Nursing Care of Patient With Chylothorax: Case Study (Focus Charting Nursing Document Writing)

Abstract

Chylothorax (or chylous effusion) is the accumulation of lymph or chyle in the pleural space due to blockage or disruption of the important thoracic or lymphatic ducts. This is a rare condition but has serious consequences if not received diagnosis and  appropriate treatment promptly. The most             common causes are complications of surgery,  spontaneous diseases, others from diseases and           unknown causes. The diagnostic method is the diagnosis of triglycerides and chylomicrons in the pleural fluid. Treatment divided into non-surgical treatment to reduce chyle leaks, limited fat intake or reducing chyle production using medications and surgical treatment, that depended on the response to non-surgical treatment. This article presents case study of a patient with chylothorax who was admitted at the surgical ward (Government university hospital). Data collected from interviewed while providing nursing care to patient, inquiry from parent/caregiver and reviewed patient care documents. The results of the study found that 19 years old female patient and caregiver were lack of knowledge and understanding about the disease, treatment guidelines and self-care. These problems were difficult for patients to understand due to the pathophysiology of chyle leakage and affects various body systems. Nurses can do             accurately assess the patient's health status, prepared the appropriate nursing care plan with the              multidisciplinary team so that patient and her parents can take care themselves continuously to               prevent complications. In this case, focus charting of nurse notes was presented, to record of specific information on important items regarding the patient's current health condition between the multidisciplinary team. As a result, This had been  continuously and increasing quality of patient caring.