POTENTIAL CONSIDERATIONSfollowing hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities)
•ineffective Airway Clearance—excessive mucus, retained secretions, [pain, fatigue]
•acute Pain—physical—surgical incision, tissue trauma, disruption of intercostal nerves, anxiety
•Self-Care Deficit—fatigue, pain/discomfort, weakness Refer to CP: Cancer for other considerations.
CHAPTER 5RESPIRATORY—PNEUMOTHORAX occurs in the absence of traumatic injury to the chest
or lungs
b.Secondary spontaneous: occurs in the presence of lung dis- ease, primarily emphysema, but can also occur with tuber- culosis (TB), sarcoidosis, cystic fibrosis, malignancy, and pulmonary fibrosis
c.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 main-stem bronchus
d.Traumatic: most common form of pneumothorax and hemothorax, caused by open or closed chest trauma related to blunt or penetrating injuries
IV. Statistics(American Lung Association, June 2005;
Schiffman, 2012)
a.Morbidity: Primary spontaneous pneumothorax affects 9000 persons per year and is more common in tall, thin men between 20 and 40 years of age.
b.Recurrence rate is about 40% for both primary and second- ary spontaneous pneumothorax, occurring in intervals of 1.5 to 2 years.
c.Mortality: Rate is 15% for those with secondary pneumo - thorax associated with underlying lung disease.
Blunt force chest trauma:Closed trauma to the chest may result in laceration of lung tissue or an artery by a rib, causing blood to collect in the pleural space.
Chest tube drainage unit (CDU):Drainage system that is con- nected to a chest tube to remove air or fluids from the chest cavity or pleural space. The device consists of a water seal and collection chambers and a suction-control chamber, or a one-way mechanical valve, depending on the amount of drainage anticipated and the client’s level of mobility.
Crepitation:A dry, crackling sound or sensation on auscultation or palpation of the skin, indicating the presence of subcuta- neous emphysema, or air trapped in the tissues, associated with a pneumothorax.
Empyema:Pus from an infection, such as pneumonia, in the pleural space.
Fremitus:Vibratory sensation or tremors felt through the chest wall during coughing or speaking.
Hemopneumothorax:Both air and blood in the pleural space.
Hemothorax:Collection of blood in the pleural space, which can exert pressure on the lung, causing it to collapse.
G L O S S A R Y
Hypercapnia:Increased level of carbon dioxide in the blood.
Hypoxemia:Decreased level of oxygen in the blood.
Penetrating chest trauma:Chest trauma in which a weapon, such as a knife, bullet, or needle, lacerates the lung.
Pleural effusion:Excessive fluid in the pleural space.
Pleural space:Area between the parietal pleura (membrane lin- ing the chest cavity) and the visceral pleura, which surrounds the lungs. Normally, this potential space holds about 50 mL of lubricating fluid that prevents friction between the pleurae as they move during inhalation and exhalation.
Pneumothorax:Buildup of air in the pleural space, exerting pressure against the lung and causing it to collapse.
Tachypnea:Abnormally rapid respirations.
Tension pneumothorax:Unrelieved accumulation of air in the intrapleural space shifts mediastinum to unaffected side, thus impairing ventilation and compromising cardiac function and venous return.
Thoracentesis:Use of a needle to rapidly remove fluid from the pleural space.
Care Setting
Client is treated in inpatient medical or surgical unit. A small pneumothorax without underlying lung disease may resolve on its own.
Related Concerns
Cardiac surgery: postoperative care, page 98 Chronic obstructive pulmonary disease (COPD) and
asthma, page 118
Psychosocial aspects of care, page 729 Pulmonary tuberculosis (TB), page 170 Ventilatory assistance (mechanical), page 157
Client Assessment Database
D I A G N O S T I C D I V I S I O N M AY R E P O R T
A
CTIVITY/R
EST•Shortness of breath
•Tiredness
•Dyspnea with activity or even at rest
M AY E X H I B I T
Findings vary depending on the amount of air and/or fluid accumulation, rate of accumulation, and underlying lung function
(continues on page 152)
D I A G N O S T I C D I V I S I O N M AY R E P O R T
(continued)C
IRCULATIONE
GOI
NTEGRITY•Anxiety, apprehension
P
AIN/D
ISCOMFORT•Unilateral chest pain, aggravated by breathing, coughing, and movement
•Sudden onset of symptoms while coughing or straining—
spontaneous pneumothorax
•Sharp, stabbing pain aggravated by deep breathing, possibly radiating to neck, shoulders, abdomen—pleural effusion
R
ESPIRATION•History of recent chest surgery or trauma; chronic lung disease, lung inflammation or infection (empyema or effusion); diffuse interstitial disease (sarcoidosis); malignancies (e.g., obstructive tumor)
•Previous spontaneous pneumothorax; spontaneous rupture of emphysematous bulla, subpleural bleb in COPD
•Difficulty breathing, “air hunger”
•Coughing, which may be presenting symptom
S
AFETY•Recent chest trauma, such as fractured ribs, penetrating wound
•Radiation and chemotherapy for malignancy
•Presence of central intravenous (IV) line
T
EACHING/L
EARNING•History of familial risk factors, such as TB, cancer
•Recent intrathoracic surgery or lung biopsy
D
ISCHARGEP
LANC
ONSIDERATIONS•Temporary assistance with self-care, homemaker and mainte- nance tasks
ÁRefer to section at end of plan for postdischarge considerations.
•Tachycardia; irregular rate, dysrhythmias
•S3or S4or gallop heart rhythm—heart failure (HF) secondary to effusion
•Apical pulse reveals point of maximal impulse (PMI) displaced in presence of mediastinal shift with tension pneumothorax
•Homan’s sign—crunching sound correlating with heartbeat, reflecting air in mediastinum
•Blood pressure (BP):Hypertension or hypotension
•Jugular vein distention (JVD), especially with tension pneumothorax
•Restlessness, irritability
•Guarding affected area
•Distraction behaviors
•Facial grimacing
•Respirations: Tachypnea
•Increased work of breathing, use of accessory muscles in chest, neck; intercostal retractions; forced abdominal expiration
•Breath sounds decreased or absent on involved side
•Fremitus decreased on involved site
•Chest percussion: Hyperresonance over air-filled area—
pneumothorax; dullness over fluid-filled area—hemothorax
•Chest observation and palpation:Unequal or paradoxical chest movement (if trauma, flail), reduced thoracic excursion on affected side
•Skin:Pallor, cyanosis, diaphoresis, subcutaneous crepitation
•Mentation:Anxiety, restlessness, confusion, stupor
•Use of positive-pressure mechanical ventilation or positive end-expiratory pressure (PEEP) therapy
M AY E X H I B I T
(continued)Client Assessment Database
(continued)CHAPTER 5RESPIRATORY—PNEUMOTHORAX
Nursing Priorities
1. Promote or maintain lung reexpansion for adequate oxy- genation and ventilation.
2. Minimize or prevent complications.
3. Reduce discomfort and pain.
4. Provide information about disease process, treatment regimen, and prognosis.
Discharge Goals
1. Adequate ventilation and oxygenation maintained.
2. Complications prevented or resolved.
3. Pain absent or controlled.
4. Disease process, prognosis, and therapy needs understood.
5. Plan in place to meet needs after discharge.
T E S T
W H Y I T I S D O N E D
IAGNOSTICS
TUDIES•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):Enhances anatomic views of the chest and locates abnormalities. Early CT may influence therapeutic management.
May show chest wall fractures, injuries to the heart or great ves- sels, and reveal air and fluid accumulation in the pleural space; may show shift of mediastinal structures (heart).
CT is more sensitive than x-ray in detecting thoracic injuries, lung contusion, hemothorax, and pneumothorax.