Possibly evidenced by
Changes in depth or equality of respirations; altered chest excursion
Use of accessory muscles, nasal flaring
Cyanosis, abnormal ABGs
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
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.
Nursing intervention with rationale:
1. Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation.
Rationale: Understanding the cause of lung collapse is necessary for proper chest tube placement and choice of other therapeutic measures.
2. Evaluate respiratory function, noting rapid or shallow respirations, dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs.
Rationale: 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. Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.
Rationale: 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. Auscultate breath sounds.
Rationale: 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. Note chest excursion and position of trachea.
Rationale: Chest excursion is unequal until lung reexpands. Trachea deviates from affected side with tension pneumothorax.
6. Assess fremitus.
Rationale: Voice and tactile fremitus (vibration) is reduced in fluid-filled or consolidated tissue.
7. Assist client with splinting painful area when coughing, or during deep breathing.
Rationale: Supporting chest and abdominal muscles makes coughing more effective and less traumatic.
8. Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as possible.
Rationale: Promotes maximal inspiration; enhances lung expansion and ventilation in unaffected side.
9. Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations.
Rationale: Assists client to deal with the physiological effects of hypoxia, which may be manifested as anxiety or fear.