Pneumothorax occurs when there is an accumulation of air in the pleural space. Pneumothorax increases intrapleural pressure, thus resulting in the collapse of the lung on the affected side. There are three major types of pneumothorax: spontaneous, traumatic, and tension. Spontaneous pneumothorax is not life-threatening. Traumatic pneumothorax can also be classified as either open (when atmospheric air enters the pleural space) or closed (when air enters the pleural space from the lung). Open traumatic pneumothorax constitutes a life-threatening emergency.
The pleural space between the visceral and the parietal pleura exerts negative pressure, which creates a vacuum that keeps the lungs from collapsing. If air accumulates, however, the pressure rises, thus leading to atelectasis (collapsed lung) and ineffective gas exchange. When the air in the pleural space cannot escape, tension pneumothorax occurs. If air accumulation is not stopped, the entire mediastinum shifts toward the unaffected side, thus causing bilateral lung collapse, which is a life-threatening condition. Tension pneumothorax can lead to shock, low blood pressure, and cardiopulmonary arrest.
The cause of a closed or primary spontaneous penumothorax is the rupture of a bleb (vesicle) on the surface of the visceral pleura. Secondary spontaneous pneumothorax can result from chronic obstructive pulmonary disease (COPD), which is related to hyperinflation or air trapping, or from the effects of cancer, which can result in the weakening of lung tissue or erosion into the
pleural space by the tumor. Blunt chest trauma and penetrating chest trauma are the primary causes of traumatic and tension pneumothorax. Other possible causes include therapeutic procedures such as thoracotomy, thoracentesis, and insertion of a central line.
Nursing care plan assessment and physical examination
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). If the patient has been shot, ask the paramedics for ballistic information, including the caliber of the weapon and the range at which the person was shot. If the patient was in a motor vehicle crash, determine the type of vehicle (truck, motorcycle, car), the speed of the vehicle, the victim’s location in the car (driver vs. passenger), and the use, if any, of safety restraints. Determine if the patient has had a recent tetanus immunization.
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.
Inspect the patient with pneumothorax for cyanosis, nasal flaring, asymmetrical chest expansion, dyspnea, tachypnea, and intercostal retractions. Observe whether the patient has a flail chest, a condition in which the patient has paradoxical chest movement with the chest wall moving outward during expiration and inward during inspiration. On 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.
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.
Patients with a pneumothorax may be confused, anxious, or restless. They may be concerned about their pain and dyspnea and could be in a panic state. Determine the patient’s past ability to manage stressors, and discuss with the significant others the most adaptive mechanisms to use. Note that approximately one-half of all traumatic injuries are associated with alcohol and other drugs of abuse.
Nursing care plan primary nursing diagnosis: Impaired gas exchange related to decreased oxygen diffusion capacity.
Nursing care plan intervention and treatment plan
The priority is to maintain airway, breathing, and circulation. The most important interventions focus on reinflating the lung by evacuating the pleural air. Patients with a primary spontaneous pneumothorax that is small with minimal symptoms may have spontaneous sealing and lung reexpansion. For patients with jeopardized gas exchange, chest tube insertion may be necessary to achieve lung re-expansion.
Maintain a closed chest drainage system; be sure to tape all connections, and secure the tube carefully at the insertion site with adhesive bandages. Regulate suction according to the chest tube system directions; generally, suction does not exceed 20 to 25 cm H2O negative pressure. Monitor a chest tube unit for any kinks or bubbling, which could indicate an air leak, but do not clamp a chest tube without a physician’s order because clamping may lead to tension pneumothorax. Stabilize the chest tube so that it does not drag or pull against the patient or against the drainage system. Maintain aseptic technique, changing the chest tube insertion site dressing and monitoring the site for signs and symptoms of infection such as redness, swelling, warmth, and drainage.
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.
Place the patient in a semi-Fowler position to improve lung expansion. Change the patient’s position every 2 hours to prevent infection and allow for lung drainage. For patients with traumatic closed pneumothorax, turn the patient onto the unaffected side to improve the ventilationto- perfusion ratio. Encourage coughing and deep breathing to remove secretions.
For patients with traumatic open pneumothorax, prepare a sterile occlusive dressing and cover the wound. Monitor carefully for a tension pneumothorax (absent breath sounds, tracheal deviation) because the occlusive dressing prevents air from escaping the lungs. Teach alternative pain relief techniques. Explain all procedures in advance to decrease the patient’s anxiety.
Nursing care plan discharge and home health care guidelines
Review all follow-up appointments, which often involve chest x-rays, arterial blood gas analysis, and a physical exam. If the injury was alcohol-related, explore the patient’s drinking pattern. Refer for counseling, if necessary. Teach the patient when to notify the physician of complications (infection, an unhealed wound, and anxiety) and to report any sudden chest pain or difficulty breathing.