bleeding, no (32) which the
receding gums, Speech is hemoglobin
and no swelling intact concentration is
Teeth: number Uvula is in the lower than
MOUTH of teeth must be midline normal which
32, white to Tonsils not results in
slight yellowish inflamed decreased
in color, no Pink oral amount of
dental carries mucous oxygen delivered
Buccal mucosa: membrane to body tissues.
hard and soft
palate are (Textbook on
pinkish and medical surgical
moist nursing, 12th
Tongue: must edition, p.910.)
be on the
midline, pinkish,
no lesions, and
must move
freely
Uvula: is in the
midline, pinkish
to red in color,
no swelling, no
lesions
Tonsils: pinkish
in color, no
swelling
Mandible:
moves
smoothly, no
pain and
tenderness upon
palpation

In the midline Trachea is in

Inspection No visible midline
No jugular vein
 , palpation masses or lumps engorgement
NECK Thyroids non-
No tenderness
upon palpation palpable
Full ROM
Trachea is in the
Cervical lymph
midline
nodes are not
Moves freely
palpable and
ROM full range
non-tender
Same as skin Breathing
color pattern is
Symmetrical regular, deep,
Spine vertically diaphragmatic
Inspection aligned and mildly
THORAX , No kyphosis, labored.
AND palpation, scoliosis, Lung
LUNGS
auscultati lordosis expansion is
on, No dyspnea, symmetrical
percussion tachypnea, Tactile
bradypnea fremitus is
No retraction symmetrical
No adventitious Percussion:
breath sounds resonant/
hyper resonant
with CTT
located at 9th
ICS Right
anterior
axillary line

HEART Auscultati No tachycardia Precordial area

on and bradycardia is flat
No dysrhythmia Heart sounds
No lift or heaves are regular at
No heart 83 bpm
murmurs (-) murmurs

Same as skin Pinkish to

BREAST
Inspection color brownish in
, palpation No edema, color
erythema, Has smooth
wrinkling, surface
retraction or
dimpling
No lesion
No mass and
tenderness upon
 palpation

Same as skin Symmetrical, Muscle guarding

Inspection color flat serves as the
, No lesions configuration defense
ABDOME auscultati Flat, soft and Normoactive mechanism of
N on, rounded bowel sounds, the abdomen to
percussion No pain and 21 sounds per alter the
, palpation tenderness upon minute pressures being
palpation Tympanitic inserted upon
Audible, soft percussion palpation.
gurgling sound Muscle
(5-20 seconds) guarding noted
No bruit, friction on the right
frubs upper
quadrant of
the abdomen.

Genitalia: no Patient refused

itching, redness
GENIO- and lesions
URINARY Rectum: no
SYSTEM lesions,
inflammation,
hemorrhoids,
and rectal
prolapsed
Urinary: no
hematuria,
nocturia, urinary
incontinence,
and no difficulty
in urinating.

Color: whitish Peripheral

pink to brown pulses are
shade to black symmetrical,
EXTREMIT Inspection Equal on both strong, and
IES , palpation sides regular
Hair evenly Muscle tone
distributed are equal with
No lesions, muscle
lump, masses, strength
and no areas of Spine is in
tenderness midline
ROM full range Gait:
 No crepitus coordinated

Anatomy and Physiology

The respiratory system is situated in

the thorax, and is responsible for
gaseous exchange between the
circulatory system and the outside
world. Air is taken in via the upper
airways (the nasal cavity, pharynx and
larynx) through the lower airways
(trachea, primary bronchi and bronchial
tree) and into the small bronchioles and
alveoli within the lung tissue.

The lungs are divided into lobes; The

left lung is composed of the upper
lobe, the lower lobe and
the lingula (a small remnant next to
the apex of the heart), the right lung is
composed of the upper,
the middle and the lower lobes. One
main-stem bronchus leads to the right lung and one to the left lung. In the
lungs, the main-stem bronchi divides into smaller bronchi and then into
even smaller tubes called bronchioles, bronchioles end in tiny air sacs
called alveoli.

Mechanics of Breathing

To take a breath in, the external intercostal

muscles contract, moving the ribcage up and
out. The diaphragm moves down at the same
time, creating negative pressure within the
thorax. The lungs are held to the thoracic
wall by the pleural membranes, and so
expand outwards as well. This creates
negative pressure within the lungs, and so air
rushes in through the upper and lower
airways.

Expiration is mainly due to the natural

elasticity of the lungs, which tend to collapse
if they are not held against the thoracic wall.
This is the mechanism behind lung collapse if
there is air in the pleural space
(pneumothorax).

Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form very narrow
terminal bronchioles, which terminate in the alveoli. There are many
millions of alveloi in each lung, and these are the areas responsible for
gaseous exchange, presenting a massive surface area for exchange to occur
over.

Each alveolus is very closely associated with a network of capillaries

containing deoxygenated blood from the pulmonary artery. The capillary and
alveolar walls are very thin, allowing rapid exchange of gases by passive
diffusion along concentration gradients.
CO2 moves into the alveolus as the concentration is much lower in the
alveolus than in the blood, and O2 moves out of the alveolus as the
continuous flow of blood through the capillaries prevents saturation of the
blood with O2 and allows maximal transfer across the membrane.
Course in the Ward

• Patient is 21 years old male, tall and lanky who came in due to sudden
onset of right sided chest pain. Consultation done and chest x-ray
showed pneumothorax right subsequent admission and chest tube
thoracotomy done. Initial drain of 200 cc

• 1st day- tachycardia, pallor, hypotension and CTT output increased to

500 cc in 1 hour. Repeat CBC showed Hgb 9 from baseline of 16.

• Thoracotomy done with clipping of bleeders and plication of bullae and

plural abrasion.

• BP- 81/40,HR- 79 O2 saturation 100% intubated, sedated, arousable,

follows commands, no murmurs, good air entry, clear breath sounds.

Date/Time Interpretation
September 9, 2010
Acute pain
2:00 PM >patient on bed, >with O2 support
conscious because of difficulty
>with O2 at 2 liters per in breathing
minute via nasal cannula >hand washing to
>pain scale 4/10 as avoid infection
verbalized
>due meds facilitated
4:00 PM >encouraged to
verbalized feelings
>encourage deep
breathing exercise
>v/s taken and recorded
>proper hand washing,
including his relatives
health teaching about
infection
September 11, 2010
2:00 PM >CTT tube on the right >CTT tube due to
bedside bottle at 300 cc pleural effusion
 with scanty blood > pain scale of 10/10
discharges due to incision for CTT
4:00 PM Severe pain insertion
>pain scale 10/10 >Ketorolac for acute
>ketorolac 1 amp IV pain
given as PRN meds
>relaxation and DBE
>pain scale 4/10
>v/s taken and recorded
>input and output done
including CTT output.
>needs attended
>still with mild pain
>chest x-ray done

September 16, 2010 >with O2 a 2 liters per >given paracetamol

min for fever at 38.9 P.O.
2:00 PM >with CTT right to bed >TSB done to
side bottle alleviate fever
>v/s taken and recorded
> with fever (38.9c º)
4:00 PM >given paracetamol
>TSB done

September 17, 2010

2:00 PM >still on O2 at 2 liters per >Salbutamol for

min. better breathing
>with CTT right to BSB pattern
>salbutamol neb: 1/2 neb >EDBE to expel
+ 2ml NSS given plegm
4:00 PM >Encourage deep
breathing exercise

>v/s taken and recorded

>intake and output done
>CTT output done
>due meds given

Health Teaching

- Frequently assess the hole that has been inserted the tube that is
affected to check if there is a sign of infection

- Advice patient to continue taking his prescribed medicines like:

  Diclofenac
 Calcium Carbonate (Caltrate +)
 Multivitamins (Nutricap)

- Maintain a quiet, pleasant, environment to promote relaxation.

- Provide clean and comfortable environment

- Provide oral and written instructions about activity, diet

recommendations, medications and follow-up visits.

- Patient will be advised to go back in the hospital in a specific date to

have a follow-up check-up after discharge

- Consult doctor for any problems or complications encountered.

- Encourage patient to increase protein for tissue repair

- Encourage patient to ask for God’s guidance

References:

• Retrieved on September 16, 2010 from :

http://www.le.ac.uk/pa/teach/va/anatomy/case2/frmst2.html

• http://erj.ersjournals.com/content/28/3/637.abstract

• http://answers.yahoo.com/question/index?
qid=20080801131255AA0mcNo

• http://content.karger.com/produktedb/produkte.asp?
typ=pdf&file=MPP2006015005338

• Smeltzer S, (2008). Textbook of Medical-Surgical Nursing 12th

Edition. Lippincott Williams and Wilkins: Philadelphia USA