case presentation on lung abscess

CASE PRESENTATION ON

LUNG ABSCESS

PRESENTED BY:

LAXMI THAPA

BSc NURSING

OBJECTIVES

To share experience and knowledge to friends and supervisor.

To get feedback from the friends and supervisor for further

improvement.

To gain confidence in presenting skills in among the group

PATIENT’S BIODATA

Name : Salina Mahato

Age/ Sex : 20 years/ Female

Education :Literate

Religion :Hindu

Occupation :Student

Marital status :Married

Date of Admission :2017-01-22

Hospital No :16120386

IP No :1701220502

Diagnosis :Right Lung Abscess with operative thoracotomy,

empyema thorasis

Chief Complaints: Cough and sputum × 15 Days

Fever × 3 Days

A. History Collection:a. Present illness:

Follow up case of lung abscess with right sided empyema thoracicchest tube insertion with right sided. 15 days earlier presented tothe CTVS opd with sputum since 4days. Cough was productive,sputum with yellowish in colour small amount, non-foul smelling.3 days after the onset of cough, the patient developed fever. It wasacute in onset, intermittent in nature, fever was seen in theevening. Maximum temperature was not recorded. Fever wasassociated with chills and rigor. It got relieved after takingparacetamol medicine. No Aggravating factors were known, nohistory of reddish discoloration in sputum, vomiting, loss ofconsciousness and chest pain.

b. Past illness:There was no any history of Hypertension, Tuberculosis, Diabetes

Mellitus, COPD, Asthma at past

c. Present Surgery:There is history of present surgery i.e. Operative thoracotomy

d. Past Surgery:There was no any history of past surgery.

e. Family History:No history of similar illness among family members. There is no any

history of Diabetes Mellitus, Mental illness, Tuberculosis, Hypertension

among family members.

Fig: Family Tree

INDEX

Female

Male

Dead Male

Patient

Personal History

Smoking : Non-smoker

Alcohol: Non-alcoholic

Food habit: Mixed diet , 2-3 times a day

Food allergy : Not known

Drug allergy: Not Known

Bowel and Bladder: Regular

Sleeping pattern: 7-8 hours per day

Hobbies: she likes to watch TV, listen to radio and work

Socio –Economic History

Type of house: Pakka house

No. of rooms: 6 rooms

Kitchen : separate

Type of drainage: open drainage

Type of toilet used: water seal

Sources of water: Hand pump

Type of fuel: wood and gas

Adequate lighting: present

Facilities available in surrounding:Temples, schools available

Monthly income: Rs 28000

Bread winner : Father-in law & Husband

INVESTIGATION

S.N Investigation Patient value Remarks

1 Hemoglobin 10.1mg/dl Anemia

2. Total leucocytes

count

10, 570 cells/ cu mm leukopenia

3. Neutrophils 83% Neutrophilic

leukocytosis

4. lymphocytes 07% lymphocytopenia

5. Platelets count 5,36,000 cells/cu.mm Thrombocytosis


6. ESR 57 mm/hr Infection

7. Creatinine 0.3 mg/dl Indicate muscular

dystrophy, Liver dz

8. Blood PH 7.30 Metabolic acidosis

9. Pco2 49.1 mm Hg Respiratory acidosis

10. Potassium 2.93 mmol/l Hypercalemia

Specimen: Fluid

Bronchial wash cytology:

Smears studies reveal plenty of polymorpho nuclear inflammatory

cells agisnt a degeneratedand preoteinaceous background

Conclusion: Acute inflammatory process


11. Calcium 0.53 mmol/L Hypocalcemia

MEDICATION

S.N Name of

Drug

Dose Route Frequency Classification

1. Inj. Pantop 40 mg I/V BD Proton pump

inhibitor

2. Inj. Tazopip 4.5gm I/V BD Antibiotic

3. Inj. Metron 500m

g

I/V TDS Antibiotic & Anti-

protozoal

4. Tab. Pcm 500m

g

P/O TDS Anti-pyretics

5. Tab Ifol 1 tab P/O OD Folic Acid

Needs Problems

Physical

Comfort

Elimination

Psychological

Unstable vital sign

ABG analysis

-PH: 7.30

-pco2: 49.1 mm Hg

Shortness of breath

Use of face mask

Pain over the chest tube drainage pipe

on chest

Use of bladder habits i.e.

catherterization

Disturbed sleep pattern

Anxiety.

Development task and

need

• Achieving new and more mature relations with age-mates of both

sexes.

• Achieving a masculine or feminine social role.

• Accepting one’s physic and using one’s body effectively.

• Desiring, accepting, and achieving socially responsible behavior.

• Achieving emotional independence from parents and other adults.

• Preparing for an economic career.

• Preparing for marriage and family life.

• Acquiring a set of values and an ethical system as a guide to

behavior-developing an ideology.

PHYSICAL EXAMINATION

Vital signs :

Blood pressure: 110/70 mm of hg

Heart rate: 88 beat per min

Respiration: 20 breath per min

Temperature: 98.4 degree Fahrenheit

PHYSICAL EXAMINATION

Findings

i. Yellowish with hemoptysis colouration sputum

ii. Chest tube drainage

iii. Dullness, decreased breath sound

iv. Coarse inspiratory crackles.

DISEASE

CONDITION

LUNG

ABSCESS

DEFINITION

Lung abscess is the necrosis of the pulmonary parenchyma caused by the microbial agents/ infection.

- Brunner and Suddharth

Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2cm) containing necrotic debris or fluid caused by microbial infection. This pus-filled cavity is often caused by aspiration, which may occur during anesthesia, sedation or unconsciousness from injury.

- wikipedia

A lung abscess is a bacterial infection that occurs in lung tissue.

- Healthline

ETIOLOGICAL FACTORSS.N Book’s picture Patient’s picture

1. Central venous system disorder

seizure

stroke

Not known

2. Drug addiction

3. Alcoholism

4. Esophageal disease

5. Compromised immune function

6. Patients without teeth

7. Those receiving NG tube feedings

8. Patients with an altered state of

consciousness due to anesthesia

PATHOPHYSIOLOGY

Invasion of infectious agents Defense mechanism of lungs

lose effectiveness and allow organisms to penetrate sterile lower

respiratory tract Inflammatory reaction occur

producing exudates WBC, mostly neutrophils also migrates into

alveoli and fill normally air containing spaces Areas of lung

are not adequately ventilated because of secretion and mucosal

edema partial oclusion of bronchi or alveoli

Decrease in alveolar oxygen tension, alveolar exudates tends to

consolidates so difficult to expectorate ventilation-

perfusion mismatch occurs in affected area of the lung.

CLINICAL FEATURES

S.N Book’s picture Patient’s picture

1. Mild productive cough to acute

illness

Productive cough with

yellowish in colour, small

amount, non—foul smelling

sputum

2. Fever Fever i.e. 100.9 F which was

acute in onset, intermittent in

nature

3. Productive cough with

moderate to copious amount of

foul smelling, sometimes

bloody sputum

present

4. Leukocytosis present

Contd………S.N Book’s picture Patient’s picture

5. Pleurisy or dull chest pain Absent

6. Dyspnea Present

7. Weakness present

8. Anorexia present

9. Weight loss Absent

DIAGNOSTIC EVALUATION


1. History collection Done

2. Physical examination Done

3. Chest X-ray Done

4. Lab test i.e Blood test,

Troponin I , II., HDL, LDL

Lab test i.e Blood test :- CBC, Hb

5. Sputum culture Done

6. Fibetopic bronchoscopy Not done

7. CT-SCAN Done


1. Pharmacological therapy:

I/V antimicrobial therapy depend on

results of sputum culture and

sensitivity

Inj. Pantop 40mg BD I/V

2. Clindamycin (cleosin) Inj. Tazopip 4.5gm BD I/V

3. Long term therapy with oral antibiotics

replaces I/V therapy for 4-12 weeks

Inj. Metron 500 mg TDS I/V

4. Adequate drainage of lung abcess

trhrough postural drainage and chest

physiotherapy

Tab Pcm 500mg TDS P/O

5. Insertion of percutaneous chest

catheter for long term drainage of

abcess

Tab Ifol OD P/O

6. A diet in high protein & calories Chest tube drainage

NURSING MANAGMENT

Administration of antibiotics and iv treatment as prescribed and monitor for side effects.

Chest physiotherapy is initiated as prescribed to facilitate drainage of abscess.

Educate the patient to perform deep-breathing and coughing exercise to help expand the lungs.

Ensure the proper nutritional fluid intake which is high in protein and calories.

Administration of oxygen if necessary.

Mobilization of patient.

Monitor vital signs.

Contd…… Monitor intake/output chart.

Maintain health to prevent the complication.

Oral care and maintain personal hygiene.

Encourage lung expansion movements.

Avoid over exertion and possible exacerbation of symptoms.

Check for the site of chest-tube insertion and check for

drainage, it’s amount and color.

Emotional support.

SURGICAL MANAGEMENT

Surgical intervention is rare, but pulmonary resection or

lobectomy is performed if massive hemoptysis (coughing of

blood) occurs or if there is no response to medical

management.

COMPLICATION

Aspiration pneumoia

Empyema

Pneumatocele

Bronchopleural fistula

Pleurisy

Atelectasis

Shock & respiratory failure

NURSING DIAGNOSIS

1. Ineffective airway clearance r/t broncho constriction,

increased mucus production, ineffective cough.

2. Ineffective breathing pattern r/t mucus, broncho constriction

and airway irritants.

3. Impaired gas exchange r/t ventilation—perfusion inequality.

4. Imbalanced nutrition pattern less than the body requirement

r/t loss of appetite.

5. Activity intolerance r/t fatigue, chest tube drainage and

ineffective breathing pattern.

6. Self-care deficit r/t fatigue secondary to increased work of

breathing and chest tube insertion/

7. Insomnia r/t hospitalization as manifested by sunken eyes.

8. Deficient knowledge about the self-management. Treatment

regimen and preventive measures.

9. Risk for infection r/t prolonged hospitalization.

10. Risk for deficient fluid volume r/t rapid respiratory rate.

HEALTH EDUCATION

1) Personal hygiene

2) Diaphragmatic breathing and coughing exerrcise.

3) Self-care

4) Follow-up

PROGRESS REPORT

Day 1 Day 2

•Patient general condition looks

ill

•Vital sign were stable

•Shortness of breathe

•SpO2 was maintained with

tracheostomy tube of 4L/m

•Kept on liquid diet

•Insertion of foley’s catheter


satisfactory


•SpO2 was maintained via

tracheostomy tube of 4L/m


•Monitoring of i/o chart

PROGRESS REPORT

Day 3 Day 4


fair


•SpO2 was maintained via face

mask

•Tracheostomy was removed

•Chest physio therapy was

provided



fair


•SpO2 was maintained via face

mask


PROGRESS REPORT

Day 5 Day 6


fair



•Foley’s catheter was removed

•Patient was able to mobilize

•Chest physiotherapy was

provided

•Patient condition was fair and

improved

•Patient was planned to shift

surgery ward

CONCLUSION

A patient named Salina mahato of 20 years female diagnosedwith lung abscess with empyema thorasis was a part of my casestudy, she was presented with complaints of cough withproductive yellowish colour sputum and fever for 3 days.

The case study includes detailed information, clinicalfeatures, book picture details on disease condition, etiology,pathophysiology, management and complications,

The case study on lung abscess with empyema thorasisallowed me to identify the difference between the diseased andnormal client of same age group. It also provided me anopportunity to gain knowledge. Experience and enhance thecompetency.

REFERENCES

• Brunner and suddharth “ A Textbook of medical surgical nursing”, 13th edition; page no. 591-592.

• B.T. Basavan thapa “Medical- Surgical Nursing”, 2nd

edition; page no:1062-1066.

• Raj kumar thapa “A companion pocketbook of pharmacy and pahrmacology” 2nd edition, page no:86-90.

• Ross and wilson “Anatomy and physiology in health and illness” 11th edition, page no:233-236.

Net sources:

• http://www.wikipedia/com.org/lungabscess.

• https://www.medscape.com/lungabscess.

http://www.wikipedia/com.org/lungabscess

https://www.medscape.com/lungabscess

case presentation on lung abscess

Health & Medicine