Northern Caribbean University

College of Allied Health and Nursing

Department of Nursing

NRSG343: Adult Nursing I

Group Fuzeon

Devon Carter- 28090137

Talietha Williams – 18051905

Tiphanie Smith – 28100039

Shaneque Greaves – 18075036

Melissa Doctor – 18090451

Nickesha Bailey – 28090077

Kadian Stewart – 60080061

Sabrina Bugam – 24075068

Theresa Williams – 60090137

Sherika Taylor – 16040223

Natalie Clarke-Boothe - 60090109

Instructor: Mr. D. Bennet

Date: November 20, 2012

Introduction

This case study seeks to evaluate the collaborative managements that were put in place in

providing holistic care to the patient. However, it also goes in dept to explore other options that

would have been appropriate for the successful outcome of the patient;researching literature

centered on the diagnosis stated below.

To provide confidentialitythe patient being studied is termed asMr. R.S,a 72 years old elderly

male diagnosed as having left Empyema, and left Para- pneumonia effusion. In 1986 and he was

admitted at Kingston Public Hospital for the removal of haemorrhoid, and in 2004 he had four

(4) gun shots gun removed from his neck. He was also admitted at the health agency National

Chest Hospital on the 22/10/12 in a wheel chair with a chest tube insitu and an underwater seal

drainage bottle attached. Prior to admission, he was well until 2/52 ago when he noticed that he

was losing weight and had a loss of appetite that caused him to seek medical attention. At the

same time he began to experience shortness of breath (sob) on exertion relieved by rest,

productive cough of white oral yellow coloured sputum, he had one episode of haemoptysis, an

intermitted fever and swollen limbs. His vital signs on admission were, Temperature-100.3◦F,

Pulse-104 bpm, Respitation-28 b/m, SPo2-94% and Blood pressure- 128/80. His weight was 169

pounds and he is five (5) feet tall. On the 23/10/12 the patient had a HB of 9.8, WBC 12, Platelet

count 183 and CO2 -24. On the 27/10/11 he had a HB of 10.4 and WBC 6.8, Platelet count 339

and CO2-20.

According to Scott (1993), “The lung is lined by two thin membranes of pleura (inner visceral

and outer parietal), which allows the lung to expand and shrink with each breath with minimal

friction.” (pg 102). Clare (2000), states that, “Empyema is the collection of pus in the pleural

space; it is caused by unresolved pneumonia, usually due to Staphylococcus Aureus (and

particularly a lung abscess) which can lead to infection that spreads to the pleural space. Other

conditions such as bronchiectasis, airway-obstructing cancer, thoracic surgery, and penetrating

wounds can also cause empyema.” (pg94). “Para-pneumonia effusion is a type of pleural

effusion that arises as result of pneumonia, lung abscess or bronchiectasis. There are three types

of para-pneumonia effusion and they are uncomplicated Para-pneumonic effusion, complicated

Para-pneumonic effusion and empyema.Shawn (1993, pg82). Beers (2003) found that, “Para-

pneumonia and empyema usually develop along the same line, therefore the same factors that

causes empyema causes para-pneumonia effusion.” (Pg283-284). According to Shawn (1993),

“Statistic has shown that these diseases are very common in across the Caribbean; however the

predominant age of incidence is in both groups with ages ranging from 30-49 years old and a

significant number occurring between ages 20-29 years old.” (pg150).

The various factors that will be examined to get a clear picture of the appropriateness of the

nursing/medical management for the patient and patient outcomeare follows:

Difficulty breathing, short of breath (sob), chest pain, generalized weakness, mild cough

with thick white sputum and swollen lower limbs.

This case study will address not only the patient’s condition but what was done for him in

comparison to what could have been done differently as it relates to the collaborative care that he

recieved.

Literature Review

Sahn (2007) defines a parapneumonic effusion (PPE) as a type of pleural effusion that

arises as a result of pneumonia. Before looking at the pathophysiology of parapneumonic

effusion background knowledge of how a pleural effusion develops need to be established. A

pleural effusion occurs when excess amounts of fluid collects in the pleural space. This is

commonly known as “water on the lungs”. Signs and symptom of a pleural effusion include:

SOB, chest pain, gastric discomfort (dyspepsia), and cough. Two thin membranes are located in

the chest cavity, the visceral pleura which line the lungs and the parietal pleura that cover the

inside of the chest wall (Sahn 2007, pg 1480-1486). Normally, small blood vessels in the pleural

linings produce a small amount of fluid that lubricates the opposed pleural membranes so that

they can glide smoothly against each other during respiration. Any extra fluid that is produced is

absorbed by blood and lymph vessels. When too much fluid forms or something prevents its

removal, the result is an excess of pleural fluid—an effusion. The most common causes are

disease of the heart or lungs, and inflammation or infection of the pleura (Thompson 2011).

According to Weyant (2007) pleural effusion itself is not a disease as much as a result of

many different diseases. There are two types of pleural effusion that may occur: the transudate

and the exudate. These two types of fluid are very different. The type of fluid present points to

what sort of disease is likely to have produced the effusion. It also can suggest the best approach

to treatment (Limsukon, 2011). A patient with parapneumonic effusion has an exudative pleural

effusion. An exudate, which often is a cloudy fluid containing cells and much protein results

from disease of the pleura itself. The causes are many and varied. Among the most common are

infections such as bacterial pneumonia and tuberculosis; blood clots in the lungs; and connective

tissue diseases, such as rheumatoid arthritis. Cancer and disease in organs such as the pancreas

also may give rise to an exudative pleural effusion (Shawn, 1993).

Hamm (1997) states that the development of pneumonia begins with the aspiration of

organisms from the oropharynx. If the organism load is high and the patient's host defences are

impaired (e.g., as a result of cigarette smoking or alcohol ingestion), the patient is more likely to

develop pneumonia. The interval between aspiration of organisms and the development of

pneumonia varies from a few days up to 1 week. Pneumonia typically begins in dependent lobes

at the periphery of the lung and, if untreated, spreads centripetally towards the hilum (Thompson,

201). If left untreated for the subsequent 2–5 days, an UPPE will likely develop. The effusion

forms because of an increased capillary permeability secondary to endothelial injury induced by

activated neutrophils. The resultant extravascular lung water increases the interstitial-pleural

pressure gradient and promotes a pleural effusion as fluid moves between mesothelial cells into

the pleural space. If interstitial fluid formation exceeds the capacity of the lung and pleural

lymphatics, a pleural effusion will accumulate. If left untreated for the subsequent 5–10 days, the

PPE transitions to the fibrinopurulent stage, which is characterized by the development of

fibrinous adhesions, increased neutrophils, and the presence of bacteria (Beers 2003).

According to Weyant (2007), fibrin forms as intravascular clotting proteins enter the

pleural space, with concomitant inhibition of pleural space fibrinolysis. Fibroblasts enter the

pleural space by 2 possible mechanisms: (1) movement of bone marrow fibrocytes to the site of

inflammation, and (2) mesothelial cell transformation to fibroblasts by cytokines, such as basic

fibroblast growth factor–2. Later in the fibrinopurulent stage, pus will be aspirated at

thoracentesis; however, the lung is typically still expandable. As the fibrinopurulent stage

progresses, it becomes increasingly unlikely that the patient can be successfully treated without

pleural space drainage. If left untreated for the subsequent 10–21 days, the PPE will evolve into

the final organizational or empyema stage, with evidence of lung entrapment due to visceral

pleural fibrosis. Patients with empyema always require pleural space drainage for adequate

resolution of pleural sepsis and often require decortication.

Empyema is a condition in which pus and fluid from infected tissue collects in a body

cavity, especially in the pleural cavity (Johnson, 2012). This condition represents the end-stage

of a progressive process evolving from a small amount of free-flowing, non-infected pleural fluid

to a large amount of frank pus that can become loculated and result in thick pleural peel. It is

most often used to refer to collections of pus in the space around the lungs (pleural cavity), but

sometimes refers to similar collections in the gall bladder or the pelvic cavity (Johnson, 2012).

Empyema in the pleural cavity is sometimes called empyema thoracis, or empyema of the chest,

to distinguish it from empyema elsewhere in the body.

Limsukon (2011) states that empyema may have a number of causes (contamination of a

wound because of inadequate skin preparation during procedures such as needle decompression,

chest tube placement, thoracentesis, or lung surgery) but is most frequently a complication of

pneumonia. Its development can be divided into three phases: an acute phase in which the body

cavity fills with a thin fluid containing some pus; a second stage in which the fluid thickens and a

fibrous, coagulation protein (fibrin) begins to accumulate within the cavity; and a third or

chronic stage in which the lung or other organ is encased within a thick covering of fibrous

material (Beers, 2003). Empyema thoracis can be caused by a number of different organisms,

including bacteria, fungi, and amebas, in connection with pneumonia, chest wounds, chest

surgery, lung abscesses, or a ruptured esophagus. The infective organism can get into the pleural

cavity either through the bloodstream or other circulatory system, in secretions from lung tissue,

or on the surfaces of surgical instruments or objects that cause open chest wounds. The most

common organisms that cause empyema are the following bacteria: Streptococcus pneumoniae,

Haemophilusinfluenzae, and Staphylococcus aureus (Sahn, 2007). When the disease organisms

arrive in the cavity surrounding the lungs, they infect the tissues that cover the lungs and line the

chest wall. As the body attempts to fight off the infection, the cavity fills up with tissue fluid,

pus, and dead tissue cells (Weyant, 2007).

Clinical Manifestations and Diagnostic Modalities of Parapneumonic Effusion and

Empyema.

All patients presenting with evidence of infection and respiratory symptoms should

undergo investigation for a parapneumonic effusion, especially those who fail to improve despite

antibiotic treatment for pneumonia (Hamm, 1997).

The initial test of choice is a chest radiograph and, if a significant effusion is seen, a

diagnostic thoracentesis (pleural aspiration) is required.Aspiration of frank pus is diagnostic of

empyema, but if this is not present, further biochemical and microbiological tests are required to

diagnose whether or not a parapneumonic effusion is complicated (Hughes, 1991).

Clinical history

Presenting symptoms

The key presenting symptoms of empyema are breathlessness (secondary to large pleural

effusion or pneumonia), fever, and pleuritic chest pain (pain worsened by deep breathing,

coughing, sneezing, and chest movement). Other associated symptoms include those of

pneumonia (productive cough, green or rust-coloured sputum, shortness of breath) and systemic

infection (anorexia, malaise, fatigue, rigors)(Sahn,1996, para. 5).

Patients tend to have a subacute history of illness, with a mean duration of symptoms before

admission of 2 weeks. Failure of patients with pneumonia to respond to antibiotics or a

deterioration in clinical condition suggests the development of a complicated parapneumonic

effusion or empyema(Sahn,1996, para. 5).

The lack of characteristic clinical signs can delay diagnosis. Immunocompromised patients or

patients who are already taking antibiotics may present with few clinical signs of infection.

Patients with anaerobic empyemas can present with a more indolent illness characterised by

weight loss, constitutional upset, and fatigue (Thomas, 2009).

Past Medical History

The majority of patients who develop empyema have a recent history of pneumonia, thoracic

trauma, or iatrogenic intervention in the pleural space such as thoracic surgery, or medical

procedures such as chest drain insertion (4%), thoracentesis (pleural aspiration), tube

thoracostomy (chest drain insertion), and aspiration of pneumothoraces or pleural effusions

(Johnson, 2012).

Patients may have a history of a medical condition predisposing them to the development of

pneumonia and hence empyema, such as pre-existing lung diseases (e.g., bronchiectasis, chronic

obstructive lung disease [COPD], lung cancer) or conditions associated with an increased risk of

aspiration (e.g., stroke, presence of a nasogastric or endotracheal tube). Immunocompromised

patients (e.g., due to haematological disease, chemotherapy, HIV, or malnutrition) are also at

increased risk of developing empyema (Sahn, 2007).

Social History

Alcohol abuse and drug addiction are additional risk factors for the development of empyema.

Clinical examination

Examination reveals evidence of a pleural effusion with or without signs of systemic infection.

Large pleural effusions are characterised by dullness on percussion (classically described as

'stony' in quality) and diminished breath sounds with reduced vocal resonance on the affected

side. Smaller pleural effusions may not be detectable on clinical examination (Sahn, 2007).

Septic shock presents with pyrexia, tachypnoea, tachycardia, and hypotension (BP <90/60). Such

patients require urgent resuscitation.

Blood tests

A complete blood count, C- reactive protein test (CRP), and blood cultures should be

undertaken in all patients with suspected empyema at presentation. In empyema, the WBC count

and the CRP will be raised as part of a systemic response to infection. Blood cultures may be

positive for specific pathogens even if the pleural fluid culture is negative. Ideally, blood cultures

should be taken before the initiation of antibiotics if the clinical state of the patient permits

(Sahn, 2007).

Sputum Culture

Sputum testing requires a sample of sputum, collected from a deep cough. Culture of

sputum is used to identify the bacteria that caused the PPE and can help determine which

antibiotic is best.Symptoms of a lung infection may include difficulty breathing, pain when

breathing, or a cough that produces bloody or greenish brown sputum. It is also used to monitor

the treatment of an infection (Thompson, 2011).

Initial imaging studies

The initial investigations of choice are chest x-ray (CXR) and thoracic ultrasound, and

should be undertaken in all patients with a suspected empyema at presentation.

An urgent CXR should be organised in all patients who present with respiratory symptoms and

evidence of sepsis, as it can demonstrate the presence of a pleural effusion.A lateral decubitus

CXR is more sensitive than a posteroanterior view for detecting an effusion, but its use has been

superseded by thoracic ultrasound (Shawn, 1993). The presence of a loculated effusion suggests

an empyema. Empyemas may have a pleurally based 'D'-shaped appearance which can be

mistaken for a lung mass. There may be associated pulmonary consolidation due to pneumonia

and, in ventilated supine patients, a pleural effusion will appear as a diffuse unilateral increase in

opacification. An effusion measuring >10 mm on a lateral decubitus CXR, in association with

evidence of infection, requires thoracentesis (pleural aspiration).

Thoracic ultrasound is more sensitive than a CXR for the detection of pleural

effusions.Features suggestive of an empyema on thoracic ultrasound include the presence of

echogenic fluid, loculations, and septations.As empyemas are often associated with a raised

hemidiaphragm or tethered lung, image guidance for all procedures is preferable (Sahn, 2007).

The use of ultrasound to guide thoracentesis (pleural aspiration) in order to reduce its associated

complication rate is advised.Ultrasonography is also recommended to guide chest drain insertion,

especially in small or loculated effusions.

Thoracentesis

All patients with evidence of infection and a significant pleural effusion should undergo

thoracentesis (pleural aspiration). Aspiration of frank pus is diagnostic of an empyema and no

other investigations are required to establish the diagnosis, with the exception of pleural fluid

microbiology to guide antibiotic therapy. If the aspirate does not reveal frank pus, further

analysis is required to assess whether it is a complicated parapneumonic effusion. This involves

measurement of the pleural fluid pH, total protein concentration, LDH level, glucose

concentration, and white cell differential (Sahn, 1990).

All samples should be sent for microscopy, culture, and sensitivity testing.Cytology may

be used in cases where the diagnosis is unclear (e.g., for the detection of malignant cells in a

malignant pleural effusion).

Pleural fluid appearance: Empyema is characterised by frank pus. Complicated parapneumonic

effusions may be serous or cloudy.

Pleural fluid odour: Putrid odour is suggestive of an anaerobic infection.

Pleural fluid pH: Samples should be stored anaerobically.Local anaesthetics can falsely lower the

pH. Physicians should have access to a blood gas analyser so that samples can be tested

immediately to enable immediate insertion of a chest drain if indicated. If the sample is frank

pus, the pH should not be tested as it can damage the analyser (Weyant, 2007).

Pleural fluid total protein concentration: If frank pus is aspirated, the protein concentration does

not require analysis.

Pleural fluid LDH level: If frank pus is aspirated, the LDH level does not require analysis.

Pleural fluid glucose concentration: If frank pus is aspirated, glucose does not require analysis. If

an accurate pleural fluid pH is not available, low glucose levels can be used as an alternative

predictor of a complicated parapneumonic effusion requiring urgent chest drain insertion. Pleural

fluid glucose has shown to be a robust predictor in this circumstance (Suzanne, 2010).

Pleural fluid white cell differential: Polymorphonuclear leukocytes are the predominating

(>90%) cell type. The predominance of lymphocytes in the exudate raises the suspicion of

tuberculosis or malignancy.

Pleural fluid microscopy, culture, and sensitivity: A positive Gram stain or culture is obtained in

60% to 70% of samples.This can be used to guide antibiotic treatment (Thompson, 2011).

Further imaging studies

Further imaging studies are performed when there is doubt about the diagnosis or to

confirm the correct position of the chest drain.

Contrast-enhanced thoracic CT can help to distinguish empyema from other pleural

effusions and lung abscesses, and should be done with tissue phase contrast.Enhancement of the

pleura with contrast is characteristic of empyema. The split pleura sign represents enhancement

of the visceral and parietal pleura with interposed fluid. Pleural thickening may be visible, but

this is also seen in malignancy. Contrast-enhanced thoracic CT is especially useful for

confirmation of the correct positioning of the chest drain and may help in the planning of surgery

(Sahn, 2007).

MRI is unable to accurately diagnose an empyema and is therefore generally reserved for

patients who are unable to undergo contrast-enhanced CT.It may show septations, loculated

pleural fluid, or chest wall invasion.A PET scan is another possible imaging technique, but its

use is limited by the fact that it is unable to distinguish between malignancy and empyema.

As the causative organism in 40% of pleural infections remains unidentified, pleural fluid

polymerase chain reaction (PCR) may aid pathogen identification, allowing specific antibiotics

to be chosen.However, further prospective evidence is required on this technique before it can be

routinely recommended (Sahn, 2007).

Laboratory Analysis of Parapnuemonic effusion and Empyema

Samples of effusions for laboratory analysis are obtained by needle aspiration. Aspiration of

pleural fluid is called thoracentesis. (Cavanaugh, 2003, p.287) Patients with pneumoniaand an

effusion of more than minimal size should have a therapeuticthoracentesis.If the fluid cannot be

removed with a therapeuticthoracentesis, a chest tube should be inserted and consideration

begiven to the intrapleural instillation of fibrinolytics. (Wright, 2006, p.75) The thoracentesis

needle is inserted when fluid appears, a stopcock and 50-mL syringe is attached to the needle and

the fluid is aspirated. The pleural fluid samples are placed in appropriate containers, labeled, and

sent promptly to the laboratory (Cavanaugh, 2003, p.287 )

The Pleural fluid analysis provides diagnostic information and guides therapy. (Sahn,

2007).The pleural fluid is analyzed by bacterial culture, Gram stain,red and white blood cell

counts, chemistry studies (glucose, amylase, lactic dehydrogenase, and protein), cytologic

analysis for malignant cells, and pH.(Brunner &Suddarths, 2011).

Pleural effusion caused by pneumonia (parapneumonic effusion) is indicated by presence of red

blood cells (5,000 per cubic millimeter);white cell count of 5,000 to 25,000 per cubicmillimeter,

consisting mainly of neutrophils andsometimes including eosinophils; pH less than7.40; and

elevated protein, pleural fluid:serumprotein ratio, LDH, and pleural fluid:serum LDH ratio.

(Cavanaugh, 2003, p.287 )If the pneumonia is of bacterial origin, theorganism may be

demonstrated on culture andthe pleural fluid glucose level may be decreased.(Cavanaugh, 2003,

p.287 )

Complications of empyema

It is believed that pus can become walled off into pockets making empyema harder to

treat. Empyema can become resistant to multiple antibiotics that make treatment more difficult

and prolonged. A complication such has air entering into the pleural space(pneumothorax), and

scarring of the lungs (pulmonary fibrosis) can occur. Pleural thickening may also occur. It is

believed if left untreated, an erosion can occur between the breathing passages (bronchial tree)

and the pleural space (bronchopleural fistula) or between the pleural space and the skin

(empyema necessitatis). Respiratory failure and septic shock are extreme complications that can

result in death. (Medical Disability Advisor. para. 1-2)

Management of Left Empyema

Empyema is managed using a combination of medications and surgical techniques. The

management of empyema involves three core principles; prompt initiation of appropriate

antibiotics, the complete evacuation of supportive pleural fluid, and the preservation or

restoration of lung expansion (Tobler et al. 2004)

Nursing Management of Left Empyema

(Tobler et al. 2004) authors of Empyema states, “Empyema is usually treated on an

inpatient basis with intravenous antibiotics for the underlying infection.”Nurses can medicate

patients with antibiotic as ordered by the doctor. Treatment with medication involves

intravenously administering a two-week course of antibiotics. It is important to give antibiotics

as soon as possible to prevent first-stage empyema from progressing to its later stages. The

antibiotics most commonly used are penicillin and vancomycin. Patients experiencing difficulty

breathing may also be administered oxygen as ordered by the doctor.

Surgical Management of Left Empyema

Surgical treatment of empyema has two goals: drainage of the infected fluid and closing

up of the space left in the pleural cavity. If the infection is still in its early stages, the fluid can be

drained by thoracentesis. In second-stage empyema, the surgeon will insert a chest tube in the

patient's rib cage or remove part of a rib in order to drain the fluid. In third-stage empyema, the

surgeon may cut or peel away the thick fibrous layer coating the lung. This procedure is called

decortication. When the fibrous covering is removed, the lung will expand to fill the space in the

chest cavity(Tobler et al. 2004).

Video-assisted techniques

Numerous variations of video-assisted decortication, including one-, two-, and three-port

approaches, have been described. One-lung ventilation has been described, either with aid of a

double-lumen endotracheal tube or mainstem intubation, but is rarely necessary. The patient is

placed in a lateral or semilateral decubitus position. Placing the patient over a large axillary role

widens the contralateral intercostals spaces and facilitates trocar insertion. The pleural space is

inspected and coagulum removed completely. Once the coagulum is completely evacuated and

the peel removed, the lung is inflated(Tobler et al. 2004). It is essential that the lung occupy the

complete hemithorax upon inflation to minimize pleural space problems such as persistent

atelectesis and recurrent empyema. The pleural space is irrigated with antibiotic solution and a

chest tube is placed via a port site. A single chest tube usually suffices. As in open thoracotomy,

chest tubes are removed when there is cessation of air leak and minimal pleural drainage.

Summary

Early surgical intervention has showed to hasten recovery and reduce morbidity. The use

of video-assisted techniques in the management of pleural space disease not only reduces

surgical morbidity further, but also appeals to non-surgical providers thereby facilitating an

earlier referral. Early video-assisted decortication provides an effective, singular procedure that

combines characterization of the pleural space fluid, cessation of the progression of the

parapneumonic process, removes the infected pleural material, allows for maximal lung

expansion and function, all with reduced pain and morbidity to the patient and a shortened

hospital stay(Tobler et al. 2004).

Management of Parapneumonic Effusion

According to Dr.Steve A. Sahn, author of Diagnosis and Management of Parapneumonic

Effusions and Empyema written in the journal Clinical Infectious Diseases, “Parapneumonic

effusion’s outcome is related to the interval between the onset of clinical symptoms and

presentation to the physician, comorbidities, and timely management. Early antibiotic treatment

usually prevents the development of a PPE and its progression to a complicated PPE and

empyema.”

Sahn(2007) further states, “The management of a Parapneumonic effusion should

proceed with a sense of urgency. It is important for the clinician to have a management plan that

limits any delay in invasive treatment. In general, early and appropriate antibiotic treatment will

prevent the development of a Parapneumonic effusion and its progression. A Parapneumonic

effusion is one of the few clinical situations in which a diagnostic thoracentesis should be

performed as soon as possible. There should be timely escalation of treatment, if the

Parapneumonic effusion progresses with continued pleural sepsis. Failure to treat elderly persons

who have a Parapneumonic effusion or empyema substantially increases the risk of death.”

Colice GL, Curtis A, Deslauriers J. authors of Medical and surgical treatment of

parapneumonic effusions : an evidence-based guideline states, “Effusions with pleural fluid

layering less than 10 mm on decubitus chest radiographs almost always resolve with appropriate

systemic antibiotics. Patients with pleural effusions that have a pleural fluid layering greater than

10 mm on lateral decubitus radiographs must have a diagnostic thoracentesis. If the diagnostic

thoracentesis yields thick pus, the patient has an empyema thoracis and definitive pleural

drainage is absolutely required.”

Antibiotic therapy

Early antibiotic therapy will prevent the development of a Parapneumonic effusion and

its progression to a Chronic Parapneumonic effusion and empyema. Virtually all antibiotics have

good pleural fluid penetration, with pleural fluid to serum levels generally exceeding 1.0, with

pleural fluid antibiotic concentrations usually exceeding the accepted MIC breakpoint for

organisms most likely to cause empyema (Taryle DA et al 1981). Nursing management for

administering antibiotics includes administering the antibiotics on time and monitoring for signs

of side effects and adverse effects on the patient.

Pleural space drainage

Clinical factors that suggest the need for pleural space drainage include prolonged

pneumonia symptoms (Taryle DA 1981), comorbid disease, failure to respond to antibiotic

therapy, and presence of anaerobic organisms. Chest radiograph findings that suggest the need

for pleural space drainage include an effusion involving >50% of the hemothorax ,loculation,

and an air-fluid level. Stranding or septation noted on an ultrasound suggests the need for pleural

space drainage, marked pleural enhancement, pleural thickening, and the split pleura sign noted

by chest CT indicate the necessity for pleural space drainage (Qureshi NR, Gleeson FV 2006).

The options for pleural space drainage include repeated thoracentesis, use of a standard

chest tube, or an image-guided insertion of a small-bore catheter. A number of nonrandomized

studies have reported a variable success rate and a mortality rate associated with repeated

thoracentesis (Storm HK et al 1992). Standard chest tubes are often placed without ultrasound or

CT guidance by thoracic surgeons for the treatment of PPE and empyema. (Huang HC et al

1999).Drainage failure is a consequence of misplacement of the chest tube, tube malfunction,

and loculations. Nursing responsibility is to assess the patient for complications of use of

standard chest tubes include pain, pneumothorax, hemorrhage, and subcutaneous emphysema.

Intrapleuralfibrinolytics

In 2004, The Cochrane Database Review stated that, although the evidence suggests that

intrapleural fibrinolysis can be considered an important adjunctive therapy to tube drainage on

the basis of evidence from randomized, controlled trials alone, routine use was not recommended

for the management of CPPE and empyema, because the number of cases was too small

(Cameron R, Davies HR 2004). Streptokinase (no longer available as a result of a lack of market

demand) and urokinase were equally efficacious and that life-threatening complications were not

reported in any of the randomized, controlled trials. Fibrinolytic agents would probably be most

effective in the early fibrinolytic stage in avoiding the need for surgical drainage (Sahn, S.,

2007).

Surgery

Surgical options include thoracoscopy, both medical and video-assisted thoracic surgery

(VATS), standard thoracotomy, and open drainage. The decision for surgery should be made as

soon as it is obvious that pleural space drainage by tube thoracostomy has been ineffective in

controlling the pleural infection. Patients with a PPE can be sent directly to surgery or treated

with a 72-h trial of fibrinolytics(Tobler et al. 2004). If fibrinolytics do not improve drainage,

decrease temperature, and lower the leukocyte count, surgery should be strongly considered.

However, it should be recognized that, with clinical improvement, despite an abnormal pleural

space, observation may be warranted. There are patients who refuse surgery, despite minimal

clinical improvement, who over several weeks to months have complete lung re-expansion

without pleural space squeal (Sahn, S., 2007).

Open thoracotomy for CPPE and empyema is recommended for persistent pleural sepsis

and failure of less invasive procedures to control the infection (Mackinlay TAA et al 1996).

Conversion to thoracotomy can be effective when VATS cannot adequately access the pleural

space and is the optimal method for successful debridement and decortications (Deslauriers J et

al 2002). However, decortication is a major operation and can often not be performed in

debilitated patients. Decortication (stripping of the visceral pleural peel) can be performed early

to control pleural sepsis and late (3–6 months after the onset of empyema or CPPE) to treat a

symptomatic, restrictive ventilatory defect. Open drainage for empyema is an alternative to

decortication in the debilitated patient who cannot undergo a standard thoracotomy (Deslauriers J

et al 2002).

Nursing Management for Parapneumonic effusion

Antipyretics should be given as ordered for fever. Administration of analgesia as ordered

is important to keep the patient comfortable, particularly in the presence of a chest drain.

Facilitate early mobilization and exercise after surgery(Tobler et al. 2004).

Medications in the management of pleural effusion and empyema

The goals of pharmacotherapy are to reduce morbidity and prevent complications.In

patients with parapneumonic effusions, empyemas, and effusions associated with esophageal

perforation and intra-abdominal abscesses. Antibiotics should be administered early when these

conditions are suspected (Rubins, J. 2012). “Therapy must be comprehensive and cover all likely

pathogens in the context of this clinical setting. Initiate therapy with intravenous antibiotics and

transition to oral agents or equivalent agents based on clinical response. Oral antibiotics can be

used to transition from intravenous therapy. They allow completion of a full course of therapy

without the need for intravascular access or inpatient hospitalization.” (Limsukon&SooHoo,

2011).

Early antibiotic treatment prevents progression of pneumonia and the development of

parapneumonic effusion and empyema. (Sahn, 2007, p.1484) Initial therapy may include broad

spectrum oral antibiotics after obtaining a pleural fluid sample. (Fakhoury&Janahi,

2008).According to bacteriology listed for a community acquired infectious diseases the first

choice will include intravenous amoxicillin with clavutanic acid or a combination of a second

generation cephalosporin(e.g. cefuroxime) and metronidazole or clindamycin if patient is

penicillin allergic (Gidhar,Bajwa&Shujaat 2012)

Amoxicillin is the most active of penicillins for non–penicillin-susceptible S pneumoniae.

It inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins.

(Limsukon&SooHoo, 2011).Addition of clavulanate inhibits beta-lactamase producing bacteria.

Clindamycin is available in parenteral form (ie, clindamycin phosphate) and oral form (ie,

clindamycin hydrochloride). Oral clindamycin absorbed rapidly and almost completely and is not

appreciably altered by presence of food in stomach. (Limsukon&SooHoo, 2011).Appropriate

serum levels are reached and sustained for at least 6 h following oral dose. Also it is effective

against aerobic and anaerobic streptococci (except enterococci). (Limsukon&SooHoo, 2011).

Nosocomial empyema needs adequate gram negative coverage, as gram negative

infections are more common in nosocomial empyema. Coverage should include carbapenem or

antipseudamonal penicillin, for example, piperacillin or tazabactrum or a third or fourth

cephalosporins (ceftazidime, cefepime) with metrodiazole. If there is a suspicion for MRSA

coinfection, vancomycin or linezolid can be added. (Girdhar et al, 2012).

Patient DataBiographic data:

Initials:

DOB: 28/11/39

Age: 72

Sex: M

Marital Status: Married

Address: South Rd Kencot P.O. HWT Rd

Family/Social History:

6 children

9bedroom house,

Pipe water,

Toilet – flushing,

Light – electricity,

Garbage collection via garbage truck,

Family history of SLE seizures

Present complaint/ History of present complaint:

Health agency – National Chest Hospital

Date of admission – 22/10/12 @ 3:30pm Ward H

Presented with difficulty breathing, SOB, chest pain, generalized weakness, mild cough, thick

white sputum, swollen lower extremities, lack of appetite, weight loss which caused him to seek

medical attention

- Duration 3weeks,

- Onset Sept 30, 2012

Diagnosis- Left Empyema, left Parapneumonia, Effusion,

Past Medical History – nil

Past Surgical History – 1986 removal of Hemorrhoids, 2004 removal of bullets at KPH, Neck

Exploration.

Admitted at KPH 8/10/12 and then NCH 22/10/12

Medication taken on ward – enalapril 10mg pobd x 1week, pethadine 75mg IM stat, then PRN x

1week, gravol 50mg IM PRN x 1week, voltaren 75mg PO bdx1week

Mode of Admission – wheelchair

General appearance – elderly male rational, clear speech, oriented x3, well attired, Left chest

tube in situ to underwater seal drainage,

Weight 169lbs

Height 5ft 8

Immunization up to date

Medication – Voltaren, Cetamol

Lab Values

27/10/12 - Hb 9.8 Na 135 BUN 3.8 PCV 29 K 4.9 Creatine 106 MCH 34 CL 98 WBC 12.0 CO2

24 P/T 183

27/10/12 - Hb 10.4 Na 134 BUN 3.9 PCV 0.31 K 3.8 Creatine 113 WBC 6.8 Cl 99 P/T 339 CO2

20

Data Analysis and Interpretation Five Day Care Analysis and Interpretation

Admission notes22/10/12 3:30pm – new pt admitted via casualty dept with referral from KPH. Was relatively ok

until 2/52 ago when pat started to experience SOB on exertion relieved by rest, cough w/

production of white/yellow sputum, hemoptysis (one episode), intermittent fever, and loss of

appetite. Visited KPH, where chest Xray revealed L pleural effusion and L thoracentesis was

done. Based on findings he was referred to chest for further management.

PMH – Nil

PSH – neck exploration and pile removal (put proper medical term for both surgeries),Gun shot

wounds to neck x 4 (8yrs ago)

Allergies – none known

On Assessment – elderly male rational and in no apparent cardiopulmonary distress.Mm pink,

moist.Dressing to thoracotomy site dry, intact. L chest tube in place attached to under water seal

drainage bottle with 300mls hemopurulent fluid, oscillation present. Nonpitting edema noted to

feet. IV access in place to L hand for medication.T-100F p-104 R-28, BP 128/80 SPO2 76%

breathing spontaneously on room air. GMR 5.2mmol/L, weight 169lbs Seen and checked by

doctor: Plan – CBC done, chest physiotherapy, medicate as ordered, liver function test, U & E;

for analgesic, antipyretic, antibiotic, and anticoagulant

Admission day management 22/10/12Had meal from home, medicated with Panadol as ordered, antipyretic measures done.

Medicated 5000units heparin, Voltaren 75mg, Zantac 300mg, fan therapy

Potential for acute pain related to soft tissue injury and potential for hyperthermia related to

inflammatory process plan – assess comfort level give analgesic as ordered and evaluate its

effectiveness. Advise patient to change position often. Monitor vitals every q4h, especially note

temp and pulse; administer tepid sponge bath; give ordered antibiotics, wash hands before and

after attending to client; change dressing using aseptic technique

Initial Analysis and Interpretation

According to Tobler et al. (2004), the three core principles of empyema management is

the prompt initiation of appropriate antibiotics; the complete evacuation of supportive pleural

fluid; and the preservation or restoration of lung expansion. In the case of patient R.S., the

presence of purulent fluid and thus the diagnosis of Empyema indicates that he was in the second

stage of Parapneumonic effusion, the fibropurulent stage. This stage has characteristic changes in

the pleural fluid, and thus both compositional studies and bacterial studies are important at this

juncture (Sahn 2007, pp. 1480-1486) . This is done through sputum culturation, and thus it is

important that the nurse collects or advocates for the collection of sputum cultures. The

collection of sputum is necessary to advise in the proscription of antibiotics (Hughes 1991).

Administration of the incorrect antibiotics will not only leave the problem untreated, but will

allow the problem to progress to a third, more deadly stage. Thus both correct identification of

and proscription of antibiotic therapy for the bacteria involved is important, and both of these

start with the collection of sputum by the nurse (Cameron 2004).

The second principle, complete evacuation of supportive pleural fluid, deals with the

removal of the infected pleural fluid from the pleural space (Tobler et al. 2004). This can be done

by several methods, mentioned above in the management section. The method chosen for this

patient was thoracentesis, done prior to admission with the placement of a chest tube for

subsequent drainage. The literature review agrees with this progression of surgical procedures, as

the production of bacteria positive sputum cultures indicate the necessity for both the initial

thoracentesis and drainage of the pleural space effected through the use of the thoracotomy

drainage system (Colice 2000, pp. 1158-71).

The third principle, the preservation or restoration of lung space, is highly subjective

patient to patient, and depends on the healing capacity of each patient’s individual body

(Tobleret al.2004). This is done in situations where lung collapse has occurred, or in cases in

which decotication, the peeling of the thick fibrotic layer present in third stage parapneumonic

effusion (Sahn 2007, pp1480-1486).

Other important areas of necessary management include antipyretic measures, necessary

both due to the infective and inflammatory raise of temperature present with parapneumoniac

effusions and pain management. Management of the patients pain is especially important, as

chest pain, will cause the patient to breathe improperly (i.e. shallow breaths) and thus be more

likely to experience atelectasis or lung collapse (Colice 2000, pp1158-71).

23/10/12 – Day 1 Post AdmissionAssessment - Breathes freely on room air, no SOB noted; left chest tube in situ attached to

underwater seal with 420cc hemopurulent drainage seen in bottle, no oscillation seen. c/o pain to

chest tube site, received sitting up in bed with grimace of pain on face; no cough noted, air entry

equal bilaterally (AEEB); IV access noted to left hand; hydration status fair; bilateral pedal

edema noted; VS T96.1F, P74bpm, spo2 97%, B/P 120/70mmHg; condition stable; Risk for

infection.

Plan – change dressing, monitor vitals, monitor condition for changes; administer medications,

provide psychological support, assist with ADLs

Interventions – medicated with Cetamol 2tabs, 5000c Heparin sc, and 4.5g Zosyn IV as

ordered; medicated with Flagyl 500mg po, Voltaren 75mg po; patient encouraged to elevate legs,

medicated with Zantac po

Outcome – patient states that he is 50% better than the day before.

Evaluation Criteria Antibiotic Therapy – Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to

combat the bacteria present within the pleural space. This is in accordance with the use of

antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).

Evacuation of Supportive Fluid – Patient R.S. was noted to have 420cc of hemopurulent

fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also,

although not seen, the lack of oscillations were noted, indicating that the nurse was monitoring

the status of the thoracotomy tube as necessary for proper evacuation (Sahn 2007, pp. 1480-

1486) .

Restoration of Lung Capacity (not necessary)

Antipyretics – The patient was initially given fan therapy and tepid sponge bath to bring the

temperature down. In addition, the medication Panadol was given, which has antipyretic

properties. By the 23, the hyperthermia had been taken care of, with subsequent administrations

of antibiotics and the analgesic Panadol preventing a recurrence. This is in accordance with the

information presented in the literature review (Colice 2000, pp1158-71).

Analgesics – The need for analgesia was indicated by the grimace of pain noted by the nurse

upon assessment.Voltaren and Panadol were both administered for the purpose of analgesia. This

is an important management, as the presence of pain not only leads to patient discomfort and

decreased compliance with treatment methods, but can lead to ineffective breathing and

complications such as atelectasis (Colice 2000, pp1158-71)..

Medication Administration – The patient was medicated as ordered in a timely fashion, an

important factor for the effective management of this condition. The patient was given Zantac to

counteract the stomach acid secretory increase caused by Voltaren which itself was administered

for the pain. The analgesics were given for pain management, while the antibiotics were given

for treatment of the primary condition, parapneumoniac effusion (Hughes 1991). Heparin was

given to prevent the formation of blood clots, due to the reduced mobility of the patient and risk

for Deep Vein Thrombosis, or DVT.

Nursing-Specific Management – Bilateral pedal edema was noted, but nothing was

indicated as having been done for this observation. Appropriate managements would have

included elevating the feet, and informing the doctor whereby diuretics could have been

administered. The diagnosis “Risk for Infection” is inaccurate, as infection has occurred (See

definition of Empyema, parapneumoniac effusion). In the assessment, the lung sounds of the

patient were not auscultated. In addition, no mention of coughing was made, yet the patient was

reported as admitted with a cough with the production of thick, yellow-white sputum. Also, no

mention of sputum collection was made, and the subsequent identification of the bacteria that

was present within R.S.’s pleural space. This is further evidenced by the administration of Flagyl

and Zosyn, which are both broadspectrum antibiotics. This is contraindicated according to the

research put forth by Hughes (Sahn 2007, pp. 1480-1486) in which he states that the correct

antibiotic must be used to provide for the accurate treatment of the condition and the prevention

of further proliferation.

Final Evaluation For Day 1 – The final evaluation for day 1 maintains that, although the

health care team, both medical and nursing responsible for this patient’s care did a good job,

important facets of the care plan as evidenced by the literature review were left out, foremost

was the lack of sputum culture by the nurse and the subsequent bacterial identification and

corresponding antibiotic proscription by the doctors.

24/10/12 -Day 2 Post AdmissionAssessment – Vital Signs T 97.2 F P82bpm R24bpm, B/P 130/80mmHg, SPO2 97%; left tube

remains in situ attached to underwater seal drainage; patient c/o pain to the left side; elderly male

alert, no obvious distress noted; chest expansion equal and bilateral, iv access in place for meds.

Left chest tube in situ with 75cc purulent fluid in underwater seal drainage bottle, oscillation

noted. Dressing intact and dry; hydration status fair

Plan – administer meds and monitor; chest expansion equal and bilateral, continue observations

and care;

Interventions – medicated with 1g Panadolpo, 500mg Flagylpo, Zosyn IV, 5000u Heparin sc,

Outcome – No outcome was mentioned in the nurses/progress notes.

Evaluation Criteria Antibiotic Therapy – Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to

combat the bacteria present within the pleural space. This is in accordance with the use of

antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).

Evacuation of Supportive Fluid – Patient R.S. was noted to have 75cc of hemopurulent

fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also,

oscillations were noted, indicating that the nurse was monitoring the status of the thoracotomy

tube as necessary for proper evacuation (Sahn 2007, pp. 1480-1486).

Antipyretics – Patient R.S. was constantly monitored to determine whether or not antipyretic

measures would be need. None were administered as the temperature was within acceptable

range (97.2F). In addition, the continuous administration of Panadol as ordered provided an

antipyretic effect. Monitoring for the presence of hyperthermia is important, as both the infection

and inflammation present in parapneumonic effusion with empyema will have a direct effect on

the temperature. Thus, if the temperature is within normal ranges, it indicates the

infection/inflammation is being adequately managed. This is in accordance with the information

presented in the literature review (Colice 2000, pp1158-71).

Restoration of Lung Capacity (not necessary)

Analgesics –The need for analgesia is indicated not only by the presence of the chest tube in

situ (Sahn 2007, pp. 1480-1486), but the patients c/o pain to his left side. Voltaren and Panadol

were both administered for the purpose of analgesia. This is an important management, as the

presence of pain not only leads to patient discomfort and decreased compliance with treatment

methods, but can lead to ineffective breathing and complications such as atelectasis (Colice

2000, pp1158-71)..

Medication Administration – The patient was medicated as ordered in a timely fashion, an

important factor for the effective management of this condition. The patient was given Zantac to

counteract the stomach acid secretory increase caused by Voltaren which itself was administered

for the pain. The analgesics were given for pain management, while the antibiotics were given

for treatment of the primary condition, parapneumonic effusion (Hughes 1991). Heparin was

given to prevent the formation of blood clots, due to the reduced mobility of the patient and risk

for Deep Vein Thrombosis, or DVT.

Final Evaluation for Day 2 – The final evaluation for day two reports that not only does

the sputum culture remain undone, but the breath sounds were not auscultated to indicate the

level of exudate infiltration within the pleural space or whether or not atelectasis, an important

complication, had started to occur. In addition, there was no mention of the patients cough and

subsequent production of sputum, nor was there mention of any teaching methods designed to

enhance the patients cough reflex.

25/10/12 – Day 3 Post Admission

Assessment – client has no complaints; alert and rational, no distress noted; left chest tube in situ

150cc purulent fluid in underwater seal bottle, oscillating; dressing intact; IV access in place for

meds to left arm; hydration fair; V/S – T96, P64 R20 SPO2 96%

Plan – change dressing, medicate and monitor

Interventions – Pethidine 75mg IM, Gravol 50mg IM, Voltaren 75mg, Zantac 150mg, Enalapril

10mg and Baralgin 1g, Panadol 1g po, Flagyl, Zosyn IV given as ordered; dressing to left chest

tube site was changed.

Outcome – No outcome was mentioned in the nurses/progress notes.

Evaluation Criteria Antibiotic Therapy – Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to

combat the bacteria present within the pleural space. This is in accordance with the use of

antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).

Evacuation of Supportive Fluid – Patient R.S. was noted to have 150cc of hemopurulent

fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also,

oscillations were noted, indicating that the nurse was monitoring the status of the thoracotomy

tube as necessary for proper evacuation (Sahn 2007, pp. 1480-1486) .

Antipyretics – Patient R.S. was constantly monitored to determine whether or not antipyretic

measures would be need. None were administered as the temperature was within acceptable

range (96 F). In addition, the continuous administration of Panadol as ordered provided an

antipyretic effect. Monitoring for the presence of hyperthermia is important, as both the infection

and inflammation present in parapneumonic effusion with empyema will have a direct effect on

the temperature. Thus, if the temperature is within normal ranges, it indicates the

infection/inflammation is being adequately managed. This is in accordance with the information

presented in the literature review (Colice 2000, pp1158-71).

Restoration of Lung Capacity (not necessary)

Analgesics –The need for analgesia is indicated not only by the presence of the chest tube in

situ (Sahn 2007, pp. 1480-1486) even though the client had no c/o of pain during the

nursesreceivalassessment. This is evidenced by the administration of Pethidine 75mg throughout

the day. Pethidine is a narcotic analgesic which can cause respiratory depressant effects, and thus

administration of this drug should have been followed by a thorough assessment of the patient’s

respiratory system, which was not noted. Voltaren and Panadol were both administered for the

purpose of analgesia. This is an important management, as the presence of pain not only leads to

patient discomfort and decreased compliance with treatment methods, but can lead to ineffective

breathing and complications such as atelectasis (Colice 2000, pp1158-71). Baralgin was also

administered, which is contraindicated in patients with infection as long term Baralgin use can

lead to agrannulocytosis, particularly with a reduction in bactericidal neutrophils. Thus, the

researcher does not agree with the prescription/administration of Baralgin.

Medication Administration – The patient was medicated as ordered in a timely fashion, an

important factor for the effective management of this condition. The patient was given Zantac to

counteract the stomach acid secretory increase caused by Voltaren which itself was administered

for the pain. The analgesics were given for pain management, while the antibiotics were given

for treatment of the primary condition, parapneumonic effusion (Hughes 1991). Heparin was

given to prevent the formation of blood clots, due to the reduced mobility of the patient and risk

for Deep Vein Thrombosis, or DVT. Enalapril was given to lower the blood pressure.

Final Evaluation for Day 3 – The final evaluation for day three reports that not only does

the sputum culture continue to remain undone, but the breath sounds were not auscultated to

indicate the level of exudate infiltration within the pleural space or whether or not atelectasis, an

important complication, had started to occur. In addition, there was no mention of the patients

cough and subsequent production of sputum, nor was there mention of any teaching methods

designed to enhance the patients cough reflex. There was also no mention of an assessment of

the wound site. Wound site assessment is important during dressing changes as it indicates the

presence or potential for reinfection/ super infection (Hughes 1991).

26/10/12 – Day Four Post Admission

Assessment – patient stated “I’m not feeling much pain at the cut but mi alright; Mi whole body

feel weak.” Elderly patient received n sitting position, conscious, oriented to person place and

time; mucus membrane pink and moist, capillary refill less than 2 seconds, chest expansion

unequal, left side diminished, no adventitious breath sounds heard; IV access noted proximal to

left wrist, left bilateral chest tube in situ attached to underwater seal drainage, 200ml purulent

fluid, oscillation noted. Dressing to thoracotomy site clean, dry and intact; abdomen slightly

enlarged; skin hydrated; vital signs – T 97.6F; P72, R18, B/P 130/82, Risk for infection related to

IV site and surgical opening of skin; Risk for injury related to generalized weakness; patient

coughed up green-flecked sputum; night nurses report that there is no evidence of cough seen.

Plan – at the end of the shift patient will be from injury and infection; monitor patients mobility;

reduce patient level of activity, advise patient to stay in bed and call for assistance, ensure that

dressings remain clean, monitor vital signs

Interventions – patient was medicated Voltaren 75mg, IM Gravol 50mg, Enalaprilpo,

Cetamolpo, Heparin sc, Zantac, Flagyl and Baralginpo

Outcome – 12:05pm – Patient stated “I’m not feeling so weak like this morning but I am still

feeling a little pain”

Evaluation Criteria Antibiotic Therapy – Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to

combat the bacteria present within the pleural space. This is in accordance with the use of

antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).

Evacuation of Supportive Fluid – Patient R.S. was noted to have 200ml of hemopurulent

fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also,

oscillations were noted, indicating that the nurse was monitoring the status of the thoracotomy

tube as necessary for proper evacuation (Sahn 2007, pp. 1480-1486) .

Antipyretics – Patient R.S. was constantly monitored to determine whether or not antipyretic

measures would be need. None were administered as the temperature was within acceptable

range (97.6F). In addition, the continuous administration of Panadol as ordered provided an

antipyretic effect. Monitoring for the presence of hyperthermia is important, as both the infection

and inflammation present in parapneumoniac effusion with empyema will have a direct effect on

the temperature. Thus, if the temperature is within normal ranges, it indicates the

infection/inflammation is being adequately managed. This is in accordance with the information

presented in the literature review (Colice 2000, pp1158-71).

Restoration of Lung Capacity (not necessary)

Analgesics –The need for analgesia is indicated by the presence of the chest tube in situ (Sahn

2007, pp. 1480-1486) even though the patient states that they were not feeling much pain.

Voltaren and Panadol were both administered for the purpose of analgesia. This is an important

management, as the presence of pain not only leads to patient discomfort and decreased

compliance with treatment methods, but can lead to ineffective breathing and complications such

as atelectasis (Colice 2000, pp1158-71). In addition, the lack of pain experienced by the patient

indicates the effectiveness of the analgesia administered not only in a curative but prophylactic

role. Baralgin was also administered, which is contraindicated in patients with infection as long

term Baralgin use can lead to agrannulocytosis, particularly with a reduction in bactericidal

neutrophils. Thus, the researcher does not agree with the prescription/administration of Baralgin.

Medication Administration – The patient was medicated as ordered in a timely fashion, an

important factor for the effective management of this condition. The patient was given Zantac to

counteract the stomach acid secretory increase caused by Voltaren which itself was administered

for the pain. The analgesics were given for pain management, while the antibiotics were given

for treatment of the primary condition, parapneumoniac effusion (Hughes 1991). Heparin was

given to prevent the formation of blood clots, due to the reduced mobility of the patient and risk

for Deep Vein Thrombosis, or DVT. Enalapril was given to lower the blood pressure (130/82),

however as the patient does not have a history of HTN, the researcher does not agree with the

prescription/administration of Enalapril in this instance.

Final Evaluation for Day 4 – The final evaluation for day four reports that the sputum

culture was not done. Also, the lack of auscultation of breath sounds indicates a deficiency in the

assessment performed by nurse, and constitutes an unacceptable practice, in accordance with the

literature review. In addition, there was no mention of the patients cough and subsequent

production of sputum, nor was there mention of any teaching methods designed to enhance the

patients cough reflex, both necessary in the removal of sputum from the patients airways.

Final Evaluation

it is interesting to note that only on day four was an assessment of the abdomen done, even

though the primary reason for seeking health care by the patient was loss of appetite and marked

weight loss. No mention of interventions whether medical or nursing to deal with this concern of

the client was made. Also, a note made in the patient’s record indicateds that an order for fluid

culture by the doctor was made on the 2/11, which was over a week after admission. Culture

collection and analysis should have been one of the first interventions done, as it is one of the

three primary principles of empyema care (Tobler et al. 2004).

Nursing Care Plan

Glossary

1. Loculation: Having, formed of, or divided into small cavities or compartments.

2. Pleural: Pleural refers to the pleura or membrane that enfolds the lungs.

3. Pleural peel: heavy fibrinous deposits on the pleura

4. Exudate:1 relating to the oozing of fluid and other materials from cells and tissues,

usually as a result of inflammation or injury. 2A fluid with a high content of protein

and cellular debris which has escaped from blood vessels and has been deposited in

tissues or on tissue surfaces, usually as a result of inflammation.

5. Fibrinopurulent: characterized by the presence of both fibrin and pus

6. Fibrin:  fibrous, non-globular protein involved in the clotting of blood

7. Visceral pleura:  a thin serous membrane tissue layer that sticks to the lung surface.

It is the innermost of the two pleural membrane layers investing the lungs.

8. Parietal pleura:  pleura that lines the inner chest walls and covers the diaphragm

9. LDH (lactate dehydrogenase): LDH is most often measured to check for tissue

damage. The protein LDH is in many body tissues, especially the heart, liver, kidney,

muscles, brain, blood cells, and lungs.

10. Trapped lung: The condition occurs when the lung is covered preventing its

expansion to the chest wall, leaving a persistent fluid-filled pleural space.

11. Polymorphonuclear leukocytes: A white blood cell, usually neutrophilic, having a

nucleus that is divided into lobes connected by strands of chromatin. 

12. Septation:the division or partitioning of a cavity into parts by a septum.

13. Suppurate: to form or discharge pus.

14. Pneumonia: Inflammation of the lungs usually caused by a virus, bacteria, or other

organism.

15. Decortication: The removal of the outer layer or cortex from a structure, esp. the

lung, brain, or other organ.The operation of removing fibrous scar tissue that prevents

expansion of the lung.

16. Concomitant: Naturally accompanying or associated.

17. Aspiration: The sucking of fluid or a foreign body into the airway when drawing

breath.

18. Centripetally: moving toward the center.

19. Oropharynx: pertaining to the mouth and the pharynx.

20. Empyema: an accumulation of pus in the space between the lung and the membrane

that surrounds it (pleural space) that occurs when an infection spreads from the lungs.

21. Thoracentesis-is a procedure to remove fluid from the space between the lining of

the outside of the lungs (pleura) and the wall of the chest.

22. Thoracostomy- is a flexible plastic tube that is inserted through the chest wall and

into the pleural space or mediastinum. It is used to remove air, fluid or pus from the

intrathoracic space.

23. Parapneumonic effusion- is a type of pleural effusion that arises as a result of a

pneumonia, lung abscess, or bronchiectasis.

24. Hemithorax- this is half of the thorax.

25. Comorbidity- this is two or more coexisting medical conditions or disease.

26. PPE-Parapneumonic Pleural effusion

27. CPPE- Chronic Parapneumonic Pleural effusion

Appendix

COMPLETE BLOOD COUNT

The complete blood count (CBC) is often used as a broad screening test to determine an

individual's general health status. According to (“Complete,” 2012), a CBC is a panel of tests

that evaluates the three types of cells that circulate in the blood; Evaluation of white blood cells,

the cells that are part of the body's defense system against infections and cancer and also play a

role in allergies and inflammation, evaluation of red blood cells, the cells that transport oxygen

throughout the body and the evaluation of platelets, cell fragments that are vital for normal blood

clotting. It can be used to:

Screen for a wide range of conditions and diseases

Help diagnose various conditions, such as anemia, infection, inflammation, bleeding

disorder or leukemia etc

Monitor the condition and/or effectiveness of treatment after a diagnosis is established

Monitor treatment that is known to affect blood cells, such as chemotherapy or radiation

therapy

CHEST PHYSIOTHERAPY

“Chest physiotherapy (CPT) is a technique used to mobilize or loose secretions in the lungs and

respiratory tract” (“Chest Physiotherapy,” 2011). This is especially helpful for patients with large

amount of secretions or ineffective cough. Chest physiotherapy consists of external mechanical

maneuvers, such as chest percussion, postural drainage, vibration, to augment mobilization and

clearance of airway secretions, diaphragmatic breathing with pursed-lips, coughing and

controlled coughing. It is indicated for patients in whom cough is insufficient to clear thick,

tenacious, or localized secretions. For example: Pneumonias in dependent lung regions.

LIVER FUNCTION TEST

Liver enzyme tests, formerly called liver function tests (LFTs), are a group of blood tests that

detect inflammation and damage to the liver. They can also check how well the liver is working.

Liver enzyme testing includes ALT, AST, alkaline phosphatase; true liver function tests (LFTs)

include PT, INR, albumin, and bilirubin. (Johnson, 2012)

UREA & ELECTROLYTE

According to (“Urea,” n.d) U&E is often used as a screening test for patients who are generally

ill, to detect abnormalities of blood chemistry, including kidney failure and dehydration.

The U&E test is a blood test and requires a few millilitres of blood from a vein.

U&E is usually performed to confirm normal kidney function (renal function) or to exclude a

serious imbalance of biochemical salts in the bloodstream. A diverse number of conditions may

be detected on the U&E test, as each parameter tested may be high or low.

SPUTUM CULTURE

According to (Thompson, 2011), A sputum culture is a test to detect and identify bacteria

or fungi that are infecting the lungs or breathing passages. Sputum is a thick fluid produced in

the lungs and in the airways leading to the lungs. A sample of sputum is placed in a container

with substances that promote the growth of bacteria or fungi. If no bacteria or fungi grow, the

culture is negative. If organisms that can cause infection grow, the culture is positive. The type

of bacterium or fungus will be identified with a microscope or by chemical tests. If bacteria or

fungi that can cause infection grow in the culture, other tests may be done to determine which

antibiotic will be most effective in treating the infection. This is called susceptibility

or sensitivity testing.

This test is done on a sample of sputum that is usually collected by coughing. For people who

can't cough deeply enough to produce a sample, they can breathe in a mist solution to help them

cough. A sputum culture is done to:

Find and identify bacteria or fungi that are causing an infection (such as

pneumonia or tuberculosis) of the lungs or the airways leading to the lungs. Symptoms of

a lung infection may include difficulty breathing, pain when breathing, or a cough that

produces bloody or greenish brown sputum.

Identify the best antibiotic to treat the infection (sensitivity testing).

Monitor treatment of an infection.

CHEST X-RAY

A chest x ray is a painless, noninvasive test that creates pictures of the structures inside the chest,

such as the heart, lungs, and blood vessels. This test is done to find the cause of symptoms such

as shortness of breath, chest pain, chronic cough (a cough that lasts a long time), and fever. Chest

x rays help doctors diagnose conditions such as pneumonia, heart failure, lung cancer, lung tissue

scarring, and sarcoidosis. Doctors also may use chest x rays to see how well treatments for

certain conditions are working. (“Chest,”2010)

CHEST TUBE THORACOSTOMY

According to (“American Thoracic Society,” 2012), a “chest tube thoracostomy is done to drain

fluid, blood, or air from the space around the lungs. Some diseases, such as pneumonia and

cancer, can cause an excess amount of fluid or blood to build up in the space around the lungs

(called a pleural effusion). Also, some severe injuries of the chest wall can cause bleeding

around the lungs. Sometimes, the lung can be accidentally punctured allowing air to gather

outside the lung, causing its collapse (called a pneumothorax). Chest tube thoracostomy

(commonly referred to as "putting in a chest tube") involves placing a hollow plastic tube

between the ribs and into the chest to drain fluid or air from around the lungs.”

THORACENTESIS

Thoracentesis is a procedure to remove fluid from the space between the lungs and the chest wall

called the pleural space. It is done with a needle  (and sometimes a plastic catheter) inserted

through the chest wall. Ultrasound pictures are often used to guide the placement of the needle.

This pleural fluid may be sent to a lab to determine what may be causing the fluid to build up in

the pleural space.

On average only a small amount of pleural fluid is present in the pleural space. A buildup of

excess pleural fluid (pleural effusion ) may be caused by many conditions, such as infection,

inflammation, heart failure, or cancer. If a large amount of fluid is present, it may be hard to

breathe. Fluid inside the pleural space may be found during a physical examination and is usually

confirmed by a chest X-ray. (Thompson, 2011)

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