The lung may collapse partially or completely because of air (pneumothorax), blood (hemothorax), or other fluid (pleural effusion) collecting in the pleural/potential space. The intrathoracic pressure changes induced by increased pleural space volumes reduce lung capacity, causing respiratory distress and gas exchange problems and producing tension on mediastinal structures that can impede cardiac and systemic circulation. Pneumothorax may be traumatic (open or closed) or spontaneous.
CARE SETTING
Inpatient medical or surgical unit.
RELATED CONCERNS
Cardiac surgery: postoperative care
Chronic obstructive pulmonary disease (COPD) and asthma
Psychosocial aspects of care
Pulmonary tuberculosis (TB)
Ventilatory assistance (mechanical)
Patient Assessment Database
Findings vary, depending on the amount of air and/or fluid accumulation, rate of accumulation, and underlying lung function.
ACTIVITY/REST
May report: Dyspnea with activity or even at rest
CIRCULATION
May exhibit: Tachycardia; irregular rate/dysrhythmias
S3 or S4/gallop heart rhythm (heart failure secondary to effusion)
Apical pulse reveals point of maximal impulse (PMI) displaced in presence of mediastinal shift (with tension pneumothorax)
Hamman’s sign (crunching sound correlating with heartbeat, reflecting air in mediastinum)
BP: Hypertension/hypotension
JVD
EGO INTEGRITY
May exhibit: Apprehension, irritability
FOOD/FLUID
May exhibit: Recent placement of central venous IV/pressure line (causative factor)
PAIN/DISCOMFORT
May report Unilateral chest pain, aggravated by breathing, coughing, and movement (depending on Sudden onset of symptoms while coughing or straining (spontaneous pneumothorax) the size/area Sharp, stabbing pain aggravated by deep breathing, possibly radiating to neck, shoulders, involved): abdomen (pleural effusion)
May exhibit: Guarding affected area
Distraction behaviors
Facial grimacing
RESPIRATION
May report: Difficulty breathing, “air hunger”
Coughing (may be presenting symptom)
History of recent chest surgery/trauma; chronic lung disease, lung inflammation/infection (empyema/ effusion); diffuse interstitial disease (sarcoidosis); malignancies (e.g., obstructive tumor)
Previous spontaneous pneumothorax; spontaneous rupture of emphysematous bulla, subpleural bleb (COPD)
May exhibit: Respirations: Rate increased/tachypnea
Increased work of breathing, use of accessory muscles in chest, neck; intercostal retractions, forced abdominal expiration
Breath sounds decreased or absent (involved side)
Fremitus decreased (involved site)
Chest percussion: Hyperresonance over air-filled area (pneumothorax); dullness over fluidfilled area (hemothorax)
Chest observation and palpation: Unequal (paradoxic) chest movement (if trauma, flail); reduced thoracic excursion (affected side)
Skin: Pallor, cyanosis, diaphoresis, subcutaneous crepitation (air in tissues on palpation)
Mentation: Anxiety, restlessness, confusion, stupor
Use of positive pressure mechanical ventilation/positive end-expiratory pressure (PEEP) therapy
SAFETY
May report: Recent chest trauma (e.g., fractured ribs, penetrating wound)
Radiation/chemotherapy for malignancy
Presence of central IV line
TEACHING/LEARNING
May report: History of familial risk factors: Tuberculosis, cancer
Recent intrathoracic surgery/lung biopsy
Evidence of failure to improve
Discharge plan DRG projected length of inpatient stay: 6.5 days
considerations: Temporary assistance with self-care, homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Thoracic CT: Studies show that CT is more sensitive than x-ray in detecting thoracic injuries, lung contusion, hemothorax, and pneumothorax. Early CT may influence therapeutic management.
Chest x-ray: Reveals air and/or fluid accumulation in the pleural space; may show shift of mediastinal structures (heart).
ABGs: Variable depending on degree of compromised lung function, altered breathing mechanics, and ability to compensate. PaCO2 occasionally elevated. PaO2 may be normal or decreased; oxygen saturation usually decreased.
Thoracentesis: Presence of blood/serosanguineous fluid indicates hemothorax.
Hb: May be decreased, indicating blood loss.
NURSING PRIORITIES
1. Promote/maintain lung re-expansion for adequate oxygenation/ventilation.
2. Minimize/prevent complications.
3. Reduce discomfort/pain.
4. Provide information about disease process, treatment regimen, and prognosis.
DISCHARGE GOALS
1. Adequate ventilation/oxygenation maintained.
2. Complications prevented/resolved.
3. Pain absent/controlled.
4. Disease process/prognosis and therapy needs understood.
5. Plan in place to meet needs after discharge.
CARE SETTING
Inpatient medical or surgical unit.
RELATED CONCERNS
Cardiac surgery: postoperative care
Chronic obstructive pulmonary disease (COPD) and asthma
Psychosocial aspects of care
Pulmonary tuberculosis (TB)
Ventilatory assistance (mechanical)
Patient Assessment Database
Findings vary, depending on the amount of air and/or fluid accumulation, rate of accumulation, and underlying lung function.
ACTIVITY/REST
May report: Dyspnea with activity or even at rest
CIRCULATION
May exhibit: Tachycardia; irregular rate/dysrhythmias
S3 or S4/gallop heart rhythm (heart failure secondary to effusion)
Apical pulse reveals point of maximal impulse (PMI) displaced in presence of mediastinal shift (with tension pneumothorax)
Hamman’s sign (crunching sound correlating with heartbeat, reflecting air in mediastinum)
BP: Hypertension/hypotension
JVD
EGO INTEGRITY
May exhibit: Apprehension, irritability
FOOD/FLUID
May exhibit: Recent placement of central venous IV/pressure line (causative factor)
PAIN/DISCOMFORT
May report Unilateral chest pain, aggravated by breathing, coughing, and movement (depending on Sudden onset of symptoms while coughing or straining (spontaneous pneumothorax) the size/area Sharp, stabbing pain aggravated by deep breathing, possibly radiating to neck, shoulders, involved): abdomen (pleural effusion)
May exhibit: Guarding affected area
Distraction behaviors
Facial grimacing
RESPIRATION
May report: Difficulty breathing, “air hunger”
Coughing (may be presenting symptom)
History of recent chest surgery/trauma; chronic lung disease, lung inflammation/infection (empyema/ effusion); diffuse interstitial disease (sarcoidosis); malignancies (e.g., obstructive tumor)
Previous spontaneous pneumothorax; spontaneous rupture of emphysematous bulla, subpleural bleb (COPD)
May exhibit: Respirations: Rate increased/tachypnea
Increased work of breathing, use of accessory muscles in chest, neck; intercostal retractions, forced abdominal expiration
Breath sounds decreased or absent (involved side)
Fremitus decreased (involved site)
Chest percussion: Hyperresonance over air-filled area (pneumothorax); dullness over fluidfilled area (hemothorax)
Chest observation and palpation: Unequal (paradoxic) chest movement (if trauma, flail); reduced thoracic excursion (affected side)
Skin: Pallor, cyanosis, diaphoresis, subcutaneous crepitation (air in tissues on palpation)
Mentation: Anxiety, restlessness, confusion, stupor
Use of positive pressure mechanical ventilation/positive end-expiratory pressure (PEEP) therapy
SAFETY
May report: Recent chest trauma (e.g., fractured ribs, penetrating wound)
Radiation/chemotherapy for malignancy
Presence of central IV line
TEACHING/LEARNING
May report: History of familial risk factors: Tuberculosis, cancer
Recent intrathoracic surgery/lung biopsy
Evidence of failure to improve
Discharge plan DRG projected length of inpatient stay: 6.5 days
considerations: Temporary assistance with self-care, homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Thoracic CT: Studies show that CT is more sensitive than x-ray in detecting thoracic injuries, lung contusion, hemothorax, and pneumothorax. Early CT may influence therapeutic management.
Chest x-ray: Reveals air and/or fluid accumulation in the pleural space; may show shift of mediastinal structures (heart).
ABGs: Variable depending on degree of compromised lung function, altered breathing mechanics, and ability to compensate. PaCO2 occasionally elevated. PaO2 may be normal or decreased; oxygen saturation usually decreased.
Thoracentesis: Presence of blood/serosanguineous fluid indicates hemothorax.
Hb: May be decreased, indicating blood loss.
NURSING PRIORITIES
1. Promote/maintain lung re-expansion for adequate oxygenation/ventilation.
2. Minimize/prevent complications.
3. Reduce discomfort/pain.
4. Provide information about disease process, treatment regimen, and prognosis.
DISCHARGE GOALS
1. Adequate ventilation/oxygenation maintained.
2. Complications prevented/resolved.
3. Pain absent/controlled.
4. Disease process/prognosis and therapy needs understood.
5. Plan in place to meet needs after discharge.
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