NCM 106 SY 2020-2021

UNION CHRISTIAN C OLLEGE

SCHOOL OF HEALTH AND SCIENCES
CITY OF SAN FERNANDO
LA UNION

CASE STUDY:
OPEN PNEUMOTHORAX

SUBMITTED BY:

ACENA, JOBELLE C.
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I. INTRODUCTION

An open pneumothorax occurs when air accumulates between the chest wall and the
lung as the result of an open chest wound or other physical defect. The larger the opening, the
greater the degree of lung collapse and difficulty of breathing. Chest pain and sometimes mild
breathlessness are the usual predominant presenting features. It occurs in individuals with
significant underlying lung disease. Signs and symptoms are tend to be more severe, as
the unaffected lung is generally not capable of replacing the loss of function in the affected
lung.

Hypoxemia (decreased blood oxygen levels) is usually present and may be observed as
cyanosis (blue discoloration of the lips and skin). Hypercapnia (accumulation of carbon
dioxide in the blood) is sometimes encountered; this may cause confusion and – if very severe –
may result in coma. It is often characterized with an increased heart rate (tachycardia), rapid
breathing (tachypnea) and low blood pressure (hypotension) in the initial stages. Risk factors
include smoking, family history of pneumothorax, and other significant lung disease like chronic
obstructive pulmonary disease, asthma and tuberculosis. Diagnostic exams include a plain
radiograph of the chest, ideally with the X-ray beams being projected from the back
(posteroanterior, or "PA"), has been the most appropriate first investigation. These are usually
performed during maximal inspiration (holding one's breath); no added information is gathered
by obtaining a chest X-ray in expiration (after exhaling).

Although the cause will influence management to some degree, some management
principles are common to each type of pneumothorax. The primary goal is to achieve reinflation
of the affected region. Small pneumothoraces may be left to resolve themselves. However,
pneumothoraces involving a significant portion of a lobe will require intervention. Apart from
administering supplemental oxygen to support the individual’s oxygenation, an intercostal
catheter will be inserted. The intercostal catheter (chest tube) is attached to a closed-chest
drainage system, which achieves negative pressure with an underwater system or by attaching
it to a low-flow suction regulator. Analgesia should be provided regularly and hourly
observation of the chest drain should be undertaken to monitor the progress and safety.

II. PATIENT’S PROFILE

NAME: PATIENT X OCCUPATION: Carpenter

GENDER: Male DATE OF ADMISSION: January 27, 2019

AGE: Parian, San Fernando City, La Union SEX: 60 years old

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CIVIL STATUS: Married

RELIGION: Roman Catholic

ATTENDING PHYSICIAN : Christopher L. Abaya, M.D.

FAMILY HISTORY

Patient has 3 children; all are apparently well. No other hereditary diseases.

PRESENT MEDICAL HISTORY

30 minutes prior to admission, a 60-year-old male, fallen off from the roof while fixing
the hole of their roof and landed on the floor and was punctured by a wood on his
lateral chest. He experienced sudden chest pain, shortness of breath and difficulty of
breathing. He was presented to ER as an accidental stabbing.

PAST MEDICAL HISTORY

No allergies to foods and drugs. No history of blood transfusions, trauma, accidents and
psychiatric illness.

III. A NATOMY AND PHYSIOLOGY

The lungs are pyramid-shaped, paired organs that are connected to the trachea by the
right and left bronchi; on the inferior surface, the lungs are bordered by the diaphragm. The
diaphragm is the flat, dome-shaped muscle located at the base of the lungs and thoracic cavity.
The lungs are enclosed by the pleurae, which are attached to the mediastinum. The right lung is
shorter and wider than the left lung, and the left lung occupies a smaller volume than the right.
The cardiac notch is an indentation on the surface of the left lung, and it allows space for the
heart. The apex of the lung is the superior region, whereas the base is the opposite region near
the diaphragm. The costal surface of the lung borders the ribs. The mediastinal surface faces
the midline.
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Each lung is composed of smaller units called lobes. Fissures separate these lobes from
each other. The right lung consists of three lobes: the superior, middle, and inferior lobes. The
left lung consists of two lobes: the superior and inferior lobes. A bronchopulmonary segment is
a division of a lobe, and each lobe houses multiple bronchopulmonary segments. Each segment
receives air from its own tertiary bronchus and is supplied with blood by its own artery. Some
diseases of the lungs typically affect one or more bronchopulmonary segments, and in some
cases, the diseased segments can be surgically removed with little influence on neighboring
segments. A pulmonary lobule is a subdivision formed as the bronchi branch into bronchioles.
Each lobule receives its own large bronchiole that has multiple branches. An interlobular
septum is a wall, composed of connective tissue, which separates lobules from one another.

Blood Supply and Nervous Innervation of the Lungs

The blood supply of the lungs plays an important role in gas exchange and serves as a
transport system for gases throughout the body. In addition, innervation by the both the
parasympathetic and sympathetic nervous systems provide an important level of control
through dilation and constriction of the airway.

Blood Supply

The major function of the lungs is to perform gas exchange, which requires blood from
the pulmonary circulation. This blood supply contains deoxygenated blood and travels to the
lungs where erythrocytes, also known as red blood cells, pick up oxygen to be transported to
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tissues throughout the body. The pulmonary artery is an artery that arises from the pulmonary
trunk and carries deoxygenated, arterial blood to the alveoli. The pulmonary artery branch
multiple times as it follows the bronchi, and each branch becomes progressively smaller in
diameter. One arteriole and an accompanying venule supply and drain one pulmonary lobule.
As they near the alveoli, the pulmonary arteries become the pulmonary capillary network. The
pulmonary capillary network consists of tiny vessels with very thin walls that lack smooth
muscle fibers. The capillaries branch and follow the bronchioles and structure of the alveoli. It is
at this point that the capillary wall meets the alveolar wall, creating the respiratory membrane.
Once the blood is oxygenated, it drains from the alveoli by way of multiple pulmonary veins,
which exit the lungs through the hilum.

Nervous Innervation

Dilation and constriction of the airway are achieved through nervous control by the
parasympathetic and sympathetic nervous systems. The parasympathetic system
causes bronchoconstriction, whereas the sympathetic nervous system
stimulates bronchodilation. Reflexes such as coughing, and the ability of the lungs to regulate
oxygen and carbon dioxide levels, also result from this autonomic nervous system control.
Sensory nerve fibers arise from the vagus nerve, and from the second to fifth thoracic ganglia.
The pulmonary plexus is a region on the lung root formed by the entrance of the nerves at the
hilum. The nerves then follow the bronchi in the lungs and branch to innervate muscle fibers,
glands, and blood vessels.

Pleura of the Lungs

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Each lung is enclosed within a cavity that is surrounded by the pleura. The pleura (plural
= pleurae) is a serous membrane that surrounds the lung. The right and left pleurae, which
enclose the right and left lungs, respectively, are separated by the mediastinum. The pleurae
consist of two layers. The visceral pleura is the layer that is superficial to the lungs, and extends
into and lines the lung fissures. In contrast, the parietal pleura is the outer layer that connects
to the thoracic wall, the mediastinum, and the diaphragm. The visceral and parietal pleurae
connect to each other at the hilum. The pleural cavity is the space between the visceral and
parietal layers.

The pleurae perform two major functions: They produce pleural fluid and create cavities
that separate the major organs. Pleural fluid is secreted by mesothelial cells from both pleural
layers and acts to lubricate their surfaces. This lubrication reduces friction between the two
layers to prevent trauma during breathing, and creates surface tension that helps maintain the
position of the lungs against the thoracic wall. This adhesive characteristic of the pleural fluid
causes the lungs to enlarge when the thoracic wall expands during ventilation, allowing the
lungs to fill with air. The pleurae also create a division between major organs that prevents
interference due to the movement of the organs, while preventing the spread of infection.

IV. INITIAL ASSESSMENT

Received patient lying in bed, vital signs was taken as follows: T= 37℃, RR= 30
breathes/min, PR= 110 bpm , BP= 140/90 mmHg, SpO2= 80%.

Skin

 (+) cyanosis

Head

 EENT- anicteric sclera

 Pale palpebral conjunctiva

CHEST

 LUNGS - diminished breath sounds

Abdomen

 Flat with normal bowel sounds

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Hair is thin
Black with a strands of white hair in color
Hair
Silky and resilient
No notable presence of infestation
Head is rounded and symmetric
Head and Skull Smooth skull contour, no nodules or masses
No lesions noted
Eyebrows and eyelashes are black in color
Evenly distributed
Eyebrows symmetrically aligned
Eyes No discharge
Anicteric sclera
Pink palpebral conjunctiva
PERRLA
Brown in color
Symmetrical
Ears Auricle aligned with outer canthus of the eye
Firm and not tender
No foul smelling discharges
Symmetric
No discharge
Nose
(+) nasal flaring
Not tender, no lesions
Lips are dry
Pink gums, no retraction
Mouth
Tongue is centered
No tenderness
RR = 30
Bleeding on the right side of the chest
Heart/Chest/Lu
Punctured wound on right side of the chest
ngs
Diminished breath sounds on the right lung field
Decreased vocal fremitus
Flat
Abdomen Normal, abdominal bowel sounds
No masses found upon palpation
Fingernails and toenails are of normal curve
Extremities No presence of abnormal discoloration
Smooth in texture
Capillary refill of more than 2 seconds
Cyanosis
Skin Has good skin turgor
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V. PATHOPHYSIOLOGY

Predisposing Factor Precipitating Factor

Age Occupation

TRAUMATIC PNEUMOTHORAX

Atmospheric air flows directly

into the pleural cavity

Air pressure in the pleural cavity becomes positive

Lung collapses on the affected side

VI. L ABORATORY AND DIAGNOSTIC TESTS

COMPLETE BLOOD COUNT

ANALYSIS AND
NORMAL VALUES RESULTS INTERPRETATION OF
RESULTS
The result is below
normal values, which
Hemoglobin ( 125-175g/l) 114g/l
is a symptom of
having an anemia.
There was slight
decrease in the
Hematocrit (0.40- 0.52) 0.33
results due to
hemodilution.
Leukocytes The result is within
(5-10 x 10g/l) 7.2
(WBC) normal values
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The result is above

normal value
Neutrophils (0.45-0.65) 0.75 indicating that there
is bacterial or
parasitic infection.
The result is within
Lymphocytes (0.20-0.35) 0.25
normal values
The result is within
Monocytes (0.0 2-0.06) 0.04
normal values.

ARTERIAL BLOOD GAS

ABG: 5 Respiratory alkalosis with hypoxemia

pH: 7.50
PaO2: 70 mmHg
PaCO2: 29 mmHg
SpO2: 80%
HCO3: 20mEq/L

DIAGNOSTIC TEST RESULT

CHEST RADIOGRAPHY

Increased translucency (dark lung fields) on side of pneumothorax

- Mild depressed diaphragm

- Mild lung collapsed
- Decreased air entry on right lower lung fields
- 20% pneumothorax

VII. MEDICAL /SURGICAL /NURSING MANAGEMENT

Surgical Management

Tube thoracostomy is the insertion of a tube (chest tube) into the pleural cavity to drain
air, blood, bile, pus, or other fluids. Whether the accumulation of air or fluid is the result of
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rapid traumatic filling with air or blood or an insidious malignant exudative fluid, placement of a
chest tube allows for continuous, large volume drainage until the underlying pathology can be
more formally addressed.

Equipments

 Chest tube drainage device with water seal (autotransfuser unit is an option)
 Suction source and tubing
 Sterile gloves
 Preparatory solution
 Sterile drapes
 Surgical marker
 Lidocaine 1% with epinephrine
 Syringes, 10-20 mL (2)
 Needle, 25 gauge (ga), 5/8 in
 Needle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for instilling local anesthesia
 Blade, No. 10, on a handle
 Large and medium Kelly clamps
 Large curved Mayo scissors
 Large straight suture scissors
 Silk or nylon suture, 0 or 1-0
 Needle driver
 Vaseline gauze
 Gauze squares, 4 x 4 in (10)
 Sterile adhesive tape, 4 in wide
 Chest tube of appropriate size: Man - 28-32F; woman - 28F; child - 12-28F; infant - 12-
16F; neonate - 10-12F

Positioning

The patient should be positioned supine or at a 45° angle. Elevating the patient lessens
the risk of diaphragm elevation and consequent misplacement of the chest tube into the
abdominal space. The arm on the affected side should be abducted and externally rotated,
simulating a position in which the palm of the hand is behind the patient's head. A soft restraint
or silk tape can be used to secure the arm in this location. If a restraint is used, make sure that
good blood flow to the hand is present.

Procedure
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Obtain informed consent from the patient or patient’s representative except when
urgent placement is required. Assemble the drainage system and connect it to the suction
source. The appearance of bubbles in the water chamber is a sign that the chest tube drainage
device is functioning properly. Position the patient as described above. Identify the patient
using two identifiers (eg, name and date of birth). If possible, match the patient's identifiers at
his or her bed side with the identifiers present on a chest radiographs or computerized
tomograms (CT) that was recently performed. Clearly mark the site of chest tube insertion
(right or left). Identify the fifth intercostal and the midaxillary line. The skin incision is made in
between the midaxillary and anterior axillary lines over a rib that is below the intercostal level
selected for chest tube insertion. A surgical marker can be used to better delineate the
anatomy. Shave excessive hair and apply a preparatory solution to a wide area of the chest
wall. Wear sterile gloves, gown, hair cover, and goggles or face shield, and apply sterile drapes
to the area.

Administer analgesia. Administer a systemic analgesic (unless contraindicated). Use the

25-ga needle to inject 5 mL of the local anesthetic solution into the skin overlying the initial skin
incision, as shown in the image below. Use the longer needle (23 or, preferably, 27 ga) to
infiltrate about 5 mL of the anesthetic solution to a wide area of subcutaneous tissue superior
to the expected initial incision. Redirect the needle to the expected course of the chest tube
(following the upper border of the rib below the fifth intercostal space), and inject
approximately 10 mL of the anesthetic solution into the periosteum (if bone is encountered),
intercostal muscle, and the pleura. Aspiration of air, blood, pus, or a combination thereof into
the syringe confirms that the needle entered the pleural cavity.

Use the No. 11 or 10 blade to make a skin incision approximately 4 cm long overlying
the rib that is below the desired intercostal level of entry. The skin incision should be in the
same direction as the rib itself. Use a hemostat or a medium Kelly clamp to bluntly dissect a
tract in the subcutaneous tissue by intermittently advancing the closed instrument and opening
it. Palpate the tract with a finger, and make sure that the tract ends at the upper border of the
rib above the skin incision. Insertion of the chest tube as close as possible to the upper border
of the rib will minimize the risks of injury to the nerve and blood vessels that follow the lower
border of each rib. Adding more local anesthetic to the intercostal muscles and pleura at this
time is recommended. Use a closed large Kelly clamp to pass through the intercostal muscles
and parietal pleura and enter into the pleural space.This maneuver requires some force and
twisting motion of the tip of the closed Kelly clamp. This motion should be done in a controlled
manner so the instrument does not enter too far into the chest, which could injure the lung or
diaphragm. Upon entry into the pleural space, a rush of air or fluid should occur. The Kelly
clamp should be opened (while still inside the pleural space) and then withdrawn so that its
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jaws enlarge the dissected tract through all layers of the chest wall. This facilitates passage of
the chest tube when it is inserted.

Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue
and possible adhesions, as shown in the image below. Rotate the finger 360º to appreciate the
presence of dense adhesions that cannot be broken and require placement of the chest tube in
a different site, preferably under fluoroscopy (ie, by interventional radiology). Measure the
length between the skin incision and the apex of the lung to estimate how far the chest tube
should be inserted. If desired, place a clamp over the tube to mark the estimated length. Some
prefer to clamp the tube at a distal point, memorizing the estimated length. Grasp the proximal
(fenestrated) end of the chest tube with the large Kelly clamp and introduce it through the tract
and into the thoracic cavity. Release the Kelly clamp and continue to advance the chest tube
posteriorly and superiorly. Make sure that all of the fenestrated holes in the chest tube are
inside the thoracic cavity.

Connect the chest tube to the drainage device as shown (some prefer to cut the distal
end of the chest tube to facilitate its connection to the drainage device tubing). Release the
cross clamp that is on the chest tube only after the chest tube is connected to the drainage
device. Before securing the tube with stitches, look for a respiration-related swing in the fluid
level of the water seal device to confirm correct intrathoracic placement. Secure the chest tube
to the skin using 0 or 1-0 silk or nylon stitches.

For securing sutures, two separate through-and-through, simple, interrupted stitches on

each side of the chest tube are recommended. This technique ensures tight closure of the skin
incision and prevents routine patient movements from dislodging the chest tube. Each stitch
should be tightly tied to the skin, then wrapped tightly around the chest tube several times to
cause slight indentation, and then tied again.

Sealing suture: A central vertical mattress stitch with ends left long and knotted together
can be placed to allow for sealing of the tract once the chest tube is removed.

Place petrolatum (eg, Vaseline) gauze over the skin incision. Create an occlusive dressing
to place over the chest tube by turning regular gauze squares (4 x 4 in) into Y-shaped
fenestrated gauze squares and using 4-in adhesive tape to secure them to the chest wall. Make
sure to provide enough padding between the chest tube and the chest wall. Strap the emerging
chest tube on to the lower trunk with a "mesentry" fold of adhesive tape, as this avoids kinking
of the tube as it passes through the chest wall. It also helps reduce wound site pain and
discomfort for the patient. All connections are then taped in their long axis to avoid
disconnections.
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Obtain a chest radiograph to ensure correct placement of the chest tube.

Indications

 Pneumothorax : Open or closed; simple or tension

 Hemothorax
 Hemopneumothorax
 Hydrothorax
 Chylothorax
 Empyema
 Pleural effusion
 Patients with penetrating chest wall injury who are intubated or about to be intubated
 Considered for those about to undergo air transport who are at risk for pneumothorax

Contraindications

 Coagulopathy
 Pulmonary bullae
 Pulmonary, pleural, or thoracic adhesions
 Loculated pleural effusion or empyema
 Skin infection over the chest tube insertion site

Complications

 unresolved/reaccumulation of pneumothorax or misplacement of the tube (too

deep/kinked)
 Tube dislodgement
 Bleeding
 Re-expansion pulmonary edema

VIII. E VALUATION

IX. IMPLICATIONS

A. NURSING PRACTICE
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This case study provides information about Open pneumothorax and its treatment. This
case study would serve as a help to the nursing practice since it provides an appropriate plan of
care for patients who have undergo this minor surgery for efficient nursing care.

B. NURSING EDUCATION

To the nursing education, this case study would help in sharing data or
information about the disease condition and its management as well as the
preoperative and postoperative nursing interventions needed for the promotion of
patient’s recovery. With these, the students as well as the teachers would gain
additional information about the disease and patient’s condition so that it would equip
them for an efficient nursing care in the future.

C. NURSING RESEARCH

This case study would help in the nursing research as a source of data for
example, in tracking the population of persons with this condition. With this
information, it would make people aware of its growing incidence rate and the need to
treatment and share the importance of early detection or early prevention of this
disease condition.

X. R ECOMMENDATIONS

A punctured lung usually won’t cause any future health complications if it’s treated quickly.
However, if the collapse was caused by trauma to your lung, it’s possible for the condition to
occur again. You’re also more likely to experience another punctured lung if you smoke.

It’s important to call your doctor immediately if you think you’re having another collapse of the
lung. Delaying treatment can lead to complications or a longer recovery period.

 Take any medications as prescribed by your doctor.

 Stay active while taking enough rest.
 Sleep in an elevated position for the first few days.
 Avoid putting unnecessary pressure on the ribcage.
 Wear loose-fitting clothing.
 Avoid smoking.
 Avoid a sudden change in air pressure.
 Avoid driving until you’re fully recovered.
 Watch for signs of a recurrence.
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 Try breathing exercises that your doctor gives you.

 Attend all of your follow-up appointments.

REFERENCES

 Healthline: https://www.healthline.com/health/punctured-lung#outlook
 MsdManuals: https://www.msdmanuals.com/home/injuries-and-poisoning/chest-
injuries/open-pneumothorax#:~:text=An%20open%20pneumothorax%20occurs
%20when,collapse%20and%20difficulty%20of%20breathing.
 Medscape: https://emedicine.medscape.com/article/80678-overview