ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Encourage alternating rest periods with activity and light tasks with heavy tasks. Emphasize avoidance of heavy lifting and isometric or strenuous upper body exercise.
Reinforce physician’s time limitations about lifting.
Generalized weakness and fatigue are usual in the early recovery period but should diminish as respiratory function improves and healing progresses. Rest and sleep enhance coping abilities, reduce ner vous ness (common in this phase), and promote healing. Note: Strenuous use of arms can place undue stress on incision because chest muscles may be weaker than normal for 3 to 6 months following surgery.
Recommend stopping any activity that causes undue fatigue or increased shortness of breath.
Exhaustion aggravates respiratory insufficiency.
Instruct and provide rationale for arm and shoulder exercises.
Have client or SO demonstrate exercises. Encourage following graded increase in number and intensity of routine repetitions.
Simple arm circles and lifting arms over the head or out to the affected side are initiated on the first or second postoperative day to restore normal range of motion (ROM) of shoulder and to prevent ankylosis of the affected shoulder.
Incision Site Care NIC
Encourage inspection of incisions. Review expectations for healing with client.
Healing begins immediately, but complete healing takes time. As healing progresses, incision lines may appear dry with crusty scabs. Under lying tissue may look bruised and feel tense, warm, and lumpy (resolving hematoma).
Instruct client and SO to watch for and report places in incision that do not heal or reopening of healed incision, any drainage (bloody or purulent), and localized area of swelling with redness or increased pain that is hot to touch.
Signs and symptoms indicating failure to heal, development of complications requiring further medical evaluation and intervention.
Suggest wearing soft cotton shirts and loose- fitting clothing;
cover portion of incision with pad, as indicated, and leave incision open to air as much as pos si ble, unless compres- sion garment is used.
Reduces suture line irritation and pressure from clothing.
Leaving incisions open to air promotes healing pro cess and may reduce risk of infection.
Shower in warm water, washing incision gently. Avoid tub baths until approved by physician.
Keeps incision clean and promotes circulation and healing.
Note: “Climbing” out of tub requires use of arms and pectoral muscles, which can put undue stress on incision.
POTENTIAL CONSIDERATIONS following hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities)
•in effec tive 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- General Considerations for additional interventions.
I. Pathophysiology (Daley et al, 2016; Schiffman, 2016) a. Partial or complete collapse of lung due to accumulation of
air (pneumothorax), blood (hemothorax), or other fl uid (pleural effusion) in the pleural space.
b. Intrathoracic pressure changes are induced by increased pleural space volumes and reduced lung capacity, causing respiratory distress and gas exchange prob lems. This produces tension on mediastinal structures that can impede cardiac and systemic circulation.
c. Complications include hypoxemia, respiratory failure, and cardiac arrest.
II. Classification
a. Primary spontaneous pneumothorax b. Secondary spontaneous pneumothorax c. Iatrogenic pneumothorax
d. Traumatic pneumothorax
CHAPTER 3 Respiratory: Pneumothorax/Hemothorax
e. Abnormal amount of fl uid in pleural space resulting from either excess fl uid production or decreased fl uid absorption (pleural effusion): Often associated with an under lying malignancy but may result from several other conditions (e.g., TB, cirrhosis with ascites, chronic pancreatitis, nephrotic syndrome, medication- associated effusion).
V. Patient pre sen ta tion and pos si ble treatment options (Bau- mann et al, 2001; Daley et al, 2016)
a. Client has no symptoms and the pneumothorax fi nding is incidental (usually on an x- ray performed for an unrelated reason). Treatment decisions may be based on the likeli- hood of recurrence.
b. Client is symptomatic but clinically stable: Treatment with small- bore catheter or chest tube placement is
recommended.
c. Client has life- threatening pneumothorax that causes hemodynamic instability. This condition is treated immediately with tube thoracostomy and treatment of under lying conditions.
VI. Statistics (Schiffman, 2016)
a. Morbidity: Primary spontaneous pneumothorax affects approximately 9000 persons per year in the United States and is more common in men between 20 and 40 years of age.
b. Recurrence rate is about 40% for both primary and secondary spontaneous pneumothorax, occurring in intervals of 1.5 to 2 years.
c. Mortality: Rate is 15% for those with secondary pneumo- thorax associated with under lying lung disease.
III. Etiology (Daley et al, 2016)
a. 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.
b. Secondary spontaneous: Occurs in the presence of lung disease (primarily emphysema) but can also occur with tuberculosis (TB), sarcoidosis, cystic fi brosis, malignancy, and pulmonary fi brosis.
c. Iatrogenic: Complication of medical or surgical proce- dures, such as therapeutic thoracentesis, tracheostomy, transthoracic needle aspiration biopsy of pulmonary nodules (most common cause), transbronchial or pleural biopsy, central venous catheter insertion (usually subcla- vian or internal jugular); acute respiratory distress syndrome (ARDS) and positive- pressure mechanical ventilation (tension pneumothorax); inadvertent intubation of right mainstem bronchus.
d. Traumatic: Most common form of pneumothorax and hemothorax, caused by open or closed chest or abdominal trauma related to blunt or penetrating injuries (e.g., chest injury from car crash; gunshot or stab wounds) and high- risk occupation (e.g., diving, fl ying).
IV. Indications for Thoracostomy
a. Pneumothorax: Open or closed; simple or tension b. Bleeding into pleural space (hemothorax)
c. Lymphatic fl uid leaking into pleural space (chylothorax) d. Pus and infected tissue fl uid in pleural space (empyema)
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 connected to a chest tube to remove air and/or fl uids 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 subcutaneous 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.
Hamman sign: Crunching sound heard in chest auscultation, which correlates with heartbeat, refl ecting air in
mediastinum.
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.
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 fl uid in the pleural space.
Pleural space: Area between the parietal pleura (membrane lining the chest cavity) and the visceral pleura, which surrounds the lungs. Normally, this potential space holds about 50 mL of lubricating fl uid 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: Accumulation of air into the intrapleural space that shifts the mediastinum to the unaffected side, thus impairing ventilation and compro- mising cardiac function and venous return.
Thoracentesis: Use of a needle to rapidly remove fl uid from the pleural space.
Thoracostomy: Minimally invasive procedure in which a thin plastic tube is inserted into the pleural space— the area between the chest wall and lungs—to remove excess fl uid or air (may be attached to a suction device).
G L O S S A R Y
RELATED CONCERNS
Cardiac surgery, page 98
Chronic obstructive pulmonary disease (COPD) and asthma, page 132
Psychosocial aspects of care, page 835 Pulmonary tuberculosis (TB), page 204
Respiratory failure/ventilatory assistance (mechanical), page 187
CARE SETTING
This care plan addresses the patient who has chest tube placement and is treated in an inpatient medical or surgical unit.
C L I E N T A S S E S S M E N T D A T A B A S E
Findings vary depending on the amount of air and/or fl uid accumulation, rate of accumulation, and under lying lung function.
D I A G N O S T I C D I V I S I O N
M A Y R E P O R T M A Y E X H I B I T
Activity/Rest
• Shortness of breath • Dyspnea with activity or even at rest
• Fatigue
Circulation
• Tachycardia; irregular rate, dysrhythmias
• S3 or S4 or 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
• Homans’ sign— crunching sound correlating with heartbeat, refl ecting air in mediastinum
• Blood pressure (BP): Hypertension or hypotension. Note:
Hypotension is an inconsistent fi nding, although is a key sign in tension pneumothorax.
• Jugular vein distention (JVD), especially with tension pneumothorax
Ego Integrity
• Anxiety, apprehension • Restlessness, irritability
Pain/Discomfort
• Unilateral chest pain, aggravated by breathing, coughing, and movement; or
• Facial grimacing
• Sudden onset of symptoms while coughing or straining—
spontaneous pneumothorax; or
• Guarding affected area
• Sharp, stabbing chest pain aggravated by deep breathing, possibly radiating to neck, shoulders, abdomen— pleural effusion
• Distraction be hav iors
Respiration
• Diffi culty breathing, “air hunger”
• Coughing, which may be presenting symptom
• Use of positive- pressure mechanical ventilation or positive end- expiratory pressure (PEEP) therapy
• History of recent chest surgery or trauma; chronic lung disease, lung infl ammation, 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
• Respirations:
• Tachypnea. Note: In tension pneumothorax, pulse may exceed 130 bpm.
• Labored breathing, use of accessory muscles in chest, neck;
intercostal retractions; forced abdominal expiration
• Respiratory distress/respiratory arrest
• Chest observation and auscultation:
• Unequal or paradoxical chest movement (if trauma, fl ail), reduced thoracic excursion on affected side
• Breath sounds distant or absent on involved side
• Ipsilateral (same side) crackles, wheezes
(continues on page 172)
CHAPTER 3 Respiratory: Pneumothorax/Hemothorax
T E S T
W H Y I T I S D O N E W H A T I T T E L L S M E
Diagnostic Studies
• Chest x- ray: Evaluates organs or structures within the chest and is the initial study of choice in blunt- force chest trauma.
May show injuries (e.g., to chest wall, ribs, heart, or great vessels) if due to trauma. May reveal air and fl uid accumulation in the pleural space; may show shift of mediastinal structures.
• Thoracic computed tomography (CT): Enhances anatomic views of the chest and locates abnormalities. Early CT may infl uence therapeutic management.
CT is more sensitive than x- ray in detecting thoracic injuries, lung contusion, hemothorax, and pneumothorax.
• Chest ultrasonography: Noninvasive diagnostic exam that produces images, used to assess the organs and structures within the chest, such as the lungs, mediastinum, and pleural space.
Bedside thoracic ultrasound can rapidly and accurately diagnose pneumothorax without the need for chest x- ray. This can greatly reduce the elapsed time between assessment for and treatment of pneumothorax in an emergency setting (Summers et al, 2016). Ultrasound can detect as little as 5 to 50 mL of pleural fl uid and has a 100% sensitivity for effusions greater than 100 mL. May also be used to guide needle insertion for chest tube placement (Daley et al, 2016; Mechem, 2015).
M A Y R E P O R T (continued) M A Y E X H I B I T (continued)
• Chest percussion:
• Hyperresonance over air- fi lled area— pneumothorax; dullness over fl uid- fi lled area— hemothorax
• Fremitus decreased on involved site
• Skin: Pallor, cyanosis, diaphoresis, subcutaneous crepitation
• Mentation: Anxiety, restlessness, confusion, stupor
Safety
• Recent chest trauma, such as fractured ribs, penetrating wound
• Radiation and chemotherapy for malignancy
• Presence of central intravenous (IV) line
Teaching/Learning
• History of familial risk factors, such as TB, cancer
• Recent intrathoracic surgery or lung biopsy
Discharge Plan Considerations
• Temporary assistance with self- care, homemaker and mainte- nance tasks
➧ Refer to section at end of plan for postdischarge considerations.
C L I E N T A S S E S S M E N T D A T A B A S E (contd.)
D I A G N O S T I C S T U D I E S
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 pro cess, treatment reg- imen, and prognosis.
DISCHARGE GOALS
1. Adequate ventilation and oxygenation maintained.
2. Complications prevented or resolved.
3. Pain absent or controlled.
4. Disease pro cess, prognosis, and therapy needs under- stood.
5. Plan in place to meet needs after discharge.
ACTIONS/INTERVENTIONS RATIONALE
Respiratory Monitoring NIC In de pen dent
Identify etiology or precipitating factors, such as trauma, malignancy, infection, complication of mechanical ventilation.
Understanding the cause of lung collapse is necessary for proper chest tube placement and choice of other thera- peutic mea sures.
Evaluate respiratory function, noting rapid or shallow respirations, dyspnea, reports of “air hunger,” develop- ment of cyanosis, and changes in vital signs.
Respiratory distress and changes in vital signs occur because of physiological stress and pain or may indicate develop- ment of shock due to hypoxia or hemorrhage.
Monitor for asynchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.
Difficulty breathing with ventilator or increasing airway pressures suggests worsening of condition and develop- ment of complications, such as a tension pneumothorax.
Auscultate breath sounds. 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 diminished sounds. Regularly scheduled evaluation also helps determine areas of good air exchange and provides a baseline to evaluate resolution of pneumothorax.
Note chest excursion and position of trachea. Chest excursion is unequal until lung reexpands. Trachea deviates from affected side with tension pneumothorax.
Assess fremitus. Voice and tactile fremitus (vibration) is reduced in fluid- filled or consolidated tissue.
Ventilation Assistance NIC
Assist client with splinting painful area when coughing or during deep breathing.
Supporting chest and abdominal muscles makes coughing more effective and less traumatic.
Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as pos si ble.
Promotes maximal inspiration; enhances lung expansion and ventilation in unaffected side.
Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations.
Assists client to deal with the physiological effects of hypoxia, which may be manifested as anxiety or fear.
Tube Care: Chest NIC
Ascertain type of client’s chest drainage system. This care plan concerns the hospitalized client whose treatment plan includes use of a traditional chest drainage system. Mobile drains are indicated for those clients who are ambulatory and do not require a suction for reinflation of lungs.
N U R S I N G D I A G N O S I S :
in effec tive Breathing Pattern
May Be Related To
Musculoskeletal impairment Pain; anxiety
Possibly Evidenced By Dyspnea, tachypnea
Alterations in depth of breathing; altered chest excursion Use of accessory muscles to breathe, nasal flaring Decreased vital capacity
Desired Outcomes/Evaluation Criteria— Client Will Respiratory Status: Ventilation NOC
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.
(continues on page 174)
CHAPTER 3 Respiratory: Pneumothorax/Hemothorax
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Once chest tube is inserted:
Seal drainage tubing connection sites securely with lengthwise tape or bands and pad bands with gauze or tape according to established policy.
Prevents disconnection and air leaks at connector sites.
Padding protects skin from irritation and pressure.
Anchor thoracic catheter to chest wall and provide extra length of tubing before turning or moving client.
Prevents thoracic catheter dislodgment or tubing disconnec- tion and reduces pain and discomfort associated with pulling or jarring of tubing.
Secure drainage unit to client’s bed or on stand or cart placed in low- traffic area.
Maintains upright position and reduces risk of accidental tipping and breaking of unit.
Monitor thoracic insertion site, noting condition of skin and presence and characteristics of drainage from around the catheter. Change and reapply sterile occlusive dressing as needed.
Provides for early recognition and treatment of developing skin or tissue erosion or infection.
Determine if dry- seal chest drain or water- seal system is used.
Some chest drains use a mechanical one- way valve in place of a conventional water seal. The one- way valve allows air to escape from the chest and prevents air from entering the chest. Dry suction- control systems regulate suction pressure mechanically rather than with a column of water.
Some dry suction systems use a screw- type valve that varies the size of the opening to the vacuum source, thereby limiting the amount of negative pressure that can be transmitted to the chest. These valves narrow the opening of the chest drain to adjust the level of negative pressure; therefore, the total amount of air that can flow out of the chest drain is also limited. Thus, this type of dry suction- control mechanism is impractical for clients with significant pleural air leaks. Note: Dry- seal setups are also used with an automatic control valve (ACV), which provides a one- way valve seal like that achieved with the water- seal system.
If water- seal system and suction is used:
Check suction- control chamber for correct amount of suction, as determined by water level, wall, or table regulator, at correct setting.
Maintains prescribed intrapleural negativity, which promotes optimum lung expansion and fluid drainage.
Check fluid level in water- seal chamber; maintain at prescribed level.
Water in a sealed chamber serves as a barrier that prevents atmospheric air from entering the pleural space should the suction source be disconnected and aids in evaluat- ing whether the chest drainage system is functioning appropriately. Note: Underfilling the water- seal chamber leaves it exposed to air, putting client at risk for pneumo- thorax or tension pneumothorax. Overfilling, a more common mistake, prevents air from easily exiting the pleural space, thus preventing resolution of pneumotho- rax and possibly creating a tension pneumothorax.
Observe for bubbling in water- seal chamber. Bubbling during expiration reflects venting of pneumothorax (desired action). Bubbling usually decreases as the lung expands or may occur only during expiration or coughing as the pleural space diminishes. Absence of bubbling may indicate complete lung reexpansion (normal) or represent complications, such as obstruction, in the tube.
Monitor water- seal chamber “tidaling.” Note whether change is transient or permanent.
The water- seal chamber serves as an intrapleural manom- eter (gauges intrapleural pressure); therefore, fluctuation, or tidaling, reflects pressure differences between inspira- tion and expiration. Tidaling of 2 to 6 cm during inspira- tion is normal and may increase briefly during coughing episodes. Continuation of excessive tidal fluctuations may indicate existence of airway obstruction or presence of a large pneumothorax.