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Pleural empyema, also known as pyothorax is an accumulation of pus in the space between the lungs and inner chest wall. This space is also called as the pleural space and the pus consists of dead and dying bacterial cells, immune system cells and fluid. The pus cannot be coughed out and needs to be drained out by a surgical approach or a needle. The two most common forms of bacteria which cause empyema are Streptococcus pneumoniae and Staphylococcus aureus. Naturally, the pleural space has some amount of fluid but the bacterial infection can lead to an increase in the amount of fluid which can cause the lung lining and chest cavity to stick together and create pockets which are called as empyema (Desai and Agrawal, 2012).This brings the breathing difficulties which is the main cause of chest pain and associated cough. The below nursing assignment presents the case history of a patient, Mr. X who is admitted to the hospital with the unique identifying number 123456. The patient is diagnosed with right-sided empyema and is admitted to the hospital for right-sided thoracostomy and decortications. The patient’s chief complaint was chest pain, cough with shortness of breath (Fletcher, et al., 2014).The below presentation ensures that the confidentiality of the patient is not breached and for addressing the patient, their family or staff, pseudonyms have been used. Further, the relevant information about the patient’s physiological, psychological, personal and social factors have been explained. The assignment also specifies the key problems the patient is suffering from and prepares a holistic nursing plan for each of these problems with a clear and a measurable goal. Each of these problems has been prioritized with specific interventions for meeting the patient’s need and preferences. Also, the treatment evaluation methods have been considered and the areas of improvement and scope are identified (Froudarakis and Bouros, 2013).
Assessment and planning of nursing care needs
Mr. X is admitted to the Intensive Care Unit of the hospital settings and is X years old. He was not feeling well the previous day and went to sleep early at 10 PM, compared to his routine schedule. At around 5:00 AM today, his wife got awake and was terrified after seeing him collapsed on the floor. He complained of breathing difficulty and was drenched with sweat. His wife was alarmed after knowing that he was suffering from chest pain which was radiating in nature. Without wasting any more time, she rushed him to the hospital where he was admitted to the Emergency ward with the chief complaint of chest pain since two hours. Upon examination, the pain was radiating and crushing in nature (Corcoran, et al., 2015).It was associated with shortness of breath and profuse sweating. Upon Electrocardiography, distinct ST elevations were found and the report was consistent of right-sided lung empyema.
General examination for Mr. X was conducted and according to the observations, he was an obese person weighing 82 kg with a height of 172 cm. He was also admitted to the hospital 2 years back due to stroke and is a known case of type 2 Diabetes mellitus. He has been advised with dietary restrictions and pharmacological interventions. According to his social history, the patient was the advertising manager of his company and had the habit of living in a high-risk environment. As a result, his stress levels were high and he was a habituated smoker with an average smoking history of 3-4 rolls of cigarettes in a day. He is a married person having 3 children with family responsibilities. Stress often keeps him occupied with work due to which he regularly consumes unhealthy, fast food and late night dinner. Her wife admits that he does not follow the exercises which were advised to him by the physician and reckons that his stressful job and associated family responsibilities are majorly keeping him unhealthy.
The vital signs recorded were BP: 142/94 mm Hg, pulse rate of 65 beats per minute, the temperature was recorded as 36 degrees Celsius and respiratory rate of 24 breaths per minute. His skin was warm to touch and no sign of cyanosis was found. The breath sounds were abnormal and the lung field did not reflect a normal air entry. Cardiovascular examination revealed thrills, heaves, and visible pulsation.
Due to this emergency, Mr. P was suffering from a plethora of problems such as acute pain due to sudden infarct. This is associated with another complication, dyspnea which accompanies fear and anxiety. Along with these issues, the patient is at a risk of developing activity intolerance, compromised cardiac output with impaired tissue perfusion. This can further lead to complications of fluid overload (Hofmann, 2013).The assessment criteria would include factors such as patient history so as to develop the etiological cause. A complete medical history must be taken so as to recognize the associated factors which are causing the exacerbation of the clinical symptoms. Occupational history may also impose significant regulatory factors which hamper the well-being of the patient. The disease manifests itself in the form of major clinical symptoms of dyspnea, cough and chest pain. Dyspnea is associated with an increased distortion of the diaphragm and chest wall. A cough in such patients is often non-productive and mild and severe cough with bloody sputum is related to an underlying respiratory lesion. Also, the chest pain, in this case, can either be localized or may radiate to the ipsilateral shoulder also (Janda and Swiston, 2012).
The physical findings are variable in case of pleural effusion and the assessment criteria also depend upon the volume of fluid present. The major assessment criteria include dullness to percussion, asymmetrical chest expansion, and reduced tactile fremitus. There exists lesser chest expansion on the side of effusion and the mediastinum shifts away from the side of effusion. Further, the breathing sound is diminished or inaudible and egophony is observed along the upper fluid margin (Kwon, 2014).This occurs due to thin liquid film separating the pleural space and this test can provide information about the lung abnormality. The concept behind this test lies in the fact that the normal lung tissue does not transmit voice sounds readily however the consolidated tissues transmit voice sounds easy. When the patient is asked to pronounce the letter ‘e’ and auscultation is done over the normal lung tissue, the usual ‘e’ tones are heard while over the abnormal lung tissue, ‘e’ sound is heard as ‘a’ during auscultation. Along with this resonance is dull during percussion in the posterior base (Shin, J.A., et al., 2013).
The patient’s pre-disposition to respiratory disorders is also crucial and along with the above-mentioned findings, the patient-related risk factors such as high stress, unhealthy diet habits, smoking habits are further some of the important factors, therefore, the nursing interventions must be based after studying each of these factors in detail (McCauley and Dean, 2015). Patient’s age, sex, preferences, values, and beliefs must always be considered as a priority before implementing any of the nursing plans.
The primary nursing interventions include airway, breathing, and circulation which should be maintained and optimized. To keep the airway patent, supplemental oxygen by the means of nasal cannula or oxygen mask needs to be administered. This will help to maximize the amount of oxygen available for tissue uptake and thereby will help in relieving the chest pain.
Along with the initial interventions, the patient is advised with tube thoracostomy which involves the insertion of chest tubes to drain out the pleural fluid promptly (Corcoran, et al., 2013).The chest tube should be positioned in the dependent part of the lung area affected with fluid using the guidewire-assistance through serial dilatation technique or a traditional cut-down method. Smaller catheters (8-14F) should be employed simultaneously to drain the non-loculated and non-purulent fluid or draining empyema. The drainage is continued unless clinical symptoms are relieved and radiological findings are improved (Porcel, et al., 2014).Also, the process should continue until the rate of fluid drainage falls below 100 mL in 24 hours with clear and non-turbid nature of the fluid.
The pain in pleural effusion occurs due to inflammation of the parietal pleural membrane which is also the site of pleural nerve fibers. At times, along with this pain, a palpable or audible pleural rub is also noticed. To manage this pleural pain, Paracetamol Ig QID orally is administered. The patient’s pain scores must be assessed by using a pain rating scale along with the assessment of the precipitating factors (Ravaglia, et al., 2012).The effect of medications must be analyzed after every 5 minutes as this will help the medical care staff to analyze the effectiveness of the employed interventions and if further interventions are required. Along with Paracetamol, a weak opioid drug, Tramadol is also advised in the dose of 100 mg (PRN). Tramadol is an analgesic advised to control the chest pain associated with a cough and surgical interventions.
The comfort measures must also be provided to assist the patient by employing the non-pharmacological techniques. Along with this, the patient must be kept in Fowler’s or Semi-Fowler’s position as elevating the patient’s head would improve the chest expansion and oxygenation. Also, relaxation techniques will help the patient to get relieved from the pain due to emotional and psychological stress. As the analgesics are usually associated with gastrointestinal disturbances, the patient was advised with 40 mg Pantoprazole through the oral route.
The drug therapy should be comprehensive to cover all the pathogens involved in this clinical setting. An intravenous or oral therapy must be initiated in response to the clinical signs. For fighting against the infectious pathogens, an antibiotic drug dose must be initiated and the choice of antibiotic depends upon the pathogen. The drug dose administered in this case was Ceftriaxone 2gm OD through the oral route. It is a third-generation cephalosporin with broad spectrum range against the gram-negative bacteria and has higher effect against the resistant organisms. It brings its effect by causing bactericidal action through the inhibition of cell wall synthesis. The drug interferes with the synthesis of peptidoglycan which is a major component of the bacterial cell wall and therefore the organisms eventually lyses due to arrest of the cell wall assembly (Schweigert, et al., 2012).Along with this, the patient was also advised with 500 mg Metformin OD through the oral route for controlling the blood sugar levels as the patient was hospitalized and was affected with diabetes as a comorbid condition. Diabetes, in this case, must be controlled as pleural empyema and effusion is common in patients affected by diabetes due to an impaired left ventricular function which impedes the cure and worsens the situation. Metformin, in this case, works by lowering the synthesis of glucose in the liver (gluconeogenesis) and improves the uptake of glucose by the body cells. This drug is specifically employed in cases where diet, weight loss, and exercises are not effective in lowering the blood glucose.
The patient was administered 5000 microns of subcutaneous Heparin drug dose twice daily. heparin is an anti-coagulant and augments the effect of antithrombin III. It prevents the transformation of fibrinogen to fibrin and inhibits thrombogenesis (Scarci, et al., 2015).This takes place as heparin prevents the reaccumulation of a thrombus after fibrinolysis occurs. The mechanism of action in high dose would be to inhibit the anti-coagulant factor IX, X, XI, XII, and thrombin and therefore prevents the conversion of fibrinogen to fibrin.
The nursing care interventions include instructing the patient to report pain immediately and providing the patient with a calm and soothing environment. The patient must also be comforted and advised to practice relaxation techniques such as slow and deep breathing, distraction behaviours, guided imagery, and visualization (Nie, et al., 2014).Assistance must be provided as required to the patient. This will decrease the external stimuli of pain and helps to relieve anxiety and cardiac stress. It also assists in improving the coping abilities of the patient and enhances their individual perception to deal with such future situation. The distraction techniques further help in decreasing the response to painful stimuli and provides a sense of self-control and belief, thereby instilling a positive attitude. Along with the medical care, a nurse is also responsible for taking into account patient’s personal choices, preferences, and values into priority and prepare a nursing care plan which abides his beliefs. (Rosenstengel, 2012).
Evaluation of nursing care
The evaluation of the nursing interventions can be based on the relief of the clinical signs and symptoms however the appropriate judgement is based on individual factors such as:
Shortness of breath occurs due to impaired breathing pattern when the patient’s ventilation needs are not met after inspiration and expiration. Inflammation of the pleura causes a localized and sharp pain that gets worse upon coughing and breathing movements. As a result, the breathing pattern is further compromised. The evaluation of affected breathing is usually made 3 hours after administering the drugs and assisted ventilation (Bhatnagar and Maskell, 2013).After 3 hours, the patient is observed to check for the coping behaviour and adopted methods to improve the breathing pattern. The patient’s improved ability to adapt more of compensatory techniques for enhanced breathing should be analyzed which indicates better patient’s participation and stress coping ability. An improvement in the breathing pattern along with an improvement in the signs of respiratory distress would help to evaluate the condition after the necessary surgical or nursing intervention. Along with this, maintenance of respiratory rate within the normal range, an absence of tissue cyanosis, adequate breathing capacity with minimal use of accessory respiratory muscles would also indicate an improvement in the breathing deficit (Thomas and Lee, 2013).
Along with breathing deficit exists an impaired gaseous exchange where the lung compensatory and defensive mechanism is ineffective and thereby bacterial colonization occurs. As a result, the bacterial organisms penetrate the lower respiratory tract and leads to the development of respiratory inflammation. Also, the ciliary motility and mechanical defensive mechanisms are disrupted which leads to inflammation of lung alveoli. The lung alveolar sacs are inflamed and filled with fluid due to which they turn incompetent in performing adequate gaseous exchange at the alveolar level (Thommi, et al., 2012).After implementation of the nursing interventions, patient’s verbal assurance in regards to the improvement of the breathing pattern shall be considered as an evaluation criterion. Further, long-term evaluation of nursing interventions can be made on the basis of adequate oxygenation of the body tissues and improved ventilation.
The next criteria to evaluate the outcome of the nursing intervention is activity intolerance which occurs in the form of a secondary symptom to breathing deficit due to fluid filled pleural space. Impaired breathing causes the lungs to recoil inward and the chest outward due to which the diaphragm depresses inferiorly and the lung volume is compromised. Tissue hypoxemia ensues and this can only be relieved by thoracentesis (Porcel, et al., 2014).Tissue hypoxemia causes activity intolerance and after the nursing interventions are employed, an improvement in the patient’s condition and signs of activity tolerance are regarded as positive evaluation criteria. On a long-term basis, the patient’s ability to perform the daily life activities without stress and use of accessory respiratory muscles are considered as an evaluation criterion. An improvement in the patient’s ability to interact and perform the daily routine tasks with minimal assistance and fatigue is regarded as positive evaluation (Suárez, et al., 2012).
Pain is another major factor and symptomatic relief in chest pain is considered as a primary evaluation criterion. After nursing interventions are employed, a reduction in the patient’s pain scale from 7 to 3 is considered as an improvement in the patient’s condition. On a long-term basis, the patient should demonstrate activities which prevent the recurrence of pain. Based on the mortality rates and the requirement of secondary interventions, thoracostomy is advised to the patient subsequent to drainage. In such case, careful evaluation of the patient is essential for several hours after the surgical procedure is performed (Tobin and Lee, 2012).
Along with such symptomatic relief, patient’s overall well-being and an improvement in patient’s fatigue shall be considered as an evaluation criterion. The patient must be advised a comprehensive treatment plan which caters his dietary needs and assists the patient to quit smoking. Along with this, this patient’s family must be educated about the life threatening complications of this disease and the preventive measures must be explained well. Further, the immediate precautionary measures should be provided in case of future complication (Shin, J.A., et al., 2013).
Pleural empyema is a grave infection of the pleural space which requires appropriate medical therapy with necessary drainage procedures. The disease compromises the host defense system due to infection of the pleural space and leads to common symptoms of a cough, chest pain, breathing difficulty and this is often accompanied by chills, fever, and loss of appetite. The medical finding can be diagnosed through the physical examination such as dullness upon percussion of the lung space, decreased vibration and asymmetrical lung expansion, inaudible breath sounds and frictional rub on the affected lung side (Burgos, et al, 2013).Chest X-ray detects the effusion in the form of white areas at the base of the lung which is either present unilaterally or bilaterally. A lateral decubitus X-ray can help to examine the movement of the pleural fluid when the person lies on their side. The above presentation describes the case study of a patient, Mr. X, suffering from chest pain, cough and breathing difficulty who has been admitted to the hospital setting and has been advised with right-sided thoracostomy and decortication (Suárez, et al., 2012).He was diagnosed with right-sided pleural empyema and the case history along with the detailed social, physiological, psychological factors have been explained. Also, the assignment aims to identify the patient’s chief problems as his priority needs and sets up a measurable goal for each problem. According to the priority, the nursing care interventions are then decided and implemented. Evaluation criteria for assessing the progress of the case have been defined and scope of improvement in the treatment strategies is identified. Patient’s confidentiality is maintained throughout the case study and therefore pseudonyms are used to address the patient, their family, and the associated staff (Tassi, et al., 2016).
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