Introduction This case study seeks to evaluate the collaborative managements that were put in place in providing holistic care to the patient. However, it also goes in dept to explore other options that would have been appropriate for the successful outcome of the patient;researching literature centered on the diagnosis stated below.To provide confidentialitythe patient being studied is termed asMr. R.S,a 72 years old elderly male diagnosed as having left Empyema, and left Para- pneumonia effusion. In 1986 and he was admitted at Kingston Public Hospital for the removal of haemorrhoid, and in 2004 he had four (4) gun shots gun removed from his neck. He was also admitted at the health agency National Chest Hospital on the 22/10/12 in a wheel chair with a chest tube insitu and an underwater seal drainage bottle attached. Prior to admission, he was well until 2/52 ago when he noticed that he was losing weight and had a loss of appetite that caused him to seek medical attention. At the same time he began to experience shortness of breath (sob) on exertion relieved by rest, productive cough of white oral yellow coloured sputum, he had one episode of haemoptysis, an intermitted fever and swollen limbs. His vital signs on admission were, Temperature-100.3F, Pulse-104 bpm, Respitation-28 b/m, SPo2-94% and Blood pressure- 128/80. His weight was 169 pounds and he is five (5) feet tall. On the 23/10/12 the patient had a HB of 9.8, WBC 12, Platelet count 183 and CO2 -24. On the 27/10/11 he had a HB of 10.4 and WBC 6.8, Platelet count 339 and CO2-20. According to Scott (1993), The lung is lined by two thin membranes of pleura (inner visceral and outer parietal), which allows the lung to expand and shrink with each breath with minimal friction. (pg 102). Clare (2000), states that, Empyema is the collection of pus in the pleural space; it is caused byunresolved pneumonia, usually due to Staphylococcus Aureus (and particularly a lung abscess) which can lead to infection that spreads to the pleural space. Other conditions such asbronchiectasis, airway-obstructing cancer, thoracic surgery, and penetrating wounds can also cause empyema. (pg94).Para-pneumonia effusion is a type of pleural effusion that arises as result of pneumonia, lung abscess or bronchiectasis. There are three types of para-pneumonia effusion and they are uncomplicated Para-pneumonic effusion, complicated Para-pneumonic effusion and empyema.Shawn (1993, pg82). Beers (2003) found that, Para-pneumonia and empyema usually develop along the same line, therefore the same factors that causes empyema causes para-pneumonia effusion. (Pg283-284). According to Shawn (1993), Statistic has shown that these diseases are very common in across the Caribbean; however the predominant age of incidence is in both groups with ages ranging from 30-49 years old and a significant number occurring between ages 20-29 years old. (pg150).The various factors that will be examined to get a clear picture of the appropriateness of the nursing/medical management for the patient and patient outcomeare follows: Difficulty breathing, short of breath (sob), chest pain, generalized weakness, mild cough with thick white sputum and swollen lower limbs. This case study will address not only the patients condition but what was done for him in comparison to what could have been done differently as it relates to the collaborative care that he recieved.

Literature ReviewSahn (2007) defines a parapneumonic effusion (PPE) as a type of pleural effusion that arises as a result of pneumonia. Before looking at the pathophysiology of parapneumonic effusion background knowledge of how a pleural effusion develops need to be established. A pleural effusion occurs when excess amounts of fluid collects in the pleural space. This is commonly known as water on the lungs. Signs and symptom of a pleural effusion include: SOB, chest pain, gastric discomfort (dyspepsia), and cough. Two thin membranes are located in the chest cavity, the visceral pleura which line the lungs and the parietal pleura that cover the inside of the chest wall (Sahn 2007, pg 1480-1486). Normally, small blood vessels in the pleural linings produce a small amount of fluid that lubricates the opposed pleural membranes so that they can glide smoothly against each other during respiration. Any extra fluid that is produced is absorbed by blood and lymph vessels. When too much fluid forms or something prevents its removal, the result is an excess of pleural fluidan effusion. The most common causes are disease of the heart or lungs, and inflammation or infection of the pleura (Thompson 2011).According to Weyant (2007) pleural effusion itself is not a disease as much as a result of many different diseases. There are two types of pleural effusion that may occur: the transudate and the exudate. These two types of fluid are very different. The type of fluid present points to what sort of disease is likely to have produced the effusion. It also can suggest the best approach to treatment (Limsukon, 2011). A patient with parapneumonic effusion has an exudative pleural effusion. An exudate, which often is a cloudy fluid containing cells and much protein results from disease of the pleura itself. The causes are many and varied. Among the most common are infections such as bacterial pneumonia and tuberculosis; blood clots in the lungs; and connective tissue diseases, such as rheumatoid arthritis. Cancer and disease in organs such as the pancreas also may give rise to an exudative pleural effusion (Shawn, 1993). Hamm (1997) states that the development of pneumonia begins with the aspiration of organisms from the oropharynx. If the organism load is high and the patient's host defences are impaired (e.g., as a result of cigarette smoking or alcohol ingestion), the patient is more likely to develop pneumonia. The interval between aspiration of organisms and the development of pneumonia varies from a few days up to 1 week. Pneumonia typically begins in dependent lobes at the periphery of the lung and, if untreated, spreads centripetally towards the hilum (Thompson, 201). If left untreated for the subsequent 25 days, an UPPE will likely develop. The effusion forms because of an increased capillary permeability secondary to endothelial injury induced by activated neutrophils. The resultant extravascular lung water increases the interstitial-pleural pressure gradient and promotes a pleural effusion as fluid moves between mesothelial cells into the pleural space. If interstitial fluid formation exceeds the capacity of the lung and pleural lymphatics, a pleural effusion will accumulate. If left untreated for the subsequent 510 days, the PPE transitions to the fibrinopurulent stage, which is characterized by the development of fibrinous adhesions, increased neutrophils, and the presence of bacteria (Beers 2003). According to Weyant (2007), fibrin forms as intravascular clotting proteins enter the pleural space, with concomitant inhibition of pleural space fibrinolysis. Fibroblasts enter the pleural space by 2 possible mechanisms: (1) movement of bone marrow fibrocytes to the site of inflammation, and (2) mesothelial cell transformation to fibroblasts by cytokines, such as basic fibroblast growth factor2. Later in the fibrinopurulent stage, pus will be aspirated at thoracentesis; however, the lung is typically still expandable. As the fibrinopurulent stage progresses, it becomes increasingly unlikely that the patient can be successfully treated without pleural space drainage. If left untreated for the subsequent 1021 days, the PPE will evolve into the final organizational or empyema stage, with evidence of lung entrapment due to visceral pleural fibrosis. Patients with empyema always require pleural space drainage for adequate resolution of pleural sepsis and often require decortication.Empyema is a condition in which pus and fluid from infected tissue collects in a body cavity, especially in the pleural cavity (Johnson, 2012). This condition represents the end-stage of a progressive process evolving from a small amount of free-flowing, non-infected pleural fluid to a large amount of frank pus that can become loculated and result in thick pleural peel. It is most often used to refer to collections of pus in the space around the lungs (pleural cavity), but sometimes refers to similar collections in the gall bladder or the pelvic cavity (Johnson, 2012). Empyema in the pleural cavity is sometimes called empyema thoracis, or empyema of the chest, to distinguish it from empyema elsewhere in the body. Limsukon (2011) states that empyema may have a number of causes (contamination of a wound because of inadequate skin preparation during procedures such as needle decompression, chest tube placement, thoracentesis, or lung surgery) but is most frequently a complication of pneumonia. Its development can be divided into three phases: an acute phase in which the body cavity fills with a thin fluid containing some pus; a second stage in which the fluid thickens and a fibrous, coagulation protein (fibrin) begins to accumulate within the cavity; and a third or chronic stage in which the lung or other organ is encased within a thick covering of fibrous material (Beers, 2003). Empyema thoracis can be caused by a number of different organisms, including bacteria, fungi, and amebas, in connection with pneumonia, chest wounds, chest surgery, lung abscesses, or a ruptured esophagus. The infective organism can get into the pleural cavity either through the bloodstream or other circulatory system, in secretions from lung tissue, or on the surfaces of surgical instruments or objects that cause open chest wounds. The most common organisms that cause empyema are the following bacteria: Streptococcus pneumoniae, Haemophilusinfluenzae, and Staphylococcus aureus (Sahn, 2007). When the disease organisms arrive in the cavity surrounding the lungs, they infect the tissues that cover the lungs and line the chest wall. As the body attempts to fight off the infection, the cavity fills up with tissue fluid, pus, and dead tissue cells (Weyant, 2007).

Clinical Manifestations and Diagnostic Modalities of Parapneumonic Effusion and Empyema.All patients presenting with evidence of infection and respiratory symptoms should undergo investigation for a parapneumonic effusion, especially those who fail to improve despite antibiotic treatment for pneumonia (Hamm, 1997).The initial test of choice is a chest radiograph and, if a significant effusion is seen, a diagnostic thoracentesis (pleural aspiration) is required.Aspiration of frank pus is diagnostic of empyema, but if this is not present, further biochemical and microbiological tests are required to diagnose whether or not a parapneumonic effusion is complicated (Hughes, 1991).Clinical history Presenting symptoms The key presenting symptoms of empyema are breathlessness (secondary to large pleural effusion or pneumonia), fever, and pleuritic chest pain (pain worsened by deep breathing, coughing, sneezing, and chest movement). Other associated symptoms include those of pneumonia (productive cough, green or rust-coloured sputum, shortness of breath) and systemic infection (anorexia, malaise, fatigue, rigors)(Sahn,1996, para. 5). Patients tend to have a subacute history of illness, with a mean duration of symptoms before admission of 2 weeks. Failure of patients with pneumonia to respond to antibiotics or a deterioration in clinical condition suggests the development of a complicated parapneumonic effusion or empyema(Sahn,1996, para. 5). The lack of characteristic clinical signs can delay diagnosis. Immunocompromised patients or patients who are already taking antibiotics may present with few clinical signs of infection. Patients with anaerobic empyemas can present with a more indolent illness characterised by weight loss, constitutional upset, and fatigue (Thomas, 2009). Past Medical History The majority of patients who develop empyema have a recent history of pneumonia, thoracic trauma, or iatrogenic intervention in the pleural space such as thoracic surgery, or medical procedures such as chest drain insertion (4%), thoracentesis (pleural aspiration), tube thoracostomy (chest drain insertion), and aspiration of pneumothoraces or pleural effusions (Johnson, 2012). Patients may have a history of a medical condition predisposing them to the development of pneumonia and hence empyema, such as pre-existing lung diseases (e.g., bronchiectasis, chronic obstructive lung disease [COPD], lung cancer) or conditions associated with an increased risk of aspiration (e.g., stroke, presence of a nasogastric or endotracheal tube). Immunocompromised patients (e.g., due to haematological disease, chemotherapy, HIV, or malnutrition) are also at increased risk of developing empyema (Sahn, 2007). Social History Alcohol abuse and drug addiction are additional risk factors for the development of empyema.Clinical examinationExamination reveals evidence of a pleural effusion with or without signs of systemic infection. Large pleural effusions are characterised by dullness on percussion (classically described as 'stony' in quality) and diminished breath sounds with reduced vocal resonance on the affected side. Smaller pleural effusions may not be detectable on clinical examination (Sahn, 2007). Septic shock presents with pyrexia, tachypnoea, tachycardia, and hypotension (BP 10 mm on a lateral decubitus CXR, in association with evidence of infection, requires thoracentesis (pleural aspiration).Thoracic ultrasound is more sensitive than a CXR for the detection of pleural effusions.Features suggestive of an empyema on thoracic ultrasound include the presence of echogenic fluid, loculations, and septations.As empyemas are often associated with a raised hemidiaphragm or tethered lung, image guidance for all procedures is preferable (Sahn, 2007). The use of ultrasound to guide thoracentesis (pleural aspiration) in order to reduce its associated complication rate is advised.Ultrasonography is also recommended to guide chest drain insertion, especially in small or loculated effusions.

ThoracentesisAll patients with evidence of infection and a significant pleural effusion should undergo thoracentesis (pleural aspiration). Aspiration of frank pus is diagnostic of an empyema and no other investigations are required to establish the diagnosis, with the exception of pleural fluid microbiology to guide antibiotic therapy. If the aspirate does not reveal frank pus, further analysis is required to assess whether it is a complicated parapneumonic effusion. This involves measurement of the pleural fluid pH, total protein concentration, LDH level, glucose concentration, and white cell differential (Sahn, 1990).All samples should be sent for microscopy, culture, and sensitivity testing.Cytology may be used in cases where the diagnosis is unclear (e.g., for the detection of malignant cells in a malignant pleural effusion). Pleural fluid appearance: Empyema is characterised by frank pus. Complicated parapneumonic effusions may be serous or cloudy. Pleural fluid odour: Putrid odour is suggestive of an anaerobic infection. Pleural fluid pH: Samples should be stored anaerobically.Local anaesthetics can falsely lower the pH. Physicians should have access to a blood gas analyser so that samples can be tested immediately to enable immediate insertion of a chest drain if indicated. If the sample is frank pus, the pH should not be tested as it can damage the analyser (Weyant, 2007). Pleural fluid total protein concentration: If frank pus is aspirated, the protein concentration does not require analysis. Pleural fluid LDH level: If frank pus is aspirated, the LDH level does not require analysis. Pleural fluid glucose concentration: If frank pus is aspirated, glucose does not require analysis. If an accurate pleural fluid pH is not available, low glucose levels can be used as an alternative predictor of a complicated parapneumonic effusion requiring urgent chest drain insertion. Pleural fluid glucose has shown to be a robust predictor in this circumstance (Suzanne, 2010). Pleural fluid white cell differential: Polymorphonuclear leukocytes are the predominating (>90%) cell type. The predominance of lymphocytes in the exudate raises the suspicion of tuberculosis or malignancy. Pleural fluid microscopy, culture, and sensitivity: A positive Gram stain or culture is obtained in 60% to 70% of samples.This can be used to guide antibiotic treatment (Thompson, 2011).Further imaging studiesFurther imaging studies are performed when there is doubt about the diagnosis or to confirm the correct position of the chest drain.Contrast-enhanced thoracic CT can help to distinguish empyema from other pleural effusions and lung abscesses, and should be done with tissue phase contrast.Enhancement of the pleura with contrast is characteristic of empyema. The split pleura sign represents enhancement of the visceral and parietal pleura with interposed fluid. Pleural thickening may be visible, but this is also seen in malignancy. Contrast-enhanced thoracic CT is especially useful for confirmation of the correct positioning of the chest drain and may help in the planning of surgery (Sahn, 2007).MRI is unable to accurately diagnose an empyema and is therefore generally reserved for patients who are unable to undergo contrast-enhanced CT.It may show septations, loculated pleural fluid, or chest wall invasion.A PET scan is another possible imaging technique, but its use is limited by the fact that it is unable to distinguish between malignancy and empyema.As the causative organism in 40% of pleural infections remains unidentified, pleural fluid polymerase chain reaction (PCR) may aid pathogen identification, allowing specific antibiotics to be chosen.However, further prospective evidence is required on this technique before it can be routinely recommended (Sahn, 2007).

Laboratory Analysis of Parapnuemonic effusion and EmpyemaSamples of effusions for laboratory analysis are obtained by needle aspiration. Aspiration of pleural fluid is called thoracentesis. (Cavanaugh, 2003, p.287) Patients with pneumoniaand an effusion of more than minimal size should have a therapeuticthoracentesis.If the fluid cannot be removed with a therapeuticthoracentesis, a chest tube should be inserted and consideration begiven to the intrapleural instillation of fibrinolytics. (Wright, 2006, p.75) The thoracentesis needle is inserted when fluid appears, a stopcock and 50-mL syringe is attached to the needle and the fluid is aspirated. The pleural fluid samples are placed in appropriate containers, labeled, and sent promptly to the laboratory (Cavanaugh, 2003, p.287 )The Pleural fluid analysis provides diagnostic information and guides therapy. (Sahn, 2007).The pleural fluid is analyzed by bacterial culture, Gram stain,red and white blood cell counts, chemistry studies (glucose, amylase, lactic dehydrogenase, and protein), cytologic analysis for malignant cells, and pH.(Brunner &Suddarths, 2011).Pleural effusion caused by pneumonia (parapneumonic effusion) is indicated by presence of red blood cells (5,000 per cubic millimeter);white cell count of 5,000 to 25,000 per cubicmillimeter, consisting mainly of neutrophils andsometimes including eosinophils; pH less than7.40; and elevated protein, pleural fluid:serumprotein ratio, LDH, and pleural fluid:serum LDH ratio.(Cavanaugh, 2003, p.287 )If the pneumonia is of bacterial origin, theorganism may be demonstrated on culture andthe pleural fluid glucose level may be decreased.(Cavanaugh, 2003, p.287 )Complications of empyemaIt is believed that pus can become walled off into pockets making empyema harder to treat. Empyema can become resistant to multiple antibiotics that make treatment more difficult and prolonged. A complication such has air entering into the pleural space(pneumothorax), and scarring of the lungs (pulmonary fibrosis) can occur. Pleural thickening may also occur. It is believed if left untreated, an erosion can occur between the breathing passages (bronchial tree) and the pleural space (bronchopleural fistula) or between the pleural space and the skin (empyema necessitatis).Respiratory failureand septic shockare extreme complications that can result in death. (Medical Disability Advisor. para. 1-2)Management of Left EmpyemaEmpyema is managed using a combination of medications and surgical techniques. The management of empyema involves three core principles; prompt initiation of appropriate antibiotics, the complete evacuation of supportive pleural fluid, and the preservation or restoration of lung expansion (Tobler et al. 2004)Nursing Management of Left Empyema(Tobler et al. 2004) authors of Empyema states, Empyema is usually treated on an inpatient basis with intravenous antibiotics for the underlying infection.Nurses can medicate patients with antibiotic as ordered by the doctor. Treatment with medication involves intravenously administering a two-week course of antibiotics. It is important to give antibiotics as soon as possible to prevent first-stage empyema from progressing to its later stages. The antibiotics most commonly used are penicillin and vancomycin. Patients experiencing difficulty breathing may also be administered oxygen as ordered by the doctor.

Surgical Management of Left EmpyemaSurgical treatment of empyema has two goals: drainage of the infected fluid and closing up of the space left in the pleural cavity. If the infection is still in its early stages, the fluid can be drained by thoracentesis. In second-stage empyema, the surgeon will insert a chest tube in the patient's rib cage or remove part of a rib in order to drain the fluid. In third-stage empyema, the surgeon may cut or peel away the thick fibrous layer coating the lung. This procedure is called decortication. When the fibrous covering is removed, the lung will expand to fill the space in the chest cavity(Tobler et al. 2004). Video-assisted techniquesNumerous variations of video-assisted decortication, including one-, two-, and three-port approaches, have been described. One-lung ventilation has been described, either with aid of a double-lumen endotracheal tube or mainstem intubation, but is rarely necessary. The patient is placed in a lateral or semilateral decubitus position. Placing the patient over a large axillary role widens the contralateral intercostals spaces and facilitates trocar insertion. The pleural space is inspected and coagulum removed completely. Once the coagulum is completely evacuated and the peel removed, the lung is inflated(Tobler et al. 2004). It is essential that the lung occupy the complete hemithorax upon inflation to minimize pleural space problems such as persistent atelectesis and recurrent empyema. The pleural space is irrigated with antibiotic solution and a chest tube is placed via a port site. A single chest tube usually suffices. As in open thoracotomy, chest tubes are removed when there is cessation of air leak and minimal pleural drainage. Summary Early surgical intervention has showed to hasten recovery and reduce morbidity. The use of video-assisted techniques in the management of pleural space disease not only reduces surgical morbidity further, but also appeals to non-surgical providers thereby facilitating an earlier referral. Early video-assisted decortication provides an effective, singular procedure that combines characterization of the pleural space fluid, cessation of the progression of the parapneumonic process, removes the infected pleural material, allows for maximal lung expansion and function, all with reduced pain and morbidity to the patient and a shortened hospital stay(Tobler et al. 2004). Management of Parapneumonic EffusionAccording to Dr.Steve A. Sahn, author of Diagnosis and Management of Parapneumonic Effusions and Empyema written in the journal Clinical Infectious Diseases, Parapneumonic effusions outcome is related to the interval between the onset of clinical symptoms and presentation to the physician, comorbidities, and timely management. Early antibiotic treatment usually prevents the development of a PPE and its progression to a complicated PPE and empyema.Sahn(2007) further states, The management of a Parapneumonic effusion should proceed with a sense of urgency. It is important for the clinician to have a management plan that limits any delay in invasive treatment. In general, early and appropriate antibiotic treatment will prevent the development of a Parapneumonic effusion and its progression. A Parapneumonic effusion is one of the few clinical situations in which a diagnostic thoracentesis should be performed as soon as possible. There should be timely escalation of treatment, if the Parapneumonic effusion progresses with continued pleural sepsis. Failure to treat elderly persons who have a Parapneumonic effusion or empyema substantially increases the risk of death.Colice GL, Curtis A, Deslauriers J. authors of Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline states, Effusions with pleural fluid layering less than 10 mm on decubitus chest radiographs almost always resolve with appropriate systemic antibiotics. Patients with pleural effusions that have a pleural fluid layering greater than 10 mm on lateral decubitus radiographs must have a diagnostic thoracentesis. If the diagnostic thoracentesis yields thick pus, the patient has an empyema thoracis and definitive pleural drainage is absolutely required.Antibiotic therapyEarly antibiotic therapy will prevent the development of a Parapneumonic effusion and its progression to a Chronic Parapneumonic effusion and empyema. Virtually all antibiotics have good pleural fluid penetration, with pleural fluid to serum levels generally exceeding 1.0, with pleural fluid antibiotic concentrations usually exceeding the accepted MIC breakpoint for organisms most likely to cause empyema (TaryleDA et al 1981). Nursing management for administering antibiotics includes administering the antibiotics on time and monitoring for signs of side effects and adverse effects on the patient.

Pleural space drainageClinical factors that suggest the need for pleural space drainage include prolonged pneumonia symptoms (TaryleDA 1981), comorbid disease, failure to respond to antibiotic therapy, and presence of anaerobic organisms. Chest radiograph findings that suggest the need for pleural space drainage include an effusion involving >50% of the hemothorax ,loculation, and an air-fluid level. Stranding or septation noted on an ultrasound suggests the need for pleural space drainage, marked pleural enhancement, pleural thickening, and the split pleura sign noted by chest CT indicate the necessity for pleural space drainage (QureshiNR,GleesonFV 2006).The options for pleural space drainage include repeated thoracentesis, use of a standard chest tube, or an image-guided insertion of a small-bore catheter. A number of nonrandomized studies have reported a variable success rate and a mortality rate associated with repeated thoracentesis (StormHK et al 1992). Standard chest tubes are often placed without ultrasound or CT guidance by thoracic surgeons for the treatment of PPE and empyema. (HuangHC et al 1999).Drainage failure is a consequence of misplacement of the chest tube, tube malfunction, and loculations. Nursing responsibility is to assess the patient for complications of use of standard chest tubes include pain, pneumothorax, hemorrhage, and subcutaneous emphysema. Intrapleuralfibrinolytics In 2004, The Cochrane Database Review stated that, although the evidence suggests that intrapleural fibrinolysis can be considered an important adjunctive therapy to tube drainage on the basis of evidence from randomized, controlled trials alone, routine use was not recommended for the management of CPPE and empyema, because the number of cases was too small (CameronR, DaviesHR 2004). Streptokinase (no longer available as a result of a lack of market demand) and urokinase were equally efficacious and that life-threatening complications were not reported in any of the randomized, controlled trials. Fibrinolytic agents would probably be most effective in the early fibrinolytic stage in avoiding the need for surgical drainage (Sahn, S., 2007). SurgerySurgical options include thoracoscopy, both medical and video-assisted thoracic surgery (VATS), standard thoracotomy, and open drainage. The decision for surgery should be made as soon as it is obvious that pleural space drainage by tube thoracostomy has been ineffective in controlling the pleural infection. Patients with a PPE can be sent directly to surgery or treated with a 72-h trial of fibrinolytics(Tobler et al. 2004). If fibrinolytics do not improve drainage, decrease temperature, and lower the leukocyte count, surgery should be strongly considered. However, it should be recognized that, with clinical improvement, despite an abnormal pleural space, observation may be warranted. There are patients who refuse surgery, despite minimal clinical improvement, who over several weeks to months have complete lung re-expansion without pleural space squeal (Sahn, S., 2007).Open thoracotomy for CPPE and empyema is recommended for persistent pleural sepsis and failure of less invasive procedures to control the infection (MackinlayTAA et al 1996). Conversion to thoracotomy can be effective when VATS cannot adequately access the pleural space and is the optimal method for successful debridement and decortications (DeslauriersJ et al 2002). However, decortication is a major operation and can often not be performed in debilitated patients. Decortication (stripping of the visceral pleural peel) can be performed early to control pleural sepsis and late (36 months after the onset of empyema or CPPE) to treat a symptomatic, restrictive ventilatory defect. Open drainage for empyema is an alternative to decortication in the debilitated patient who cannot undergo a standard thoracotomy (DeslauriersJ et al 2002).Nursing Management for Parapneumonic effusionAntipyretics should be given as ordered for fever. Administration of analgesia as ordered is important to keep the patient comfortable, particularly in the presence of a chest drain. Facilitate early mobilization and exercise after surgery(Tobler et al. 2004).Medications in the management of pleural effusion and empyemaThe goals of pharmacotherapy are to reduce morbidity and prevent complications.In patients with parapneumonic effusions, empyemas, and effusions associated with esophageal perforation and intra-abdominal abscesses. Antibiotics should be administered early when these conditions are suspected (Rubins, J. 2012). Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. Initiate therapy with intravenous antibiotics and transition to oral agents or equivalent agents based on clinical response. Oral antibiotics can be used to transition from intravenous therapy. They allow completion of a full course of therapy without the need for intravascular access or inpatient hospitalization. (Limsukon&SooHoo, 2011).Early antibiotic treatment prevents progression of pneumonia and the development of parapneumonic effusion and empyema. (Sahn, 2007, p.1484) Initial therapy may include broad spectrum oral antibiotics after obtaining a pleural fluid sample. (Fakhoury&Janahi, 2008).According to bacteriology listed for a community acquired infectious diseases the first choice will include intravenous amoxicillin with clavutanic acid or a combination of a second generation cephalosporin(e.g. cefuroxime) and metronidazole or clindamycin if patient is penicillin allergic (Gidhar,Bajwa&Shujaat 2012) Amoxicillin is the most active of penicillins for nonpenicillin-susceptible S pneumoniae. It inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. (Limsukon&SooHoo, 2011).Addition of clavulanate inhibits beta-lactamase producing bacteria. Clindamycin is available in parenteral form (ie, clindamycin phosphate) and oral form (ie, clindamycin hydrochloride). Oral clindamycin absorbed rapidly and almost completely and is not appreciably altered by presence of food in stomach. (Limsukon&SooHoo, 2011).Appropriate serum levels are reached and sustained for at least 6 h following oral dose. Also it is effective against aerobic and anaerobic streptococci (except enterococci). (Limsukon&SooHoo, 2011).Nosocomial empyema needs adequate gram negative coverage, as gram negative infections are more common in nosocomial empyema. Coverage should include carbapenem or antipseudamonal penicillin, for example, piperacillin or tazabactrum or a third or fourth cephalosporins (ceftazidime, cefepime) with metrodiazole. If there is a suspicion for MRSA coinfection, vancomycin or linezolid can be added. (Girdhar et al, 2012).

Patient DataBiographic data:Initials: DOB: 28/11/39 Age: 72Sex: MMarital Status: MarriedAddress: South Rd Kencot P.O. HWT Rd

Family/Social History: 6 children 9bedroom house, Pipe water, Toilet flushing, Light electricity, Garbage collection via garbage truck,Family history of SLE seizures

Present complaint/ History of present complaint:Health agency National Chest Hospital Date of admission 22/10/12 @ 3:30pm Ward H Presented with difficulty breathing, SOB, chest pain, generalized weakness, mild cough, thick white sputum, swollen lower extremities, lack of appetite, weight loss which caused him to seek medical attention Duration 3weeks, Onset Sept 30, 2012

Diagnosis- Left Empyema, left Parapneumonia, Effusion,

Past Medical History nilPast Surgical History 1986 removal of Hemorrhoids, 2004 removal of bullets at KPH, Neck Exploration.Admitted at KPH 8/10/12 and then NCH 22/10/12Medication taken on ward enalapril 10mg pobd x 1week, pethadine 75mg IM stat, then PRN x 1week, gravol 50mg IM PRN x 1week, voltaren 75mg PO bdx1week

Mode of Admission wheelchairGeneral appearance elderly male rational, clear speech, oriented x3, well attired, Left chest tube in situ to underwater seal drainage, Weight 169lbsHeight 5ft 8 Immunization up to dateMedication Voltaren, CetamolLab Values27/10/12 - Hb 9.8 Na 135 BUN 3.8 PCV 29 K 4.9 Creatine 106 MCH 34 CL 98 WBC 12.0 CO2 24 P/T 18327/10/12 - Hb 10.4 Na 134 BUN 3.9 PCV 0.31 K 3.8 Creatine 113 WBC 6.8 Cl 99 P/T 339 CO2 20

Data Analysis and Interpretation Five Day Care Analysis and Interpretation

Admission notes22/10/12 3:30pm new pt admitted via casualty dept with referral from KPH. Was relatively ok until 2/52 ago when pat started to experience SOB on exertion relieved by rest, cough w/ production of white/yellow sputum, hemoptysis (one episode), intermittent fever, and loss of appetite. Visited KPH, where chest Xray revealed L pleural effusion and L thoracentesis was done. Based on findings he was referred to chest for further management. PMH NilPSH neck exploration and pile removal (put proper medical term for both surgeries),Gun shot wounds to neck x 4 (8yrs ago) Allergies none knownOn Assessment elderly male rational and in no apparent cardiopulmonary distress.Mm pink, moist.Dressing to thoracotomy site dry, intact. L chest tube in place attached to under water seal drainage bottle with 300mls hemopurulent fluid, oscillation present. Nonpitting edema noted to feet. IV access in place to L hand for medication.T-100F p-104 R-28, BP 128/80 SPO2 76% breathing spontaneously on room air. GMR 5.2mmol/L, weight 169lbs Seen and checked by doctor: Plan CBC done, chest physiotherapy, medicate as ordered, liver function test, U & E; for analgesic, antipyretic, antibiotic, and anticoagulant

Admission day management 22/10/12Had meal from home, medicated with Panadol as ordered, antipyretic measures done. Medicated 5000units heparin, Voltaren 75mg, Zantac 300mg, fan therapyPotential for acute pain related to soft tissue injury and potential for hyperthermia related to inflammatory process plan assess comfort level give analgesic as ordered and evaluate its effectiveness. Advise patient to change position often. Monitor vitals every q4h, especially note temp and pulse; administer tepid sponge bath; give ordered antibiotics, wash hands before and after attending to client; change dressing using aseptic technique

Initial Analysis and InterpretationAccording to Tobler et al. (2004), the three core principles of empyema management is the prompt initiation of appropriate antibiotics; the complete evacuation of supportive pleural fluid; and the preservation or restoration of lung expansion. In the case of patient R.S., the presence of purulent fluid and thus the diagnosis of Empyema indicates that he was in the second stage of Parapneumonic effusion, the fibropurulent stage. This stage has characteristic changes in the pleural fluid, and thus both compositional studies and bacterial studies are important at this juncture (Sahn 2007, pp. 1480-1486) . This is done through sputum culturation, and thus it is important that the nurse collects or advocates for the collection of sputum cultures. The collection of sputum is necessary to advise in the proscription of antibiotics (Hughes 1991). Administration of the incorrect antibiotics will not only leave the problem untreated, but will allow the problem to progress to a third, more deadly stage. Thus both correct identification of and proscription of antibiotic therapy for the bacteria involved is important, and both of these start with the collection of sputum by the nurse (Cameron 2004). The second principle, complete evacuation of supportive pleural fluid, deals with the removal of the infected pleural fluid from the pleural space (Tobler et al. 2004). This can be done by several methods, mentioned above in the management section. The method chosen for this patient was thoracentesis, done prior to admission with the placement of a chest tube for subsequent drainage. The literature review agrees with this progression of surgical procedures, as the production of bacteria positive sputum cultures indicate the necessity for both the initial thoracentesis and drainage of the pleural space effected through the use of the thoracotomy drainage system (Colice 2000, pp. 1158-71). The third principle, the preservation or restoration of lung space, is highly subjective patient to patient, and depends on the healing capacity of each patients individual body (Tobleret al.2004). This is done in situations where lung collapse has occurred, or in cases in which decotication, the peeling of the thick fibrotic layer present in third stage parapneumonic effusion (Sahn 2007, pp1480-1486).Other important areas of necessary management include antipyretic measures, necessary both due to the infective and inflammatory raise of temperature present with parapneumoniac effusions and pain management. Management of the patients pain is especially important, as chest pain, will cause the patient to breathe improperly (i.e. shallow breaths) and thus be more likely to experience atelectasis or lung collapse (Colice 2000, pp1158-71).

23/10/12 Day 1 Post AdmissionAssessment - Breathes freely on room air, no SOB noted; left chest tube in situ attached to underwater seal with 420cc hemopurulent drainage seen in bottle, no oscillation seen. c/o pain to chest tube site, received sitting up in bed with grimace of pain on face; no cough noted, air entry equal bilaterally (AEEB); IV access noted to left hand; hydration status fair; bilateral pedal edema noted; VS T96.1F, P74bpm, spo2 97%, B/P 120/70mmHg; condition stable; Risk for infection.Plan change dressing, monitor vitals, monitor condition for changes; administer medications, provide psychological support, assist with ADLsInterventions medicated with Cetamol 2tabs, 5000c Heparin sc, and 4.5g Zosyn IV as ordered; medicated with Flagyl 500mg po, Voltaren 75mg po; patient encouraged to elevate legs, medicated with Zantac poOutcome patient states that he is 50% better than the day before.

Evaluation Criteria Antibiotic Therapy Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to combat the bacteria present within the pleural space. This is in accordance with the use of antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).Evacuation of Supportive Fluid Patient R.S. was noted to have 420cc of hemopurulent fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also, although not seen, the lack of oscillations were noted, indicating that the nurse was monitoring the status of the thoracotomy tube as necessary for proper evacuation (Sahn 2007, pp. 1480-1486) .Restoration of Lung Capacity (not necessary)Antipyretics The patient was initially given fan therapy and tepid sponge bath to bring the temperature down. In addition, the medication Panadol was given, which has antipyretic properties. By the 23, the hyperthermia had been taken care of, with subsequent administrations of antibiotics and the analgesic Panadol preventing a recurrence. This is in accordance with the information presented in the literature review (Colice 2000, pp1158-71).Analgesics The need for analgesia was indicated by the grimace of pain noted by the nurse upon assessment.Voltaren and Panadol were both administered for the purpose of analgesia. This is an important management, as the presence of pain not only leads to patient discomfort and decreased compliance with treatment methods, but can lead to ineffective breathing and complications such as atelectasis (Colice 2000, pp1158-71)..Medication Administration The patient was medicated as ordered in a timely fashion, an important factor for the effective management of this condition. The patient was given Zantac to counteract the stomach acid secretory increase caused by Voltaren which itself was administered for the pain. The analgesics were given for pain management, while the antibiotics were given for treatment of the primary condition, parapneumoniac effusion (Hughes 1991). Heparin was given to prevent the formation of blood clots, due to the reduced mobility of the patient and risk for Deep Vein Thrombosis, or DVT.Nursing-Specific Management Bilateral pedal edema was noted, but nothing was indicated as having been done for this observation. Appropriate managements would have included elevating the feet, and informing the doctor whereby diuretics could have been administered. The diagnosis Risk for Infection is inaccurate, as infection has occurred (See definition of Empyema, parapneumoniac effusion). In the assessment, the lung sounds of the patient were not auscultated. In addition, no mention of coughing was made, yet the patient was reported as admitted with a cough with the production of thick, yellow-white sputum. Also, no mention of sputum collection was made, and the subsequent identification of the bacteria that was present within R.S.s pleural space. This is further evidenced by the administration of Flagyl and Zosyn, which are both broadspectrum antibiotics. This is contraindicated according to the research put forth by Hughes (Sahn 2007, pp. 1480-1486) in which he states that the correct antibiotic must be used to provide for the accurate treatment of the condition and the prevention of further proliferation. Final Evaluation For Day 1 The final evaluation for day 1 maintains that, although the health care team, both medical and nursing responsible for this patients care did a good job, important facets of the care plan as evidenced by the literature review were left out, foremost was the lack of sputum culture by the nurse and the subsequent bacterial identification and corresponding antibiotic proscription by the doctors.

24/10/12 -Day 2 Post AdmissionAssessment Vital Signs T 97.2 F P82bpm R24bpm, B/P 130/80mmHg, SPO2 97%; left tube remains in situ attached to underwater seal drainage; patient c/o pain to the left side; elderly male alert, no obvious distress noted; chest expansion equal and bilateral, iv access in place for meds. Left chest tube in situ with 75cc purulent fluid in underwater seal drainage bottle, oscillation noted. Dressing intact and dry; hydration status fairPlan administer meds and monitor; chest expansion equal and bilateral, continue observations and care; Interventions medicated with 1g Panadolpo, 500mg Flagylpo, Zosyn IV, 5000u Heparin sc, Outcome No outcome was mentioned in the nurses/progress notes.

Evaluation Criteria Antibiotic Therapy Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to combat the bacteria present within the pleural space. This is in accordance with the use of antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).Evacuation of Supportive Fluid Patient R.S. was noted to have 75cc of hemopurulent fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also, oscillations were noted, indicating that the nurse was monitoring the status of the thoracotomy tube as necessary for proper evacuation (Sahn 2007, pp. 1480-1486).Antipyretics Patient R.S. was constantly monitored to determine whether or not antipyretic measures would be need. None were administered as the temperature was within acceptable range (97.2F). In addition, the continuous administration of Panadol as ordered provided an antipyretic effect. Monitoring for the presence of hyperthermia is important, as both the infection and inflammation present in parapneumonic effusion with empyema will have a direct effect on the temperature. Thus, if the temperature is within normal ranges, it indicates the infection/inflammation is being adequately managed. This is in accordance with the information presented in the literature review (Colice 2000, pp1158-71).Restoration of Lung Capacity (not necessary)Analgesics The need for analgesia is indicated not only by the presence of the chest tube in situ (Sahn 2007, pp. 1480-1486), but the patients c/o pain to his left side. Voltaren and Panadol were both administered for the purpose of analgesia. This is an important management, as the presence of pain not only leads to patient discomfort and decreased compliance with treatment methods, but can lead to ineffective breathing and complications such as atelectasis (Colice 2000, pp1158-71)..Medication Administration The patient was medicated as ordered in a timely fashion, an important factor for the effective management of this condition. The patient was given Zantac to counteract the stomach acid secretory increase caused by Voltaren which itself was administered for the pain. The analgesics were given for pain management, while the antibiotics were given for treatment of the primary condition, parapneumonic effusion (Hughes 1991). Heparin was given to prevent the formation of blood clots, due to the reduced mobility of the patient and risk for Deep Vein Thrombosis, or DVT.Final Evaluation for Day 2 The final evaluation for day two reports that not only does the sputum culture remain undone, but the breath sounds were not auscultated to indicate the level of exudate infiltration within the pleural space or whether or not atelectasis, an important complication, had started to occur. In addition, there was no mention of the patients cough and subsequent production of sputum, nor was there mention of any teaching methods designed to enhance the patients cough reflex.

25/10/12 Day 3 Post AdmissionAssessment client has no complaints; alert and rational, no distress noted; left chest tube in situ 150cc purulent fluid in underwater seal bottle, oscillating; dressing intact; IV access in place for meds to left arm; hydration fair; V/S T96, P64 R20 SPO2 96%Plan change dressing, medicate and monitorInterventions Pethidine 75mg IM, Gravol 50mg IM, Voltaren 75mg, Zantac 150mg, Enalapril 10mg and Baralgin 1g, Panadol 1g po, Flagyl, Zosyn IV given as ordered; dressing to left chest tube site was changed. Outcome No outcome was mentioned in the nurses/progress notes.

Evaluation Criteria Antibiotic Therapy Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to combat the bacteria present within the pleural space. This is in accordance with the use of antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).Evacuation of Supportive Fluid Patient R.S. was noted to have 150cc of hemopurulent fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also, oscillations were noted, indicating that the nurse was monitoring the status of the thoracotomy tube as necessary for proper evacuation (Sahn 2007, pp. 1480-1486) .Antipyretics Patient R.S. was constantly monitored to determine whether or not antipyretic measures would be need. None were administered as the temperature was within acceptable range (96 F). In addition, the continuous administration of Panadol as ordered provided an antipyretic effect. Monitoring for the presence of hyperthermia is important, as both the infection and inflammation present in parapneumonic effusion with empyema will have a direct effect on the temperature. Thus, if the temperature is within normal ranges, it indicates the infection/inflammation is being adequately managed. This is in accordance with the information presented in the literature review (Colice 2000, pp1158-71).Restoration of Lung Capacity (not necessary)Analgesics The need for analgesia is indicated not only by the presence of the chest tube in situ (Sahn 2007, pp. 1480-1486) even though the client had no c/o of pain during the nursesreceivalassessment. This is evidenced by the administration of Pethidine 75mg throughout the day. Pethidine is a narcotic analgesic which can cause respiratory depressant effects, and thus administration of this drug should have been followed by a thorough assessment of the patients respiratory system, which was not noted. Voltaren and Panadol were both administered for the purpose of analgesia. This is an important management, as the presence of pain not only leads to patient discomfort and decreased compliance with treatment methods, but can lead to ineffective breathing and complications such as atelectasis (Colice 2000, pp1158-71). Baralgin was also administered, which is contraindicated in patients with infection as long term Baralgin use can lead to agrannulocytosis, particularly with a reduction in bactericidal neutrophils. Thus, the researcher does not agree with the prescription/administration of Baralgin. Medication Administration The patient was medicated as ordered in a timely fashion, an important factor for the effective management of this condition. The patient was given Zantac to counteract the stomach acid secretory increase caused by Voltaren which itself was administered for the pain. The analgesics were given for pain management, while the antibiotics were given for treatment of the primary condition, parapneumonic effusion (Hughes 1991). Heparin was given to prevent the formation of blood clots, due to the reduced mobility of the patient and risk for Deep Vein Thrombosis, or DVT. Enalapril was given to lower the blood pressure.Final Evaluation for Day 3 The final evaluation for day three reports that not only does the sputum culture continue to remain undone, but the breath sounds were not auscultated to indicate the level of exudate infiltration within the pleural space or whether or not atelectasis, an important complication, had started to occur. In addition, there was no mention of the patients cough and subsequent production of sputum, nor was there mention of any teaching methods designed to enhance the patients cough reflex. There was also no mention of an assessment of the wound site. Wound site assessment is important during dressing changes as it indicates the presence or potential for reinfection/ super infection (Hughes 1991).

26/10/12 Day Four Post AdmissionAssessment patient stated Im not feeling much pain at the cut but mi alright; Mi whole body feel weak. Elderly patient received n sitting position, conscious, oriented to person place and time; mucus membrane pink and moist, capillary refill less than 2 seconds, chest expansion unequal, left side diminished, no adventitious breath sounds heard; IV access noted proximal to left wrist, left bilateral chest tube in situ attached to underwater seal drainage, 200ml purulent fluid, oscillation noted. Dressing to thoracotomy site clean, dry and intact; abdomen slightly enlarged; skin hydrated; vital signs T 97.6F; P72, R18, B/P 130/82, Risk for infection related to IV site and surgical opening of skin; Risk for injury related to generalized weakness; patient coughed up green-flecked sputum; night nurses report that there is no evidence of cough seen. Plan at the end of the shift patient will be from injury and infection; monitor patients mobility; reduce patient level of activity, advise patient to stay in bed and call for assistance, ensure that dressings remain clean, monitor vital signsInterventions patient was medicated Voltaren 75mg, IM Gravol 50mg, Enalaprilpo, Cetamolpo, Heparin sc, Zantac, Flagyl and BaralginpoOutcome 12:05pm Patient stated Im not feeling so weak like this morning but I am still feeling a little pain

Evaluation Criteria Antibiotic Therapy Patient R. S. was given Flagyl and Zosyn, two antibiotic agents to combat the bacteria present within the pleural space. This is in accordance with the use of antibiotic therapy as a priority in the treatment of this condition as stated by Tobler et al. (2004).Evacuation of Supportive Fluid Patient R.S. was noted to have 200ml of hemopurulent fluid present within the drainage bottle, indicating that the fluid was being evacuated. Also, oscillations were noted, indicating that the nurse was monitoring the status of the thoracotomy tube as necessary for proper evacuation (Sahn 2007, pp. 1480-1486) .Antipyretics Patient R.S. was constantly monitored to determine whether or not antipyretic measures would be need. None were administered as the temperature was within acceptable range (97.6F). In addition, the continuous administration of Panadol as ordered provided an antipyretic effect. Monitoring for the presence of hyperthermia is important, as both the infection and inflammation present in parapneumoniac effusion with empyema will have a direct effect on the temperature. Thus, if the temperature is within normal ranges, it indicates the infection/inflammation is being adequately managed. This is in accordance with the information presented in the literature review (Colice 2000, pp1158-71).Restoration of Lung Capacity (not necessary)Analgesics The need for analgesia is indicated by the presence of the chest tube in situ (Sahn 2007, pp. 1480-1486) even though the patient states that they were not feeling much pain. Voltaren and Panadol were both administered for the purpose of analgesia. This is an important management, as the presence of pain not only leads to patient discomfort and decreased compliance with treatment methods, but can lead to ineffective breathing and complications such as atelectasis (Colice 2000, pp1158-71). In addition, the lack of pain experienced by the patient indicates the effectiveness of the analgesia administered not only in a curative but prophylactic role. Baralgin was also administered, which is contraindicated in patients with infection as long term Baralgin use can lead to agrannulocytosis, particularly with a reduction in bactericidal neutrophils. Thus, the researcher does not agree with the prescription/administration of Baralgin. Medication Administration The patient was medicated as ordered in a timely fashion, an important factor for the effective management of this condition. The patient was given Zantac to counteract the stomach acid secretory increase caused by Voltaren which itself was administered for the pain. The analgesics were given for pain management, while the antibiotics were given for treatment of the primary condition, parapneumoniac effusion (Hughes 1991). Heparin was given to prevent the formation of blood clots, due to the reduced mobility of the patient and risk for Deep Vein Thrombosis, or DVT. Enalapril was given to lower the blood pressure (130/82), however as the patient does not have a history of HTN, the researcher does not agree with the prescription/administration of Enalapril in this instance.Final Evaluation for Day 4 The final evaluation for day four reports that the sputum culture was not done. Also, the lack of auscultation of breath sounds indicates a deficiency in the assessment performed by nurse, and constitutes an unacceptable practice, in accordance with the literature review. In addition, there was no mention of the patients cough and subsequent production of sputum, nor was there mention of any teaching methods designed to enhance the patients cough reflex, both necessary in the removal of sputum from the patients airways. Final Evaluation it is interesting to note that only on day four was an assessment of the abdomen done, even though the primary reason for seeking health care by the patient was loss of appetite and marked weight loss. No mention of interventions whether medical or nursing to deal with this concern of the client was made. Also, a note made in the patients record indicateds that an order for fluid culture by the doctor was made on the 2/11, which was over a week after admission. Culture collection and analysis should have been one of the first interventions done, as it is one of the three primary principles of empyema care (Tobler et al. 2004).

Nursing Care Plan

Glossary 1. Loculation: Having, formed of, or divided into small cavities or compartments.2. Pleural: Pleural refers to the pleura or membrane that enfolds the lungs.3. Pleural peel: heavy fibrinous deposits on the pleura4. Exudate:1 relating to the oozing of fluid and other materials from cells and tissues, usually as a result of inflammation or injury. 2A fluid with a high content of protein and cellular debris which has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation.5. Fibrinopurulent: characterized by the presence of both fibrin and pus6. Fibrin: fibrous, non-globularproteininvolved in the clotting of blood7. Visceral pleura: a thin serous membrane tissue layer that sticks to the lung surface. It is the innermost of the two pleural membrane layers investing the lungs.8. Parietal pleura: pleura that lines the inner chest walls and covers the diaphragm9. LDH (lactate dehydrogenase): LDH is most often measured to check for tissue damage. Theprotein LDH is in many body tissues, especially the heart, liver, kidney, muscles, brain, blood cells, and lungs.10. Trapped lung: The condition occurs when the lung is covered preventing its expansion to the chest wall, leaving a persistent fluid-filled pleural space.11. Polymorphonuclear leukocytes: A white blood cell, usually neutrophilic, having a nucleus that is divided into lobes connected by strands of chromatin.12. Septation:the division or partitioning of a cavity into parts by a septum.13. Suppurate: to form or discharge pus.14. Pneumonia: Inflammation of the lungs usually caused by a virus, bacteria, or other organism.15. Decortication: The removal of the outer layer or cortex from a structure, esp. the lung, brain, or other organ.The operation of removing fibrous scar tissue that prevents expansion of the lung.16. Concomitant: Naturally accompanying or associated.17. Aspiration: The sucking of fluid or a foreign body into the airway when drawing breath.18. Centripetally: moving toward the center.19. Oropharynx: pertaining to the mouth and the pharynx.20. Empyema: an accumulation of pus in the space between the lung and the membrane that surrounds it (pleural space) that occurs when an infection spreads from the lungs.21. Thoracentesis-is a procedure to remove fluid from the space between the lining of the outside of the lungs (pleura) and the wall of the chest.22. Thoracostomy- is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air, fluid or pus from the intrathoracic space.23. Parapneumonic effusion- is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis.24. Hemithorax- this is half of the thorax.25. Comorbidity- this is two or more coexisting medical conditions or disease.26. PPE-Parapneumonic Pleural effusion27. CPPE- Chronic Parapneumonic Pleural effusion

Appendix COMPLETE BLOOD COUNT The complete blood count (CBC) is often used as a broad screening test to determine an individual's general health status. According to (Complete, 2012), a CBC is a panel of tests that evaluates the three types of cells that circulate in the blood; Evaluation of white blood cells, the cells that are part of the body's defense system against infections and cancer and also play a role inallergiesand inflammation, evaluation of red blood cells, the cells that transport oxygen throughout the body and the evaluation of platelets, cell fragments that are vital for normal blood clotting. It can be used to: Screen for a wide range of conditions and diseases Help diagnose various conditions, such asanemia,infection,inflammation,bleeding disorderorleukemia etc Monitor the condition and/or effectiveness of treatment after a diagnosis is established Monitor treatment that is known to affect blood cells, such as chemotherapy or radiation therapyCHEST PHYSIOTHERAPYChest physiotherapy (CPT) isa technique used tomobilize or loosesecretions in the lungsand respiratory tract (Chest Physiotherapy, 2011).This is especially helpful for patients with large amount of secretions or ineffective cough. Chest physiotherapy consists of external mechanical maneuvers, such as chest percussion, postural drainage, vibration, to augment mobilization and clearance of airway secretions, diaphragmatic breathing with pursed-lips, coughing and controlled coughing. It is indicated for patients in whom cough is insufficient to clear thick, tenacious, or localized secretions. For example: Pneumonias in dependent lung regions.LIVER FUNCTION TESTLiver enzyme tests, formerly called liver function tests (LFTs), are a group of blood tests that detect inflammation and damage to the liver. They can also check how well the liver is working. Liver enzyme testing includes ALT, AST, alkaline phosphatase; true liver function tests (LFTs) include PT, INR, albumin, and bilirubin. (Johnson, 2012)

UREA & ELECTROLYTE According to (Urea, n.d) U&Eis often used as a screening test for patients who are generally ill, to detect abnormalities of blood chemistry, including kidney failure and dehydration. TheU&Etest is a blood test and requires a few millilitres of blood from a vein.U&Eis usually performed to confirm normal kidney function (renal function) or to exclude a serious imbalance of biochemical salts in the bloodstream. A diverse number of conditions may be detected on theU&Etest, as each parameter tested may be high or low. SPUTUM CULTUREAccording to (Thompson, 2011), A sputum culture is a test to detect and identify bacteria orfungi that are infecting thelungsor breathing passages. Sputum is a thick fluid produced in the lungs and in the airways leading to the lungs. A sample of sputum is placed in a container with substances that promote the growth of bacteria or fungi. If no bacteria or fungi grow, the culture is negative. If organisms that can cause infection grow, the culture is positive. The type of bacterium or fungus will be identified with a microscope or by chemical tests. If bacteria or fungi that can cause infection grow in the culture, other tests may be done to determine which antibiotic will be most effective in treating the infection. This is called susceptibility orsensitivity testing.This test is done on a sample of sputum that is usually collected by coughing. For people who can't cough deeply enough to produce a sample, they can breathe in a mist solution to help them cough. A sputum culture is done to: Find and identify bacteria or fungi that are causing an infection (such as pneumoniaortuberculosis) of the lungs or the airways leading to the lungs. Symptoms of a lung infection may include difficulty breathing, pain when breathing, or a cough that produces bloody or greenish brownsputum. Identify the bestantibioticto treat the infection (sensitivity testing). Monitor treatment of an infection.CHEST X-RAYA chest x ray is a painless, noninvasive test that creates pictures of the structures inside the chest, such as the heart, lungs, and blood vessels. This test is done to find the cause of symptoms such as shortness of breath, chest pain,chronic cough(a cough that lasts a long time), and fever. Chest x rays help doctors diagnose conditions such aspneumonia, heart failure, lung cancer,lung tissue scarring, andsarcoidosis. Doctors also may use chest x rays to see how well treatments for certain conditions are working. (Chest,2010) CHEST TUBE THORACOSTOMYAccording to (American Thoracic Society, 2012), a chest tube thoracostomy is done to drain fluid, blood, or air from the space around the lungs. Some diseases, such as pneumonia and cancer, can cause an excess amount of fluid or blood to build up in the space around the lungs (called a pleural effusion). Also, some severe injuries of the chest wall can cause bleeding around the lungs. Sometimes, the lung can be accidentally punctured allowing air to gather outside the lung, causing its collapse (called a pneumothorax). Chest tube thoracostomy (commonly referred to as "putting in a chest tube") involves placing a hollow plastic tube between the ribs and into the chest to drain fluid or air from around the lungs.

THORACENTESISThoracentesis is a procedure to remove fluid from the space between the lungs and the chest wall called the pleural space. It is done with aneedle(and sometimes a plastic catheter) inserted through the chest wall.Ultrasoundpictures are often used to guide the placement of the needle. This pleural fluid may be sent to a lab to determine what may be causing the fluid to build up in the pleural space.On average only a small amount of pleural fluid is present in the pleural space. A buildup of excess pleural fluid (pleural effusion) may be caused by many conditions, such as infection, inflammation,heart failure, orcancer. If a large amount of fluid is present, it may be hard to breathe. Fluid inside the pleural space may be found during aphysical examinationand is usually confirmed by a chestX-ray. (Thompson, 2011)

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