Nursing Care Plans Pneumothorax

Definition of Pneumothorax (collapsed lung), Pneumothorax is is defined as the presence of air in the pleural space. Air in the pleural space occurring spontaneously or from trauma. In patients with chest trauma, it is usually the result of a laceration to the lung parenchyma, tracheobronchial tree, or esophagus. The patient’s clinical status depends on the rate of air leakage and size of wound. The amount of air or gas trapped in the intrapleural space determines the degree of lung collapse. 

Classification of Pneumothorax 

• Spontaneous Pneumothorax sudden onset of air in the pleural space with deflation of the affected lung in the absence of trauma. 
• Open Pneumothorax (sucking wound of chest) implies an opening in the chest wall large enough to allow air to pass freely in and out of thoracic cavity with each attempted respiration. 
• Tension Pneumothorax buildup of air under pressure in the pleural space resulting in interference with filling of both the heart and lungs. 
• Traumatic Pneumothorax; Traumatic Pneumothorax may result from insertion of a central venous line, thoracic surgery, or a penetrating chest injury, such as a gunshot or knife wound, or it may follow a transbronchial biopsy. It may also occur during thoracentesis or a closed pleural biopsy. When traumatic Pneumothorax follows a penetrating chest injury, hemothorax (blood in the pleural space) may also occur. 

Other classification of Pneumothorax : Primary spontaneous Pneumothorax Secondary spontaneous Pneumothorax Iatrogenic Pneumothorax Traumatic Pneumothorax 

Clinical Manifestations of Pneumothorax Hyperresonance; 

diminished breath sounds. Reduced mobility of affected half of thorax. Tracheal deviation away from affected side in tension pneumothorax Clinical picture of open or tension pneumothorax is one of air hunger, agitation, hypotension, and cyanosis Mild to moderate dyspnea and chest discomfort may be present with spontaneous pneumothorax 

Pneumothorax Etiology 

Primary spontaneous: rupture of pleural blebs typically occurs in young people without parenchymal lung disease or occurs in the absence of traumatic injury to the chest or lungs Secondary spontaneous: occurs in the presence of lung disease, primarily emphysema, but can also occur with tuberculosis (TB), sarcoidosis, cystic fibrosis, malignancy, and pulmonary fibrosis Iatrogenic: complication of medical or surgical procedures, such as therapeutic thoracentesis, tracheostomy, pleural biopsy, central venous catheter insertion, positive pressure mechanical ventilation, inadvertent intubation of right mainstem bronchus Traumatic: most common form of pneumothorax and hemothorax, caused by open or closed chest trauma related to blunt or penetrating injuries 

Complications 

Acute respiratory failure. Cardiovascular collapse with tension Pneumothorax Hypoxemia 

Pneumothorax Treatment. 

Treatment is conservative for spontaneous pneumothorax in which no signs of increased pleural pressure appear (indicating tension Pneumothorax), lung collapse is less than 30%, and the patient shows no signs of Dyspnea or other indications of physiologic compromise. Such treatment consists of bed rest, careful monitoring of blood pressure, pulse rate, and respirations, oxygen administration, and needle aspiration. If more than 30% of the lung is collapsed, treatment to reexpand the lung includes placing a thoracostomy tube in the second or third intercostal space in the midclavicular line, connected to an underwater seal or low-pressure suction. Oxygen therapy and mechanical ventilation are prescribed as needed. Surgical interventions include removing the penetrating object, exploratory thoracotomy if necessary, thoracentesis, and thoracotomy for patients with two or more episodes of spontaneous pneumothorax or patients with pneumothorax that does not resolve within 1 week. 

Spontaneous Pneumothorax 

Treatment is generally nonoperative if Pneumothorax is not too extensive; Observe and allow for spontaneous resolution for less than 50% pneumothorax in otherwise healthy person, Needle aspiration or chest tube drainage may be necessary to achieve reexpansion of collapsed lung if greater than 30% pneumothorax. Surgical intervention by pleurodesis or thoracotomy with resection of apical blebs is advised for patients with recurrent spontaneous pneumothorax. 

Tension Pneumothorax Immediate decompression to prevent cardiovascular collapse by thoracentesis or chest tube insertion to let air escape. Chest tube drainage with underwater-seal suction to allow for full lung expansion and healing 

Open Pneumothorax

Close the chest wound immediately to restore adequate ventilation and respiration. Patient is instructed to inhale and exhale gently against a closed glottis (Valsalva maneuver) as a pressure dressing (petroleum gauze secured with elastic adhesive) is applied. This maneuver helps to expand collapsed lung. Chest tube is inserted and water-seal drainage set up to permit evacuation of fluid/air and produce reexpansion of the lung. Surgical intervention may be necessary to repair trauma. Recurring spontaneous pneumothorax treated by instilling a sclerosing agent through a thoracostomy tube or during thoracostomy. Thoracotomy and pleurectomy are other procedures that prevent recurrence by causing the lung to adhere to the parietal pleura. Traumatic and tension pneumothoraces require chest tube drainage. Traumatic Pneumothorax may also require surgical repair. 

Nursing Assessment 

Patient History, Obtain history for chronic respiratory disease, trauma, and onset of symptoms. The patient history reveals sudden, sharp, pleuritic pain. The patient may report that chest movement, breathing, and coughing exacerbate the pain. He may also report shortness of breath. Ask about chest pain; determine its onset, intensity, and location. Ask if the patient has shortness of breath or difficulty in breathing or fatigue. Elicit a history of COPD or emphysema or if the patient has had a thoracotomy, thoracentesis, or insertion of a central line. Ask if the patient smokes cigarettes For patients who have experienced chest trauma, establish a history of the mechanism of injury by including a detailed report from the prehospital professionals, witnesses, or significant others. Specify the type of trauma (blunt or penetrating). Physical Examination The severity of the symptoms depends on the extent of any underlying disease and the amount of air in the pleural space. Examine the patient’s chest for a visible wound that may have been caused by a penetrating object. Patients with an open Pneumothorax also exhibit a sucking sound on inspiration. Inspection typically reveals asymmetrical chest wall movement with overexpansion and rigidity on the affected side. The patient may appear cyanotic. In tension pneumothorax, he may have distended neck veins and pallor, and he may exhibit anxiety. Observe whether the patient has a flail chest. Examine the thorax area, including the anterior chest, posterior chest, and axillae, for contusions, abrasions, hematomas, and penetrating wounds. Note that even small penetrating wounds can be life-threatening if vital structures are perforated. Observe the patient carefully for pallor. Take the patient’s blood pressure and pulse rate, noting the early signs of shock or massive bleeding, such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill. Continue to monitor the vital signs frequently during periods of instability to determine changes in the condition or the development of complications. Palpation, note any tracheal deviation toward the unaffected side, subcutaneous emphysema (also known as crepitus; a dry, crackling sound caused by air trapped in the subcutaneous tissues), or decreased to absent tactile fremitus over the affected area. Percussion may elicit a hyperresonant or tympanitic sound. Auscultation reveals decreased or absent breath sounds over the affected area and no adventitious sounds other than a possible pleural rub. Auscultate chest for diminished breath sounds and percuss for hyperresonance. Percussion may reveals hyperresonance on the affected side 

Diagnostic Test For Pneumothorax 

Blood Tests Arterial blood gases (ABGs): Measures oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia. Hemoglobin/hematocrit (Hgb/Hct): Assesses relationship of red blood cells (RBCs) to fluid volume or viscosity. Other Diagnostic Studies Chest x-ray: Evaluates organs or structures within the chest and is the initial study of choice in blunt force chest trauma. Thoracic computed tomography (CT): Enhance anatomic views of the chest and locates abnormalities. Early CT may influence therapeutic management. Thoracic ultrasound: Assists in determining abnormalities in the chest. Thoracentesis: Performed to relieve the intrathoracic pressure due to accumulation of fluid in the pleural space. 

Nursing diagnosis Pneumothorax 

Common Nursing Diagnosis That Could Be Found In Patient with Pneumothorax: 

Ineffective Breathing Pattern Risk for Trauma/Suffocation Deficient Knowledge [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs Acute pain Anxiety Fear Impaired gas exchange related to decreased oxygen diffusion capacity Ineffective coping Ineffective tissue perfusion: Cardiopulmonary Risk for infection 

Nursing Interventions Nursing Diagnosis Ineffective Breathing Pattern 

Respiratory Monitoring 

Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation. Evaluate respiratory function, noting rapid or shallow respirations, Dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs. Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures. Auscultate breath sounds. Note chest excursion and position of trachea. Assess fremitus. 

Ventilation Assistance 

Assist client with splinting painful area when coughing, or during deep breathing. Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as possible. Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations. 

Tube Care: Chest

If thoracic catheter is disconnected or dislodged: Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing and suction, using clean technique. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify physician at once. After thoracic catheter is removed: Cover insertion site with sterile occlusive dressing. Observe for signs or symptoms that may indicate recurrence of pneumothorax, such as shortness of breath and reports of pain. Inspect insertion site, noting character of drainage. 

Ventilation Assistance 

Monitor and graph serial ABGs and pulse oximetry. Review vital capacity and tidal volume measurements. Administer supplemental oxygen via cannula, mask, or mechanical ventilation, as indicated. Administer analgesics and sedatives, as indicated. 

Complete Sample Nursing Care Plans for Pneumothorax

Nursing Diagnosis	Intervention	Rational	Evaluation (Expected Out Come)
Ineffective Breathing Pattern related to : Decreased lung expansion due to air or fluid accumulation Musculoskeletal impairment Pain and anxiety Inflammatory process	Respiratory Monitoring        1.      Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation.       2.      Evaluate respiratory function, noting rapid or shallow respirations, dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs.        3.      Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.       4.      Auscultate breath sounds.       5.      Note chest excursion and position of trachea.       6.      Assess fremitus. Ventilation Assistance 1.     Assist client with splinting painful area when coughing, or during deep breathing. 2.     Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as possible. 3.     Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations. Tube Care: Chest 1.    If thoracic catheter is disconnected or dislodged: Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing and suction, using clean technique. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify physician at once. 2.    After thoracic catheter is removed: Cover insertion site with sterile occlusive dressing. Observe for signs or symptoms that may indicate recurrence of pneumothorax, such as shortness of breath and reports of pain. Inspect insertion site, noting character of drainage. Ventilation Assistance 1.    Monitor and graph serial ABGs and pulse oximetry. Review vital capacity and tidal volume measurements.  2.    Administer supplemental oxygen via cannula, mask, or  mechanical ventilation, as indicated. 3.    Administer analgesics and sedatives, as indicated.	1.        Understanding the cause of lung collapse is necessary for proper chest tube placement and choice of other therapeutic measures.  2.        Respiratory distress and changes in vital signs occur because of physiological stress and pain or may indicate development of shock due to hypoxia or hemorrhage. 3.        Difficulty breathing with ventilator or increasing airway pressures suggests worsening of condition and development of complications, such as spontaneous rupture of a bleb creating a new pneumothorax. 4.        Breath sounds may be diminished or absent in a lobe, lung segment, or entire lung field (unilateral). Atelectatic area will have no breath sounds, and partially collapsed areas have decreased sounds. Regularly scheduled evaluation also helps determine areas of good air exchange and provides a baseline to evaluate resolution of  pneumothorax. 5.        Chest excursion is unequal until lung reexpands. Trachea deviates from affected side with tension pneumothorax. 6.        Voice and tactile fremitus (vibration) is reduced in fluid-filled or consolidated tissue.  1.        Supporting chest and abdominal muscles makes coughing more effective and less traumatic. 2.        Promotes maximal inspiration; enhances lung expansion and ventilation in unaffected side. 3.        Assists client to deal with the physiological effects of hypoxia, which may be manifested as anxiety or fear.    1.         Pneumothorax may recur, requiring prompt intervention to prevent fatal pulmonary and circulatory impairment.    2.        Early detection of a developing complication, such as recurrence of pneumothorax or presence of infection, is essential.         1.      Assesses status of gas exchange and ventilation and need for continuation or alterations in therapy.         2.      Aids in reducing work of breathing; promotes relief of respiratory distress and cyanosis associated with hypoxemia.     3.      Given to manage pleuritic pain and reduce anxiety and tachycardia associated with impaired respiratory function, especially when client is on a ventilator.	Establish a normal and effective respiratory pattern with ABGs within client’s normal range. Be free of cyanosis and other signs or symptoms of hypoxia.
Risk for Trauma/Suffocation	Teaching: Procedure/Treatment 1.    Review with client purpose and function of CDU, taking note of safety features. 2.    Instruct client to refrain from lying or pulling on tubing. 3.     Identify changes and situations that should be reported to caregivers, such as change in sound of bubbling, sudden “air hunger” and chest pain, and disconnection of equipment. Tube Care: Chest 1.    Anchor thoracic catheter to chest wall and provide extra length of tubing before turning or moving client. 2.    Secure tubing connection sites. Pad banding sites with gauze or tape. 3.    Secure drainage unit to client’s bed or on stand or cart placed in low-traffic area. 4.    Provide safe transportation if client is sent off unit for diagnostic purposes. Before transporting, check water-seal chamber for correct fluid level; presence or absence of bubbling; and presence, degree, and timing of tidaling. Ascertain whether chest tube can be clamped or disconnected from suction source. 5.    Monitor thoracic insertion site, noting condition of skin and presence and characteristics of drainage from around the catheter. 6.    Change and reapply sterile occlusive dressing as needed. 7.    Observe for signs of respiratory distress if thoracic catheter is disconnected or dislodged.	1.      Information on how system works provides reassurance, reducing client anxiety. 2.        Reduces risk of obstructing drainage or inadvertently disconnecting tubing. 3.        Timely intervention may prevent serious complications. 1.        Prevents thoracic catheter dislodgment or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing. 2.        Prevents tubing disconnection. 3.        Protects skin from irritation and pressure. 4.        Maintains upright position and reduces risk of accidental tipping and breaking of unit. 5.        Promotes continuation of optimal evacuation of fluid or air during transport. If client is draining large amounts of chest fluid or air, tube should not be clamped or suction interrupted because of risk of accumulating fluid or air, compromising respiratory status. 6.        Provides for early recognition and treatment of developing skin or tissue erosion or infection. 7.        Pneumothorax may recur or worsen, compromising respiratory function and requiring emergency intervention.	Correct and avoid environmental and physical hazards.
Deficient Knowledge [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs related to Lack of exposure to information	Teaching: Disease Process 1.    Review pathology of individual problem. 2.    Identify likelihood for recurrence or long-term complications. 3.    Review signs and symptoms requiring immediate medical evaluation, for example, sudden chest pain, dyspnea, air hunger, and progressive respiratory distress.  4.    Review significance of good health practices, such as adequate nutrition, rest, and exercise. 5.    Emphasize need for smoking cessation when indicated.	1.      Information reduces fear of unknown. Provides knowledge base for understanding underlying dynamics of condition and significance of therapeutic interventions.       2.      Certain underlying lung diseases, such as severe COPD and malignancies, may increase incidence of recurrence. In otherwise healthy clients who suffered a spontaneous pneumothorax, incidence of recurrence is 10% to 50%.Those who have a second spontaneous episode are at high risk for a third incident (60%). 3.        Recurrence of pneumothorax and hemothorax requires medical intervention to prevent and reduce potential complications. 4.        Maintenance of general well-being promotes healing and may prevent or limit recurrences. 5.        Prevents recurrence of pneumothorax or respiratory complications, such as fibrotic changes.	Verbalize understanding of cause of problem (when known). Identify signs or symptoms requiring medical follow-up. Follow therapeutic regimen and demonstrate lifestyle changes, if necessary, to prevent recurrence.

Patient teaching Discharge and home healthcare guidance for patient with Pneumothorax;

Review all follow-up appointments, which often involve chest x-rays, arterial blood gas analysis, and a physical exam. Refer for counseling, if necessary. Teach the patient when to notify the physician of complications and to report any sudden chest pain or difficulty breathing 

• Reassure the patient. Explain what Pneumothorax is, what causes it, and all diagnostic tests and procedures. 
• If the patient is having surgery or chest tubes inserted, explain why he needs these procedures. Reassure him that the chest tubes are inserted to make him more comfortable. 
• Encourage the patient to perform deep-breathing exercises every hour when awake. 
• Discuss the potential for recurrent spontaneous Pneumothorax, and review its signs and symptoms. Emphasize the need for immediate medical intervention if these should occur. 
• Instruct patient to continue use of the incentive spirometer at home. 
• For patients with spontaneous Pneumothorax, there is an increased risk for repeat occurrence; therefore, encourage these patients to report sudden Dyspnea immediately.