EMPYEMA SECONDARY TO PNEUMONIA

1. VELEZ COLLEGE – COLLEGE OF NURSING
A CASE STUDY OF PATIENT K. S. DIAGNOSED WITH EMPYEMA
SECONDARY TO PNEUMONIA
Presented by: Dave Jay S. Manriquez, RN.
CHAPTER ONE
INTRODUCTION
This is a case study on patient KNS, 3 months old, female, Roman Catholic, Filipino, residing at Candabo, Argao and born on January 26, 2007 via Normal Spontaneous Vaginal Delivery
(NSVD) at Argao Isidro Quintana Memorial Hospital, who was admitted for the 1st time in Cebu Velez General Hospital (CVGH) for complaints of fever, cough, and convulsion. The patient was
admitted under the services of Dr. Lydia Chang and Dr. Maribel Du under the Department of Pediatrics and Surgery with the case number of 87395 and hospital number of 039874.
The case was chosen by the researchers on May 9, 2007 at around 12 noon.
PNEUMONIA
Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites. Although different types of
pneumonia tend to affect children in different age groups, pneumonia is most commonly caused by viruses. Some viruses that cause pneumonia are adenoviruses, rhinovirus, influenza virus (flu),
respiratory syncytial virus (RSV), and parainfluenza virus (the virus that causes croup).
• Often pneumonia begins after an upper respiratory tract infection (an infection of the nose and throat). When this happens, symptoms of pneumonia begin after 2 or 3 days of a cold or sore
throat.
Types of Pneumonia
1. Community-acquired pneumonia(CAP)
a. Pneumococcal –causative agent: S. pneumonia; incidence are common on elderly, with COPD, CHF, alcoholism
b. Influenzae pneumonia or Haemophilus influenza- CA: H. pneumoniae; I: splenectomy, alcoholics, in chronic care facilities

2. c. Viral pneumonia (occur in every 2-3 years) – CA: Influenza viruses A and B, adenovirus, parainfluenza, cytomegalovirus. I: adults
d. Aspiration pneumonia- CA: aspiration of food or gastric contents I: children and elderly.
2. Hospital acquired pneumonia
a. Pseudomonas pneumonia - CA: pseudomonas aeruginosa
b. Staphylococcal pneumonia- CA: Staphylococcus aureus
c. Klebsiella pneumonia- CA: Klebsiella pneumonia; I: immunosupressed, IV drug users, complication of epidemic nfluenza
3. In immunocompromised Host
a. Pneumocystic carnii pneumonia (PCP)- CA: Pneumocystis carnii; I: patients with AIDS, immunosupressed patients, recipients of organ transplants
b. Fungal pneumonia- CA: Aspegillus fumigates; I: immunosupressed patients, recipients of organ transplants immunosupresse patients, neutopenic patients
Incubation
The incubation period for pneumonia varies, depending on the type of virus or bacteria causing the infection. Some common incubation periods are: respiratory syncytial virus, 4 to 6 days; influenza, 18
to 72 hours.
Duration
With treatment, most types of bacterial pneumonia can be cured within 1 to 2 weeks. Viral pneumonia may last longer. Mycoplasmal pneumonia may take 4 to 6 weeks to resolve completely.
Contagiousness
The viruses and bacteria that cause pneumonia are contagious and are usually found in fluid from the mouth or nose of an infected person. Illness can spread when an infected person coughs or sneezes
on a person, by sharing drinking glasses and eating utensils, and when a person touches the used tissues or handkerchiefs of an infected person.
Signs and Symptoms
Symptoms of pneumonia vary, depending on the age of the child and the cause of the pneumonia. Some common symptoms include:
• fever
• chills
• cough
• unusually rapid breathing
• breathing with grunting or wheezing sounds
• labored breathing that makes a child's rib muscles retract (when muscles under the rib cage or between ribs draw inward with each breath)

3. • vomiting
• chest pain
• abdominal pain
• decreased activity
• loss of appetite (in older children) or poor feeding (in infants)
• in extreme cases, bluish or gray color of the lips and fingernails
Sometimes a child's only symptom is rapid breathing. Sometimes when the pneumonia is in the lower part of the lungs near the abdomen, there may be no breathing problems at all, but there may be
fever and abdominal pain or vomiting. When pneumonia is caused by bacteria, an infected child usually becomes sick relatively quickly and experiences the sudden onset of high fever and unusually
rapid breathing. When pneumonia is caused by viruses, symptoms tend to appear more gradually and are often less severe than in bacterial pneumonia. Wheezing may be more common in viral
pneumonia. Some types of pneumonia cause symptoms that give important clues about which germ is causing the illness. For example, in older children and adolescents, pneumonia due to Mycoplasma
(also called walking pneumonia) is notorious for causing a sore throat and headache in addition to the usual symptoms of pneumonia.
In infants, pneumonia due to chlamydia may cause conjunctivitis (pinkeye) with only mild illness and no fever. When pneumonia is due to whooping cough (pertussis), the child may have long
coughing spells, turn blue from lack of air, or make a classic quot;whoopquot; sound when trying to take a breath.
Prevention
There are vaccines to prevent infections by viruses or bacteria that cause some types of pneumonia. Children usually receive routine immunizations against Haemophilus influenzae and pertussis
(whooping cough) beginning at 2 months of age. (The pertussis immunization is the quot;Pquot; part of the routine DTaP injection.) Vaccines are now also given against the pneumococcus organism (PCV), a
common cause of bacterial pneumonia.
When to seek prompt treatment?
Call your child's doctor immediately if your child has any of the signs and symptoms of pneumonia, but especially if your child:
- is having trouble breathing or is breathing abnormally fast
- has a bluish or gray color to the fingernails or lips
- has a fever of 102 degrees Fahrenheit (38.9 degrees Celsius), or above 100.4 degrees Fahrenheit (38 degrees Celsius) in infants under 6 months of age
Treatment

4. Doctors usually make the diagnosis of pneumonia after a physical examination. The doctor may possibly use a chest X-ray, blood tests, and (sometimes) bacterial cultures of mucus produced by
coughing when making a diagnosis. In most cases, pneumonia can be treated with oral antibiotics given to your child at home. The type of antibiotic used depends on the type of pneumonia.
Children may be hospitalized for treatment if they have pneumonia caused by pertussis or other bacterial pneumonia that causes high fevers and respiratory distress. They may also be hospitalized if
supplemental oxygen is needed, if they have lung infections that may have spread into the bloodstream, if they have chronic illnesses that affect the immune system, if they are vomiting so much that
they cannot take medicine by mouth, or if they have recurrent episodes of pneumonia.
EMPYEMA
Empyema is a pus within a natural body cavity. It must be differentiated from an abscess, which is a collection of pus in a newly formed capsule rather than a pre-existing cavity. Empyema can occur
as a complication of pneumonia, tuberculosis or surgical procedures (postsurgical empyema). The incidence of empyema is not well characterized, although a recent study suggests empyema may be
common in patients admitted to the medical ICU. Fartoukh et al. reported an 8.4% of patients admitted to the medical ICU had physical and radiographic evidence of pleural effusion. Diagnostic
thoracentesis was performed in 73% of these patients, and empyema was diagnosed in 17% of cases of pleural effusion. 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. Microorganisms associated with empyema
included Staphylococcus aureus , Streptococcus spp. , E. coli , K. pneumoniae , M. tuberculosis , and PeptoStreptococcus.
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.
In humans, the pleural space surrounding the lungs is most commonly affected. This particular condition is called pyothorax and is usually caused by a bacterial infection of the lungs (pneumonia).
Other common empyemas include appendicitis and pyometra.
Pleural space empyema
Symptoms
Typical symptoms are just about the same as tuberculosis which includes: fever (which may be spiking), chest pain, cough, sweating and shortness of breath.
Clubbing of the fingernails is present. There is a dull percussion note and reduced breath sounds on the affected side of the chest. Chest x-ray shows a pleural effusion, often with a lateral bulge and
pleural thickening. Ultrasound confirms the size and location of the pocket of pus and the presence of fibrin aggregates.There are 3 stages:Exudative, fibrinopurulent and organizing. In the exudative
stage, the pus accumulates. This is followed by the fibrinopurulent stage in which there is loculation of the pleural fluid (the creation of grapelike pus pockets). In the final organizing stage there is the
potential for lung entrapment by scarring. If it makes it to the final stage and scarring occurs there is a good chance of pulmonary fibrosis and other conditions that will happen in years to come, such as

5. right sided heart failure (cor pulmonale). This is due to the high pulmonary pressures due to the scarring and the treatment is most likely a single lung transplant. The only drug that might have any
effect is prednisone, but the use of prednisone is only temporary.
Diagnosis
Diagnosis is confirmed by thoracentesis, X-Ray and CT Scan. Frank pus may be aspirated from the pleural space. The pleural fluid has a low pH, and the blood has a high white blood cell count usually
above 20,000. Aspirated fluid is cultured to identify the causitive organism. Arterial blood gases are drawn to determine the pH, CO2 and O2 levels. Another test to confirm empyema is a pleural
tap(removing 3-4 pieces of 1 to 2cm of the pleura).
Treatment
A chest tube is inserted to drain the pus from the pleural space, using ultrasound scan guidance. Intravenous antibiotics are given. If this is insufficient, surgical decortication of the pleura may be
required.And 02 therapy.
Some evidence suggests that intrapleural fibrinolytic drugs may be useful, especially in children. Also supplemental oxygen via nasal cannula is usually a good idea since the O2 sats will be near 93%
or below. If below 90% a venti mask or non-re-breather for higher doses of oxygen is recommended. This is usually when it's in the 3rd stage.
Empyema is treated using a combination of medications and surgical techniques. 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 are also given oxygen therapy.
Prognosis
The prognosis for recovery is generally good, except in those cases with complications, such as a brain abscess or blood poisoning, or cases caused by certain types of streptococci.

6. RATIONALE OF STUDY
Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites.
According to the World Health Organization, the ten leading causes of morbidity in the Philippines are diarrhea, bronchitis/bronchiolitis, pneumonia, influenza, hypertension, tuberculosis, diseases of
the heart, malaria, measles and chickenpox. The prevalence of communicable diseases is still very high while that of non-communicable diseases is increasing and will continue to do so. This double
burden of disease places a great toll on the health and economy of the people and of the nation as a whole. The top ten leading causes of mortality are diseases of the heart, diseases of the vascular
system, pneumonia, malignant neoplasms, accidents, tuberculosis, chronic obstructive pulmonary diseases, diabetes mellitus, other diseases of the respiratory system, nephritis/nephritic syndrome and
nephrosis.
The fact that lung disease and other breathing problems are the number one killer of babies younger than one year old is very alarming. Infants and children are born to enjoy and to explore
into this world. They are the most fragile citizens of this world and should be taken care of. They should be protected from harm that the environment can give them. They should be shielded and
guarded.
But if these delicate infants get sick, this reflects greatly on how neglectful his environment is and the people responsible for his well being. This caught our concern, as good citizen of society
and as nursing students. It is our great duty, to protect these innocent beings. Respiratory disease is life-threatening, thus, prompting the need to let others be sensitive of the great significance to know
its cause and how it affects little children.
It is essential that the process of the disease be taken into in-depth study. The feature common to all types of pneumonia is an inflammatory pulmonary response to the offending organism or
agent. With the defense mechanism of the lungs, lose effectiveness and allow organisms to penetrate the sterile lower respiratory tract, where inflammation develops. Disruption of the mechanical
defenses of cough and cilliary motility leads to colonization of the lungs and subsequent infection. Inflamed and fluid filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively.
Alveolar exudates tend to consolidate, so it is increasingly difficult t expectorate. Bacterial pneumonia maybe associated with significant ventilation-perfusion mismatched as the infection grows.
This study is guided by the following theories by: Comfort Theory of Katharine Kolcaba, Betty Neuman’s Systems Model, and Casey’s Model of Nursing. The comfort theory of Katharine
Kolcaba states that in view of these relationships and the fact that children and families want to be comforted in stressful healthcare situations, comfort is an important outcome to measure for pediatric

7. care and research. With its inherent emphasis on simultaneous physical, psychospiritual, sociocultural, and environmental aspects of comfort, will contribute to a well-articulated, multifaceted approach
to pediatric education and practice. On the other hand, the Neuman’s Systems Model emphasized that broad and comprehensive enough to provide structural nursing interventions to not only older
patients but to pediatric clients as well. This theory is applicable in this study because of how it describes the patient as an open system. The environment both internal and external, play a very crucial
task in the development of a child as presented by the 5 interrelated variables. Furthermore, Casey’s model of nursing stresses that with the importance of the partnership between the parents and
caregiver, the service rendered to the child will be adequate enough to bring back his optimum level of functioning.
REVIEW OF RELATED LITERATURE
CASE REPORT
A 3 year-old Caucasian boy, with a past history of croup, presented with a three-day history of vomiting and diarrhea. He was admitted to hospital because of right middle lobe and lower lobe
consolidation, neutropenia and a markedly elevated C-reactive protein of 216 mg/L consistent with a diagnosis of pneumonia. Treatment was started with intravenous penicillin and cefotaxime.
On day 3, blood Streptococcus pneumoniae, fully sensitive to penicillin, was isolated from blood cultures. By then his fever had settled and treatment was continued with high dose penicillin only. On
day 5, his fever recurred. A chest X-ray demonstrated a small right-sided loculated effusion, but an ultrasound revealed only a 1 cm rim of fluid that was deemed ‘not drainable’. Cefotaxime was
restarted.
By day 10, an ultrasound revealed that the pleural fluid collection on the right side was 3 cm deep and contained particulate matter and septa. Intravenous flucloxacillin was substituted for penicillin.
Because the child had clinically deteriorated with worsening fever, tachypnea and an increasing oxygen requirement, an urgent right thoracotomy, decortication and chest tube insertion under general
anesthesia was performed. A left internal jugular central line was inserted at the same time due to problems with peripheral venous access. The pleural fluid drained was seropurulent with many
leukocytes, but no organisms were found on culture.
On day 12, the patient again deteriorated and a chest X-ray revealed left sided collapse/consolidation with pleural effusion. An ultrasound revealed a left sided 4 cm loculated pleural fluid collection. A
left thoracotomy, decortication and chest tube insertion was performed under general anesthesia. After consultation with the hospital’s infectious diseases service, oral rifampicin was added to the
flucloxacillin and cefotaxime antibiotic regimen. Culture of the pleural fluid did not reveal any organisms. Abdominal, cardiac and major vessel ultrasounds did not reveal any other infective sites,
thrombosis, or fluid collections. Serum immunoglobulin levels were normal.
Subsequently the child’s condition slowly improved. He was discharged home well on day 26.
REVIEW
Empyema in children is usually the result of under-lying lung infection with Staphylococcus aureus or Streptococcus pneumoniae. Several studies report an increase in the incidence of
empyema in children; even in developed countries.1 Staphylococcal infections now outnumber streptococcal infections as the leading cause in countries where widespread pneumococcal vaccination
occurs.1 Haemophilus influenzae infection is now a rare cause of empyema, again due to an effective vaccination strategy. Mycoplasma pneumoniae commonly causes a parapneumonic effusion, and is
a recognized cause of empyema in children.2 Mixed infections, including anaerobes, can also occur, especi-ally in adults with underlying illnesses.3 In developed countries it is now most common for the
purulent fluid drained from the pleural cavity to be sterile, due to prolonged and broad-spectrum antibiotic treatment prior to drainage. In the United States of America, initial treatment with vancomycin

8. or clindamycin has been recommended due to the prevalence of resistant staphylococcal and streptococcal organisms.1 In Australia severe pediatric pneumonia with effusion is usually treated initially
with flucloxacillin and a third generation cephalosporin, with or without a macrolide antibiotic, as resistant pneumococcal disease is rare. Vancomycin is used initially only if meningitis is suspected.4
Staging of parapneumonic effusions
An exudative parapneumonic effusion without loculations or septa (Stage 1) has minimal leukocytes in the fluid. The fluid is characterized by an elevated lactate dehydrogenase (LDH), a low pH and
low glucose concentration. In the fibrinopurulent stage (Stage 2) these biochemical abnormalities worsen, the leukocyte count remains low, although there still may be extensive fibrinous coating of the
pleura and loculations. In Stage 3 disease frank pus develops. Stage 4 disease is characterised by loculated pus. The ideal management strategy for empyema has not been elucidated due to a paucity of
properly conducted randomized controlled trails. This situation is compounded by the fact that parapneumonic effusions (Stage 1 and 2 disease) are much more common that true empyema (Stage 3 and
4 disease). Earlier stage disease could be over- or under-represented in the various case series. Staging is also unreliable when based on clinical criteria, e.g. the age of the fluid collection. It is known
that Stage 4 disease can occur within 7 days of the initial fluid collection, but the fluid can remain relatively serous for much longer than this.5 Accurate staging of an empyema can only be done by a
combination of computerized tomography and fluid aspiration. In adults, empyema increases the mortality related to community-acquired pneumonia, usually from over-whelming sepsis, by seven
times if bilateral and by more than three times if unilateral.5 The overall mortality in several series ranges from 1 - 61%.6 Out-comes are almost certainly influenced by management strategy.
Daily thoracentesis
In a case series from Denmark,3 adults with empyema had markedly reduced hospital stays (2.3 vs 5 weeks), fewer complications (bronchopleural or pleurocutaneous fistulae) and less need for
thoracotomy or rib resection (6 vs 79%), if their empyema was managed by daily needle thoracentesis and lavage with or without intrapleural antibiotic administration versus chest tube drainage.
Mortality was equal between the two groups at 8.5%. The two groups of patients were managed by different units (medical and surgical) and may have had different illness severities or other
compounding factors. Daily thoracentesis, even if effective, may be impractical in children due to the daily requirement for deep sedation or general anesthesia.
Initial chest tube drainage
In a series of complex adult patients from Taiwan, 6 with mostly Gram-negative bacterial infections, unsuccessful initial chest tube drainage (defined as incomplete drainage with ongoing signs of
sepsis or death) resulted in a significantly higher mortality (47%) and longer hospital stays (28 days vs 16 days) than immediate thoracotomy and decortication or successful chest tube drainage (6% and
11% mortality respectively). Similar findings have been reported previously.7 It appears that incomplete drainage with ongoing signs of sepsis heralds a poor prognosis. It is important to note that
inflammatory markers such as CRP and ESR can remain elevated for up to 4 weeks despite adequate antibiotic treatment and drainage, although blood leukocyte count and fever falls by one week post
drainage.8 This delayed resolution of inflammatory markers makes assessment of recovery after drainage difficult. The efficacy of pleural fluid drainage thus remains the key to the clinical decision-
making process.
A large survey of practice in Britain indicates that only 11% of all pediatric empyemas are managed surgically. Long-term outcome is excellent.9 Most cases are adequately treated with simple chest
tube drainage. In a recent series from Great Ormond Street, later chest drain insertion (8.1 vs 6.3 days after effusion detected) was associated with a trend towards requirement for surgical drainage. 8
Those children requiring surgery had a longer hospital stay (18.6 vs 13.4 days), but surgery was only undertaken if chest tube drainage failed to result in complete drainage and clinical symptoms
persisted. The authors felt that inadequate chest tube size contributed to some failures. Chest tube size need not be routinely large, but should be determined by the degree of viscosity of the fluid.5
The adult literature reveals a key point, which is that successful complete drainage by chest tube alone can occur even when loculations are evident on ultrasound or computerized tomography scan.
However, the presence of loculations makes complete chest tube drainage less likely, with only 40% of loculated effusions drained completely versus 76% of simple effusions.5 A non-dependent chest
tube position does not affect drainage in non-loculated effusions. Truly loculated effusions require ultrasound guidance to achieve the correct tube location. Surprisingly a lower pleural fluid leukocyte
count is associated with failure of conservative management.5
Fibrinolytic therapy

9. In adults the addition of fibrinolytic agents to the pleural cavity can improve chest tube drainage impeded by loculations and fibrin debris,10 and may reduce the need for thoracotomy or video assisted
thoracoscopic surgery (VATS).11,12 In a series of 501 children with multiloculated empyema intrapleural fibrinolytic therapy (IPFT) was successful in avoiding surgery in 81% of cases.13 In a series of
22 children with complicated parapneumonic effusions from Taiwan, streptokinase resulted in a reduction in requirement for surgery and shorter duration of fever when compared with 20 historical
controls.14 There is one randomized controlled trial from India of routine administration of streptokinase intrapleurally 24 hours after chest tube insertion. No benefit was detected in terms of chest tube
drainage rates, duration of illness or development of loculatons.15 Intrapleural streptokinase may rarely lead to local bleeding complications. This was seen in one child administered 250,000 units of
streptokinase.13 Streptokinase can cause fever, pleural pain, arthralgia, anaphylaxis and the acute respiratory distress syndrome (ARDS).11 Urokinase may be the safest choice, with no recorded
complications at a dose of 100,000 Units intrapleurally used in the Oscelik series13 and in another series from Israel.16
Pigtailed catheters and tissue plasminogen activator (tPA)
Literature regarding the use of intrapleural tissue plasminogen (tPA) activator is limited, with only one report of its use in 12 children17 until Hawkins et al,18 published a recent report of tPA combined
with small bore pigtail catheter drainage of empyema in children. They reported successful management of empyema in 54 of 58 cases with a mean time to catheter removal of 6 days and a mean
hospital stay of 9.1 days, using this minimally invasive technique.
Video assisted thoracoscopic surgery (VATS)
Surgical options include a choice between VATS and formal thoracotomy. A study in 1997 of 20 adults compared VATS with chest tube drainage plus IPFT with streptokinase in loculated effusions
unresponsive to isolated chest tube drainage only.19 Ninety one percent of patients undergoing VATS avoided further surgery. However, 44% of the chest tube plus IPFT treated group required further
thoracotomy. In another study comparing immediate VATS with VATS after failed chest tube drainage and IPFT in late stage disease,20 shorter hospital stays (4.5 versus 7.5 days) were demonstrated in
the early VATS group. At least two adult studies report VATS debridement to be better than thoracotomy in terms of hospital stay and cosmesis.21,22 VATS is reported to be rapidly successful in the
majority of pediatric empyema cases with failed chest tube drainage when performed within 7 days of the initial attempt at chest tube drainage.23,24 VATS also resulted in shorter hospital stays (9 - 13
days) when compared with previous series of children managed with chest tube drainage and delayed thoracotomy. In the recent series of 230 children from the United States of America, 1 children that
received very early VATS (within 48 hours of admission), had a shorter hospital stay (11.5 versus 15.2 days, P = 0.008) than those who had VATS performed later. However, VATS is not widely
available, especially for children.
Early thoracotomy
Thoracotomy is traditionally resorted to only after the more conservative management strategies, discussed above, have failed. This surgery is associated with potential anesthesia difficulties,
complications such as pneumothorax, postoperative pain and cosmetic scarring. Some authors have challenged this traditional notion of deferring thoracotomy. Hoff et al,25 in a series of 61 children,
reported that resolution of the disease process was more prolonged in patients managed by chest tube alone (16.8 days in hospital) than resolution after thoracotomy (6.7 days, P < 0.001). Carey et al, 26
reported a series of 22 children with empyema referred to a pediatric cardiothoracic unit. Those children who had immediate thoracotomy (18 cases) were afebrile and had their chest tubes removed by
2 days. Their mean hospital stay was 4 days. The authors suggested that early thoracotomy remains the benchmark treatment. A similar case series of 44 children undergoing thoracotomy27 also revealed
very short duration of fever (mean 1 day) and an average of 3 days until chest tube removal. Both series authors point out that their mean hospital stays were shorter than series of children managed with
VATS.
In summary, the available evidence indicates early and complete drainage of an empyema remains the cornerstone of treatment, however it is achieved. Morbidity and mortality increases with
increasing delay in achieving this goal. Most patients can be managed with antibiotics and chest tube drainage only, especially early in the disease process. It is harder to treat late stage disease
conservatively. Conservative treatment results in prolonged hospital stays. Intrapleural fibrinolytics, ideally urokinase, may help to avoid surgery. Surgery in the form of VATS or thoracotomy, when

10. done early, appears to result in the most rapid disease resolution, from the limited pediatric evidence available. Thoracotomy may be superior to VATS in terms of length of stay, contrary to the adult
literature. The former has significant cosmetic disadvantages; the latter is not as widely available.
CONCLUSION
Empyema in children occurs infrequently in Western societies. The underlying causative organism is usually Staphylococcus aureus or Streptococcus pneum-oniae. Optimal management strategies
have not been developed due to a paucity of randomised controlled trials. Staging is difficult to assess clinically and radiologically. Most cases can be successfully managed with simple chest tube
drainage, plus appropriate antibiotic therapy. Based on available evidence, thoracotomy with decortication, in children, may provide the most effective treatment when compared with VATS and chest
tube drainage with or without intrapleural fibrinolytic therapy. The more conservative approaches to treatment may be appropriate initially to avoid the cosmetic disadvantages of thoracotomy.
However, delayed complete drainage increases morbidity and potentially mortality. The case presented might have been managed differently. Under general anesthesia, a pleural tap would have
revealed the relatively serous nature of the fluid and chest tube drainage only may well have been successful. However, the loculated nature of the collection and the illness of the child prompted initial
thoracotomy. VATS is not available for children in our institution. Our treatment decision is difficult to criticize in light of the available evidence that early thoracotomy leads to the most rapid
resolution of the disease process, earlier discharge, and reduced mortality. The major drawback of thoracotomy is the life-long surgical scar. This drawback is not insignificant, but has to be weighed
against the potential morbidity and mortality from ongoing infection. In retrospect, it is the authors’ view that a less aggressive approach in our case could also have been justified and may have resulted
in a better cosmetic result. This approach would be initial chest tube drainage only, under ultrasound guidance, instillation of urokinase on the second day if required, then proceeding to thoracotomy
within 48 - 72 hours of initial chest tube insertion if pleural fluid drainage were incomplete.
REFERENCES
1. Schultz KD, Fan LL, Pinsky J et al. The changing face of pleural effusions in children: Epidemiology and Management. Pediatrics 2004;113:1735-1740. 2. Chan W, Keyser-Gauvin E, Davis GM, Nguyen LT, Laberge
JM. Empyema thoracis in children: A 26 year review of the Montreal Children’s Hospital experience. J Ped Surg 1997;32:870-872. 3. Storm HKR, Krasnik M, Bang K, Frimodt-Moller N. Treatment of pleural empyema
secondary to pneumonia: thoracentesis regimen versus tube drainage. Thorax 1992;47:821-824. 4. Paxton G, Munro J, eds. Paediatric Handbook. Blackwell Publishing, Carlton, 2003. 5. Light RW, Rodriguez RM.
Management of parapneumonic effusions. Clinics Chest Med 1998;19:373-382. 6. Huang HC, Chang HY, Chen CW, Lee CH, Hsiue TR.
Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion or empyema. Chest 1999;115:751-756.
7. Pothula V, Krellenstein DJ. Early aggressive surgical management of parapneumonic empyemas. Chest. 1994;105:832-836.
8. Chan PWK, Crawford O, Wallis C, Dinwiddie R. Treatment of pleural empyema. J Paediatr Child health 2000;36:375-377.
9. McLaughlin FJ, Goldmann DA, Rosenbaum DM, Harris GBC, Schuster SR, Strieder DJ. Empyema in children: Clinical course and long-term follow-up. Pediatrics 1984;73:587-593.
10. Chin NK, Lim TK. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions. Chest 1997;111:275-279.
11. Bilaceroglu S, Cagirici U, Cakan A. Management of complicated patapneumonic effusions with image-guided drainage and intrapleural urokinase or streptokinase – A controlled randomised trial. Eur Respir J
1997;10:325S.
12. Bouros D, Schiza S, Patsourakis G, Chalkiadakis G, Panagou P, Siafakas NM. Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: A prospective, double-blind study.
Am J Respir Crit Care Med 1997;155:291-295.
13. Ozcelik C, Inci I, Nizam O, Onat S. Intrapleural fibrinolytic treatment of multiloculated postpneumonic pediatric empyemas. Ann Thorac Surg 2003;76:1849-1853
14. Yao CT, Wu JM, Liu CC, Wu MH, Chuang HY, Wang JN. Treatment of complicated streptokinase in children. Chest 2004;125:566-571.
15. Singh M, Mathew JL, Chandra S, Katariya S, Kumar L. Randomized controlled trial of intrapleural streptokinase in empyema thoracis in children. Acta Paediatr 2004;93:1443-1445.
16. Kornecki A, Sivan Y. Treatment of loculated pleural effusion with intrapleural urokinase in children. J Pediatr Surg 1997;32:1473-1475.
17. Weinstein M, Restrepo R, Chait PG, Connolly B, Temple M, Macarthur C. Effectiveness and safety of tissue plasminogen activator in the management of complicated parapneumonic effusions. Pediatrics
2004;113:182-185.
18. Hawkins JA, Scaife ES, Hillman ND, Feola GP. Current treatment of pediatric empyema. Semin Thorac Cardiovasc Surg 2004;16:196-200.
19. Wait MA, Sharma S, Holn J, Nogare AD. A randomised trial of empyema therapy. Chest 1997;111:1548-1551.

11. 20. Petrakis IE, Kogerakis NE, Drositis IE, Lasithiotakis KG, Bouros D, Chalkiadakis GE. Video-assisted thoracoscopic surgery for thoracic empyema: primarily, or after fibrinolytic therapy failure? Am J Surg.
2004;187:471-474.
21. Angelillo Mackinlay TA, Lyons GA, Chimondeguy DJ, Piedras MA, Angaramo G, Emery J. VATS debridement versus thoracotomy in the treatment of loculated postpneumonia empyema. Ann Thorac Surg
1996;61:1626-1630.
22. Lawrence DR, Ohri SK, Moxon RE, Townsend ER, Fountain SW. Thoracoscopic debridement of empyema thoracis. Ann Thorac Surg 1997;64:1448-1450.
23. Stovroff M, Teague G, Heiss KF, Parker P, Ricketts RR. Thoracoscopy in the management of pediatric empyema. J Pediatr
Surg 1995;30:1211-1215.
24. Kern JA, Rodgers BM. Thoracoscopy in the management of empyema in children. J Pediatr Surg 1993;28:1128-1132.
25. Hoff SJ, Neblett WW, Edwards KM, et al. Parapneumonic empyema in children: Decortication hastens recovery in patients
with severe pleural infections. Pediatr Infect Dis 1991;10:194-199.
26. Carey JA, Hamilton JRL, Spencer DA, Gould K, Hasan A. Empyema thoracis: A role for open thoracotomy and decortication.
Arch Dis Child 1998;79:510-513.
27. Alexiou C, Goyal A, Firmin RK, Hickey MJ. Is open thoracotomy still a good treatment option for the management of
empyema in children? Ann Thorac Surg 2003;76:1854-58.
http://www.jficm.anzca.edu.au/pdfdocs/Journal/Journal2005/J2005%20(b)%20June/Case1a.p
ANATOMY OF THE RESPIRATORY SYSTEM
The respiratory system can be conveniently subdivided into an upper respiratory tract (or conducting zone) and lower
respiratory tract (respiratory zone), trachea and lungs.
The conducting zone starts with the nares (nostrils) of the nose, which open into the nasopharynx (nasal cavity). The
primary functions of the nasal passages are to: 1) filter, 2) warm, 3) moisten, and 4) provide resonance in speech. The
nasopharnyx opens into the oropharynx (behind the oral cavity). The oropharynx leads to the laryngopharynx, and
empties into the larynx (voicebox), which contains the vocal cords, passing through the glottis, connecting to the
trachea (wind pipe).
The trachea leads down to the thoracic cavity (chest) where it divides into the right and left quot;main stemquot; bronchi. The
subdivision of the bronchus are: primary, secondary, and tertiary divisions (first, second and third levels). In all, they
divide 16 more times into even smaller bronchioles.
The bronchioles lead to the respiratory zone of the lungs which consists of respiratory bronchioles, alveolar ducts and
the alveoli, the multi-lobulated sacs in which most of the gas exchange occurs.
Ventilation of the lungs is carried out by the muscles of respiration.
Ventilation occurs under the control of the autonomic nervous system from the part of the brain stem, the medulla
oblongata and the pons. This area of the brain forms the respiration regulatory center, a series of interconnected
neurons within the lower and middle brain stem which coordinate respiratory movements. The sections are the
pneumotaxic center, the apneustic center, and the dorsal and ventral respiratory groups. This section is especially
sensitive during infancy, and the neurons can be destroyed if the infant is dropped or shaken violently. The result can
be death due to quot;shaken baby syndrome.quot;[1]

12. Inhalation is initiated by the diaphragm and supported by the external intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute. Its time period is 2 seconds. During vigorous
inhalation (at rates exceeding 35 breaths per minute), or in approaching respiratory failure, accessory muscles of respiration are recruited for support. These consist of sternocleidomastoid, platysma, and
the strap muscles of the neck.
Inhalation is driven primarily by the diaphragm. When the diaphragm contracts, the ribcage expands and the contents of the abdomen are moved downward. This results in a larger thoracic volume,
which in turn causes a decrease in intrathoracic pressure. As the pressure in the chest falls, air moves into the conducting zone. Here, the air is filtered, warmed, and humidified as it flows to the lungs.
During forced inhalation, as when taking a deep breath, the external intercostal muscles and accessory muscles further expand the thoracic cavity.
Exhalation is generally a passive process, however active or forced exhalation is achieved by the abdominal and the internal intercostal muscles.
The lungs have a natural elasticity; as they recoil from the stretch of inhalation, air flows back out until the pressures in the chest and the atmosphere reach equilibrium.[2]
During forced exhalation, as when blowing out a candle, expiratory muscles including the abdominal muscles and internal intercostal muscles, generate abdominal and thoracic pressure, which forces
air out of the lungs.
The right side of the heart pumps blood from the right ventricle through the pulmonary semilunar valve into the pulmonary trunk. The trunk branches into right and left pulmonary arteries to the
pulmonary blood vessels. The vessels generally accompany the airways and also undergo numerous branchings. Once the gas exchange process is complete in the pulmonary capillaries, blood is
returned to the left side of the heart through four pulmonary veins, two from each side. The pulmonary circulation has a very low resistance, due to the short distance within the lungs, compared to the
systemic circulation, and for this reason, all the pressures within the pulmonary blood vessels are normally low as compared to the pressure of the systemic circulation loop.
Virtually all the body's blood travels through the lungs every minute. The lungs add and remove many chemical messengers from the blood as it flows through pulmonary capillary bed . The fine
capillaries also trap blood clots that have formed in systemic veins.
The major function of the respiratory system is gas exchange. As gas exchange occurs, the acid-base balance of the body is maintained as part of homeostasis. If proper ventilation is not maintained two
opposing conditions could occur: 1) respiratory acidosis, a life threatening condition, and 2) respiratory alkalosis.
Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic functional component of the lungs. The alveolar walls are extremely thin (approx. 0.2 micrometres), and are
permeable to gases. The alveoli are lined with pulmonary capillaries, the walls of which are also thin enough to permit gas exchange. All gases diffuse from the alveolar air to the blood in the pulmonary
capillaries, as carbon dioxide diffuses in the opposite direction, from capillary blood to alveolar air. At this point, the pulmonary blood is oxygen-rich, and the lungs are holding carbon dioxide.
Exhalation follows, thereby ridding the body of the carbon dioxide and completing the cycle of respiration.
In an average resting adult, the lungs take up about 250ml of oxygen every minute while excreting about 200ml of carbon dioxide. During an average breath, an adult will exchange from 500 ml to 700
ml of air. This average breath capacity is called tidal volume.
The respiratory system lies dormant in the human fetus during pregnancy. At birth, the respiratory system is drained of fluid and cleaned to assure proper functioning of the system. If an infant is born
before forty weeks gestational age, the newborn may experience respiratory failure due to the under-developed lungs. This is due to the incomplete development of the alveoli type II cells in the lungs.
The infant lungs do not function due to the collapse of the alveoli caused by surface tension of water remaining in the lungs. Surfactant is lacking from the lungs, leading to the condition. This condition
may be avoided if the mother is given a series of steroid shots in the final week prior to delivery. The steriods accelerate the development of the type II cells.
STATEMENT OF THE PROBLEM
This case study aims to determine “How the patient acquired the illness, and the process by which the body responds to the situation”.
This also specifically attempts to answer the following questions:
• What is Pneumonia and Empyema?
• What organs and parts of the body are affected by the disease process?

13. • Where and how the illness was obtained, how it progressed and affected the body?
• What were the predisposing factors that lead the patient to acquire the disease?
• What interventions are needed to manage the such condition?
• Why was Chest Tube Thoracotomy was performed to the patient?
• Were the interventions effective in helping the patient recover?
CHAPTER TWO
Data Collection, Analysis and Interpretation
OPT Model
CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION
KNS, 3 months old, female, Roman Catholic, ER Blotter Doctor’s Orders
Filipino, residing at Candabo, Argao and born At the CVGH-ER, patient was given oxygen
on January 26, 2007 via Normal Spontaneous Accompanied by mother and aunt, patient inhalation at 1L/min via nasal cannula at
Vaginal Delivery (NSVD) at Argao Isidro arrived at CVGH-ER at 10:58pm on May 5, 11:40pm. He was started with an IVF of
Quintana Memorial Hospital, was admitted for 2007 per ambulance, febrile, with the following D5IMB 1 pint at 27ugtts/min.
the 1st time in Cebu Velez General Hospital vital signs: PR: 116 bpm RR: 78 cpm T: 38.1 C/
(CVGH) for complaints of fever, cough, and axilla. At around 12:10 am, she was admitted to
convulsion. Patient was admitted under the the Pediatrics department under the services of
services of Dr. Lydia Chang and Dr. Maribel Dr. Lydia Chang and Dr. Maribel Du with case
Du under the Department of Pediatrics and # 87395 and was transported around 12:30 am
Surgery with the case number of 87395 and to Ward 6-A per mother’s arm in a wheelchair.
hospital number of 039874.
DATE OF ASSESSMENT: May 9, 2007
History of Present Illness General Measurements:
mid-arm: 15.5 cm
1 month PTA, patient had an onset of chest circumference: 45 cm
intermittent nonproductive cough. No medical Head circumference: 40.5 cm
consult was done. Abdominal circumference: 48 cm
9 days PTA, patient had an onset of intermittent Ht: 63.5 cm
fever ranging from 38.0-38.5oC/axilla with Wt: 6.5 kg

14. nonproductive cough still noted. No chills nor IBW: 8.3 kg
convulsion were manifested. This prompted the Fontanels: anterior: open
patient’s mother to seek consultation at Dr. posterior: closed
Villaflor’s clinic at Argao Isidro Quintana
Memorial Hospital where the patient was Physiologic Measurements
nebulized with Salbutamol 1 cycle (a T°: 37°C/axilla
bronchodilator which binds to beta-2 adrenergic RR: 78 cpm
receptors in airway smooth muscle, leading to PR: 120 bpm
activation of adenyl cyclase and increased
levels of -3, -5 adenosine monophosphate) and May 9, 2007
GENERAL APPEARANCE
was prescribed with cetirizine (an antihistamine
which antagonizes the effect of histamine at 3pm >seen per aunt’s arm, awake, conscious,
with O2 inhalation via nasal cannula at 1L/min,
H1-receptor sites; does not bind to or inactivate
histamine) and amoxicillin (an anti-infective with Chest Tube Thoracotomy (CTT) attached
on left lung in the left lower chest, with IVF 3
which binds to bacterial cell wall, causing cel
death), both of unrecalled dose. Ibuprofen D5IMB 1 pint @ 27 mgtts per minute infusing
well on right hand, with pulse oximeter on big
(Dolan) 100mg/5ml 2ml (an antipyretic, non-
opioid analgesic and a non-steroidal anti- toe of right foot, with the following vital signs:
PR: 120 bpm RR: 60 cpm
inflammatory agent, which inhibits
prostaglandin synthesis) as needed for T: 37°C/axilla
temperature above 38oC/axilla was also
Skin and appendages: Presence of IV catheter
prescribed. There was no relief of fever and
on right arm, with good skin turgor, no edema,
cough, as claimed by patient’s mother.
no lesions, long fingernails and toenails with
1 week PTA, patient had an acute attack of
convulsion with fever of 40oC/axilla, pinkish nail beds, CRT <2 secs, no cyanosis, as
well as jaundice.
accompanied by pallor, profuse sweating and
Head: normocephalic, (+) ROM, Hair is fine,
nonproductive cough; thus, was brought to
straight, black and evenly distributed, with no
Miller Hospital. There, nebulization of
dandruff nor lice infestations, open anterior
Salbutamol was done and patient was
fontanel, closed posterior fontanel.
prescribed with ceftriaxone (an anti-infective
and 3rd generation cephalosporin, which binds Eyes : symmetrical, anicteric sclerae, smooth,
moist and pale palpebral conjunctivae and clear
to bacterial cell wall membrane, causing cell
bulbar conjuctivae, (-)discharges, equal
death), prostaphlin (an anti-infective and
distribution of eyebrows and eyelashes, (+)
penicillin, which binds to bacterial cell wall,
Pupils Equally Round and Reactive to Light and
resulting in cell death) and ibuprofen, all of
Accomodation,
unrecalled dose. Chest X-ray was done and
Ears : symmetrical, no lesions, pinna is in line
revealed moderate pleural fluid on left lung.

15. 3 days after Chest X-ray was done, patient was with the outer canthus of the eye, no swelling,
referred to CVGH for insertion of Chest Tube pinna is nontender, no discharges noted on
Thoracotomy. auditory meatus.
Nose: symmetrical, no masses, no discharges,
PAST HISTORY nasal septum at midline
Prenatal History Mouth and throat: lips are symmetrical but
pale, no ulcerations and no lesions, buccal
Mother is a 35 year old with an obstetrical score mucosa pink, pinkish gums with no ulcerations,
of G4P4004. Prenatal care was started at 5 tongue located at midline, uvula at midline, no
months Age of Gestation (AOG) at their deciduous teeth
Barangay Health Center in Argao. Regular pre- Chest: Symmetrical, no lesions, equal chest
natal check-up was done once every month expansion, presence of CTT incision on left
thereafter. Mother claimed to have had an onset anterior lower chest.
of fever during the course of pregnancy, Lungs: Equal lung expansion, (+) rales on left
specifically during the 7th month AOG and was lower lung field upon auscultation, CTT
prescribed Paracetamol (Biogesic) 500mg (an attached to left lung
anti-pyretic, non-opioid analgesic, which Heart: distinct s1 and s2 heart sounds upon
inhibits the synthesis of prostaglandins that may ausculation, no murmurs heard, heart rate of
serve as mediators of pain and fever, primarily 120 bpm with regular rhythm.
in the central nervous system) three times a day Abdomen: protuberant, no masses, no
upon pre-natal visit. Condition improved. tenderness, presence of bowel sounds at 15
Vitamins taken during the course of pregnancy gurgling sounds/minute auscultated at right
included Ferrous Sulfate (an anti-anemic and lower quadrant
iron supplement, which is required for the GUT-Reproductive: grossly female, no
production of hemoglobin necessary for O2 swelling, no abnormal discharges, no lesions,
transport to cells), which was prescribed by the no rashes.
physician at the Health Center. Mother claimed Anus: no lesions, no hemorrhoids, no rashes.
to have had a complete Tetanus Toxoid Extremities: symmetrical, (+) ROM for all
immunization. Mother was confined for a day at extremities, no lesions, presence of pulse
Argao Isidro Quintana Memorial Hospital after oximeter on right toe.
delivery and was discharged with improved Musculoskeletal: no deformities, good muscle
condition. No distress was detected on the baby. tone.
Previous Hospitalizations: NEUROLOGIC ASSESSMENT
Patient has no previous hospitalization. Mental Status/Cerebral Functioning
Awake, alert, coherent. Able to cry. Irritable
Labor and Delivery behavior

16. Motor/Cerebellar Functioning
Age of Gestation was 9 months. Patient’s Able to grasp student nurse’s fingers tightly.
mother experienced 1 hour and 45 minutes of Extremities symmetrically folded inward with
spontaneous labor. She delivered a live baby good muscle tone.
girl with cephalic presentation at Argao Isidro Reflexes
Quintana Memorial Hospital, assisted by an (+) palmar grasp
obstetrician of unrecalled name. The patient (+)babinski reflex
was 6.5 pounds upon birth. Patient had a loud
Sensory Functioning
cry upon delivery and had no congenital
Responsive to light touch (hanky) and pain (slight
anomalies noted. Patient was given a shot of
pinch) at both upper and lower extremities and both
Vitamin K and Hepatitis B vaccine as well as
sides of the face.
terramycin (an anti-infective and tetracycline,
Cranial Nerve Testing
which inhibits bacterial protein synthesis at the CN 1 (Olfactory) – not assessed cannot verbally
level of the 30s bacterial ribosome), express himself
immediately after delivery. Patient stayed for a CN 2 (Optic) – (+) PERRLA, (+) Blinking reflex
day at the hospital and was discharged CN 3 (Oculomotor) – (+) PERRLA
improved. CN 4 (Trochlear) – (+) PERRLA
CN 5 (Trigeminal) – (+) rooting reflex, (+) sucking
reflex
Feeding History
CN 6 (Abducens) – (+) PERRLA
CN 7 (Facial) – able to close eyes, can smile,
Patient was immediately breastfed after birth.
wrinkle forehead, cry.
Currently, the patient is breastfed every 2 hours
CN 8 (Auditory) – (+) moro reflex with loud noise,
or per demand. Vitamins taken were Ceelin (for eyes follow direction of sound
treatment and prevention for vitamin C CN 9 (Glossopharyngeal) – (+) gag reflex, able to
deficiency in infants and children) and Tiki- swallow
Tiki, a multivitamin supplement, 0.6 ml thrice a CN 10 (Vagus)- (+) gag reflex , able to swallow
day prescribed by Dr. Lydia Chang. CN 11 (Accessory) – cannot be assessed
CN 12 (Hypoglossal) – mouth opens when nose is
pinched, tongue midline at protrusion
Health History
Current Developmental Skills
Patient has no known food and drug allergies. Gross Motor skills:
Immunizations received were BCG1, DPT1 and (+) Landau reflex , able to lift head on prone
DPT 2, Hep1 and Hep2 as well as OPV1. position, slight lag present when pulled to a sitting
position, able to support part of weight upon
Elimination Pattern standing
Fine Motor Skills:
Can attempt to reach for pacifier
Patient defecates at least 4 times a day with

17. Language skills:
soft, light brown stools and urinates at least 4 to
Makes cooing sounds and is able to slightly laugh,
5 times a day.
cries when hungry or wet
Family History:
Developmental Theories:
Patient’s father, a 40 year old, is a highschool Jean Piaget’s theory of Cognitive Development:
graduate, currently working as a house painter. sensory motor stage
His mother is a 35-year old housewife and is a Patient relates through senses, primarily reflex
highschool undergraduate. The patient has 3 behavior.
siblings; the first of which is a 6-year old male,
currently in kindergarten, followed by a 4- year
Erikson's Psychosocial Development:
old male, now enrolled in Day Care and the
Trust vs. mistrust
third sibling is a 2-year old female.
The patient was provided with 3 primary care givers
The patient has no known heredofamilial
with whom trust can be established. The student
diseases (HFDs) on both maternal and paternal nurses provided experiences that add to security,
side. such as keeping voices low and providing soft
touches.
Genogram:
Freud’s theory of Psychosexual development:
oral stage
Paternal
Maternal Patient uses a pacifier (oral stimulation) and is
breastfed by the mother every 2 hours or as needed.
DATE OF ASSESSMENT: May 10, 2007
General Appearance:
3pm> Seen lying on bed, awake, conscious,
afebrile, with O2 inhalation via nasal cannula at
1L/min, with CTT attached to left lung, with
IVF of 5 D5 IMB 1 pint @ 27 ugtts / min,
Legend:
infusing well at right hand, with pulse oximeter
attached to big toe of right foot, with the
Deceased male
Deceased female
following vital signs:
Temperature: 36.3ºC/axilla
female male
Pulse Rate: 136 bpm
Respiratory rate: 70 cpm
patient
Significant findings:

18. Skin and appendages: Presence of IV catheter
Personal and Social history: on right arm
Eyes: pale palpebral conjuntivae
Mouth and Throat: pale lips
The personal caretaker of the child is her
Lungs: rales still heard upon auscultation of left
mother. Mother also readily feeds the patient
lower lung fields. CTT still attached to left
through breastfeeding every 2 hours or per
anterior lower chest
demand. The baby sleeps in between her mother
Extremities: pulse oximeter still attached to
and father using one pillow. There is only 1
right toe
room in the house and 6 people in the
household. The family goes to church every
Sunday, as claimed by the patient’s mother.
Patient’s parents have been married for 7 years
DATE OF ASSESSMENT: May 11, 2007
now. They believe in consulting a doctor
General Appearance:
whenever a health problem arises. They do not
3pm> Seen per mother’s arm, awake,
believe in quack doctors.
conscious, afebrile, with O2 inhalation via nasal
cannula at 1L/min, with CTT attached to left
Environmental History:
lung, with IVF of 6 D5 IMB 1 pint @ 27 ugtts /
min, infusing well at right hand, with the
Patient lives with her mother, father, and 3
following vital signs:
siblings in Candabo, Argao, Cebu in a 1-storey
Temperature: 36.5ºC/axilla
house made of mixed materials. They have 1
Pulse Rate: 144 bpm
bedroom, a separate room for the living room
Respiratory rate: 60 cpm
and the dining room. It has enough ventilation
owing to 6 screened windows. Their house is
Significant findings:
furnished. It has a TV set and 3 electric fans.
Skin and appendages: Presence of IV catheter
Water source is from MCWD. Electricity is
on right arm
from CEBECO. Drainage is closed. Toilet is
Eyes: pale palpebral conjuntivae
water sealed type. Their garbage disposal is
Lungs: rales still heard upon auscultation of left
through motorized garbage collection. They live
lower lung fields. CTT still attached to left
5 meters from the main road, 75meters from the
anterior lower chest
market, police station, and church and 60
meters from the nearest Barangay Health
LABORATORY FINDINGS
Center. They live in a congested area, as
claimed by the patient’s mother.
January 26, 2007
X-RAY
Chest AP:

19. Chest reveals a band like density along the left
lateral chest wall. Heart and the rest of the lungs
are essentially normal.
Findings:
Moderate Pleural Fluid Left
May 1, 2007
Chest X-ray
Revealed moderate pleural fluid, left
May 2, 2007
Specimen: CSF
Culture: No growth after 72 hrs. of incubation
Blood Culture with ARD
May 7, 2007
CT Scan of chest: plain and contrast
Pre and post contrast CT scan of the chest
demonstrate fluid collection in the left
hemithorax with areas of loculations. The left
lung parenchyma is compressed. There is
segmental consolidation seen on the right lower
lung. The mediastinal structures are shifted to
the right. The thymus is not enlarged. Trachea
is normal in caliber. The superior mediastinal
vessels are preserved. There are no enlarged
mediastinal or hilar lymph nodes seen. The
cardiac chambers and pericardial sac are intact.
The thoracic aorta and esophagus are within
normal limits. The soft tissue and visualized
osseous structures are unremarkable.
Remarks:
Left pleural effusion with areas of loculations
on the left hemithorax
Atelectasis, left lung
Inflammatory process, right lower lung

20. May 7, 2007
Creatinine 0.3 Low N˚0.6-1.5 mg/dL
May 7, 2007
CBC
This is a basic screening test in all patients and
is one of the most frequently ordered
laboratory procedure. The significant
findings in the CBC gives valuable
information about patient’s diagnosis,
response to treatment and recovery
WBC 23.7 K/uL
NEU 14.9 63.0 %N
LYM 3.47 14.7 %L
MONO 3.40 14.4 %N
EOS .972 4.11 %E
BASO .914 3.86 %B
RBC 4.11 M/uL
HGB 10.1 g/dL
HCT 29.5%
MCV 71.9 fL
MCH 24.7 pg
MCHC 34.3 g/dL
RDW 18.6%
PLT 477.6 K/uL
MPV 7.57 fL
Comments: Few Hypochromic red cells
Implications:
Increase in neutrophil count may indicate
presence of Vitamin B12 and Folic acid
deficiency. This may occur in hemolysis, tissue

21. break down as in burns, hemolytic transfusion
reactions and after surgery. Decrease in
lymophocyte may be due to presence of trauma
and burns. Increase in eosinophil usually occur
during the late stages of inflammation. Increase
in basophil may indicate IDA, chronic
hemolytic anemia and inflammation. Decrease
in hematocrit signifies presence of severe
dehydration and shock. MCH is a measurement
of the average weight of Hgb in RBC.
Normal Limits
WBC 4.1-10.9 K/uL
NEU 2.5-7.5 47-80 %N
LYM 1-4 13-40 %L
MONO .1-1.2 2-11 %N
EOS 0-.5 0-5 %E
BASO 0-.1 0-2 %B
RBC 4-5.2 M/uL
HGB 12-16g/dL
HCT 36-46
MCV 80-100 fL
MCH 26-34 pg
MCHC 31-36g/dL
RDW 11.6-18%
PLT 140-440 K/uL
MPV 0-100
Acid Fast Bacilli (AFB) Smear
May 8: Specimen (Chest Tube Thoracostomy)
May 9: Gram Staining : no microorganism
seen
Pus cells: abundant
P.R.: Smear of culture: Gram (+)

22. cocci in pairs and in clusters
May 10: P.R.:
Culture: Methicillin Resistant Staphylococcus
aureus
Remarks: Sensitivity Test result of culture
MRSA
May 11: P.R.: Remarks: No other pathogens
isolated
AFB Staining
May 9, 2007
Smear of specimen
AFB STAINING: NEGATIVE FOR ACID
FAST BACILLI
National TB Program Scale= 0
Remarks:
1.) conc. Method done
2.) AFB National TB Program Scale
0= no AFB seen/ 300 visual fields
+ (1-9)= 1-9 AFB seen/100 visual fields
1+= 10-99 AFB seen/ 100 visual fields
2+= 1-10 AFB seen/ at least 50 fields
3+= more than 10/ at least 20 fields
5/7 3.) Final report after 6 weeks of incubation
5/7 Gram Staining: No microorganisms seen
May 9, 2007
X-ray
Chest APL:
Examination reveals there are patchy densities
noted in the left lower lung. There are hazy
densities noted in the hemithorax. There is chest
tube in the left hemithorax.
Conclusion : Pneumonia left lower lung
: Pleural thickening and effusion
left

23. : Chest tube left
May 9, 2007
Appendum Report
 A comparative study with the outside
film taken on May 5, 2007 shows
diminution of fluid in the left
hemithorax
May 10, 2007
Creatinine 0.3 Low N˚0.6-1.5 mg/dL
KEY ISSUES
Date Identified: May 9, 2007
1. Ineffective Airway Clearance related to
exudates in the alveoli secondary to pleural
effusion as manifested by rales and crackles
upon auscultation on left lower lung fields,
Independent Interventions: Desired Outcome
dyspnea, irritability and increase in respiratory
1. Assessed rate and depth of respirations as Within 15 to 30 minutes of nurse-client
rate, RR=78cpm
well as chest movement. interaction, the patient will be able to:
R: Tachypnea, shallow respirations, and -maintain airway patency
SB: The inflammation and increased secretions
asymmetric chest movement are frequently -demonstrate reduction of congestion with
seen with pneumonia make it difficult to
present because of discomfort of moving chest breath sounds clear, respirations noiseless
maintain a patent airway.
wall and fluid in the lung. -have an RR within normal range (36-40 cpm)
(Black, Joyce. Medical-Surgical Nursing.
2. Auscultated both lung fields as well as breath
P1842)
sounds Actual outcome:
R: to ascertain status and note progression May 9, 2007
3 Changed position in bed as needed. After 15 to 30 minutes of nurse-client
R: To enhance drainage of and ventilation to interaction, the patient was able to have an RR
different lung segments. of 56 cpm and had rales heard on the left lower
4. Did chest tapping for 10 minutes. lung field upon auscultation. Dyspnea was no
R: To mobilize secretions longer noted; however, the baby was still
5. Provided opportunities for rest irritable.
R: to prevent fatigue

24. Collaborative Interventions: May 10, 2007
1. Administered O2 @ 1L/min via nasal cannula After 15 to 30 minutes of nurse-client
R: To provide supplemental oxygen interaction, the patient was able to have an RR
2. Measured and drained CTT drainage of 58 cpm, rales still noted on left lower lung
R: To ascertain amount of fluid inside the lungs field. Nonproductive cough was still noted.
and to allow re-expansion the lungs Baby was irritable despite absence of dyspnea.
May 11, 2007
After 15 to 30 minutes of nurse-client
interaction, the patient was able to have an RR
of 60 cpm, rales still noted on left lower lung
Date Identified: May 9, 2007 field upon auscultation; however, sounds
2. Impaired Gas Exchange related to alveolar- became fainter. Nonproductive cough was still
capillary membrane changes as manifested by noted with absence of dyspnea.
restlessness, an abnormal rate of breathing with Independent interventions
RR= 78cpm 1. Noted respiratory rate and depth
R: Manifestations of respiratory distress are Desired outcome
S.B: Pneumonia is an inflammatory process in dependent on and indicative of the degree of Within 2 to 3 minutes of nurse-client
the lung parenchyma usually associated with a lung involvement and underlying general health interaction, the client will be able to
marked increase in interstitial and alveolar status. demonstrate improved ventilation and adequate
fluid. 2. Observed baby’s skin color, mucous oxygenation of tissues within the client’s
membranes, and nailbeds normal limits and will be able to exhibit
(Black-Hawk.Medical-Surgical Nursing.6th Ed. R: Cyanosis of nailbeds may represent absence of symptoms of respiratory distress.
Vol.2.page 1711) vasoconstriction or the body’s response to fever
or chills; however, cyanosis of earlobes, Actual outcome
mucous membranes, and skin around the mouth After 3 minutes of nurse-client interaction:
is indicative of systemic hypoxemia.
3. Monitored heart rate and rhythm May 9 and 10, 2007: client’s RR remained
R: Tachycardia is usually present as a result of elevated (above 60 cpm); restlessness and
fever. irritability were both still noted.
4. Monitored body temperature.
R: High fever greatly increases metabolic
demands and oxygen consumption and alters
cellular oxygenation.
5. Encouraged frequent position changes
R: promote optimal chest expansion and

25. drainage of secretions
6. Maintained adequate I/O.
R: for mobilization of secretions, at the same
time, avoiding fluid overload.
7. Encouraged adequate rest and limit activities
to within patient tolerance.
R: helps limit oxygen needs/ consumption.
8. Promoted calm/restful environment.
R: helps limit oxygen needs/ consumption.
9. Kept environment allergen/ pollutant.
R: to reduce irritant effect on airways.
Collaborative Interventions
1. Insertion of CTT at bedside done by Dr.
Maribel Du
R: to improve respiratory function/ oxygen-
carrying capacity.
2. Administered O2 @ 1L/min via nasal cannula
R: To provide supplemental oxygen and to
maintain PaO2 above 60 mmHg.
3. Monitored pulse oximetry.
R: Follows progress of disease process and
Date Identified: May 9, 2007 facilitates alterations in pulmonary therapy.
3. Ineffective Breathing Pattern related to
inflamed and fluid-filled alveolar sacs Independent Interventions
secondary to pneumonia as manifested by 1. Performed handwashing before handling the
RR=78 cpm, nonproductive cough, and patient. Desired Outcome
presence of CTT drainage. R: to prevent spread of microorganisms Within 30 minutes of student nurse-patient
2. Monitored vital signs, auscultated chest, and interaction, the patient will be able to establish a
SB: Many clients experience compensatory noted presence of secretions normal or effective respiratory pattern, within
tachypnea because of an inability to meet R: to identify precipitating factors 40 to 60 cpm, will not use accessory muscles
metabolic demands. This occurs because affecte 3. Kept head of bed elevated when breathing and will not have signs of nasal
alveoli cannot effectively exhange oxygen and R: to facilitate ease in respiration flaring.
carbon dioxide. 8. Chest tapping done
(Black, Joyce. Medical-Surgical Nursing. R: Facilitates mobilization of secretions Actual Outcome
-1842-43) 5. Kept incision clean and dry. After 30 minutes of student nurse-patient
R: To reduce risk of infection interaction:

26. 6. Provided adequate rest periods between May 9, 10 and 11, 2007: patient’s RR were 56
activities. cpm, 58 cpm and 60 cpm respectively. Patient
R: To limit fatigue did not make use of accessory muscles when
breathing and showed no signs of nasal flaring.
Collaborative Interventions CTT drainage was in place at left anterior lower
1. Administered oxygen via nasal cannula at 1 chest.
liter/minute.
R: to provide adequate ventilation and
oxygenation
Date Identified: May 9, 2007
4. Acute pain related to surgical incision on left
Independent Interventions
hemithorax (Chest Tube Thoracotomy)
1. Assessed client’s pain including type,
secondary to pleural effusion as manifested
Desired Outcome
location, and intensity.
by restlessness, crying, irritability, and
Within 4 hours of nursing interventions, the
R: Assessment provides clues to underlying
RR=78cpm
client will be able to manifest signs of
cause of pain & provides a baseline for
decreased pain perception such as being able to
developing appropriate pain relief strategies.
SB: All clients who have just had surgery will
sleep, minimize crying, RR within normal limits
2. Provided comfort measures, such as helping
experience pain (Medical-Surigical Nursing by
(40-60cpm) and be less irritable
with positioning and using pillows for
Black. 6th edition. P.311)
support.
Actual Outcome
R: Comfort measures reduce stress and anxiety,
Pain after thoracotomy may be severe,
May 9, 2007: After 4 hours of nursing
elevate mood, and raise pain threshold.
depending on the type of incision and the
intervention, the client’s RR decreased to
3. Monitored vital signs
patient’s reaction to and ability to cope with
70cpm, was still crying intensely, still irritable,
R: Usually altered in acute pain
pain. Deep inspiration is very painful after
and was able to sleep for about 2 hours.
4. Provided quiet and calm environment
thoracotomy. (Medical-Surgical Nursing by
May 10, 2007: After 4 hours of nursing
R: To help control pain
Smeltzer & Bare. 10th edition. P 634)
intervention, the client’s RR decreased to
5. Provided adequate rest periods
48cpm, still cries when she sees the student
R: To prevent fatigue and minimize pain
nurses, still irritable, and was able to sleep for
perception
about 2 hours.
6. Encouraged SO to carry/hold baby when
May 11, 2007: After 4 hours of nursing
crying
intervention, the client’s RR= 48cpm, cries
R: This helps the patient to feel secured and
when she sees a new student nurse, was
minimize pain felt
irritable, and was able to sleep for about 4
7. Assessed patient’s response to pain relief
hours.
measures.
R: Follow-up assessment is essential to
determine the effectiveness of pain relief
measures used and need for any change.

27. Collaborative Interventions
1. Administered ibuprofen (Dolan) 100 mg/5
ml, 2 mL q 6 hrs round the clock, as
prescribed
R: this drug is an antipyretic and an analgesic as
well to help lower pain perception by inhibiting
prostaglandin synthesis
Date Identified: May 10, 2007 Independent Interventions
5. Hyperthermia related to the inflammatory 1. Monitored v/s especially body temperature.
process secondary to pneumonia as R: temperature is an indicator of fever
manifested by increased body temperature 2. Maintained a well-ventilated environment. Desired Outcome
38.1ºc/axilla and skin warm to touch R: to reduce stimulation of ↑ temperature Within 30 minutes to 1 hour of nursing
3. Loosened clothing interventions, patient’s body temperature will
SB: The signs and symptoms of pneumonia R: to reduce heat fall within normal limits (36.5-37.5ºC/axilla)
vary widely, depending on the age and health 4. TSB (Tepid Sponge Bath) done
status of the infected persons, the onset usually R: to reduce heat by conduction Actual Outcome
is sudden and is characterized by malaise, a 5. Noted developmental age After 1 hour of nursing interventions, the
severe, shaking chills, and fever. The R: children are more susceptible to acquiring patient’s body temperature decreased to 37.5ºC/
temperature may go s high as 106OF. fever due to underdeveloped immune system axilla. Body temperature remained within
(Pathophysiology Concepts of Altered Health normal limits (36.5-37.5 degrees Celsius)
6. Promoted rest and sleep
Status 6th Ed., page 613). R: to reduce metabolic demands and oxygen
consumption
7. Instructed SO to increase fluid intake of the
baby through breastfeeding
R: to prevent dehydration
8. Maintained a calm attitude
R: to reduce stimulants
Collaborative Interventions
1. Administered Ibuprofen (Dolan) 100 mg per
5 ml, 2 ml q 6 hours round the clock.
R: It inhibits prostaglandin synthesis.
Date Identified: May 9, 2007 Independent Interventions
6. Impaired Skin Integrity related to presence of 1. Noted changes in vital signs.

28. Chest tube thoracotomy secondary to empyema R: To detect any deviations from the normal. Desired Outcome
as manifested by presence of incision site 2. Noted signs of infection such as increase in Within 8 hours of nursing intervention, the
located at the left lower anterior chest. temperature, presence of purulent incision site will not show signs of infection
discharges, redness, inflammation or edema. (redness, swelling, increase in temperature,
SB: Injury to skin and surrounding soft tissue R: To assess the extent of injury. presence of purulent discharges), and the patient
can occur from sharp objects, blunt force, injury 3. Kept incision area clean and dry. will maintain physical well-being.
scraping mechanism or surgical procedures R: To assist body’s natural process of repair.
resulting in lacerations, abrasions, avulsions, 4. Encouraged SO and other care givers Actual Outcome
puncture wounds. (p.2502. Medical Surgical handwashing. After 8 hours of nursing intervention:
Nursing by Joyce Black, 7th ed. Vol.2) R: To lessen introduction of microorganisms. May 9,10,11, 2007- the incision site did not
5. Encouraged mother in breastfeeding. show signs of infection and the patient
R: To aid in healing and maintain general good maintained a physical well-being.
health.
6. Encouraged mother and other care givers to
position the client properly.
R: To secure chest tube.
7. Removed wet/wrinkled linens.
R: Moisture potentiates skin breakdown.
8. Monitored IV site for signs of infection such
as inflammation and thrombophlebitis while
administering Vancomycin.
R: vancomycin is irritating to tissue cells and
veins upon administration
Collaborative Interventions
1. Administered Vancomycin 65mg IV
infusion over 1 hour every 6 hours
R: Hinders bacterial cell wall synthesis,
damaging the bacterial plasma membrane and
making the cell more vulnerable to osmotic
pressure. Also interferes with RNA synthesis.
2. Change of dressing done by the pediatric
intern
R: Prevents growth of microorganisms and
facilitate healing.
Date Identified: May 9, 2007 Independent Interventions