Nursing Care Plan Pneumothorax / Hemothorax

PNEUMOTHORAX/HEMOTHORAX

I. Pathophysiology
a. Partial or complete collapse of lung due to accumulation of
air (pneumothorax), blood (hemothorax), or other fluid
(pleural effusion) in the pleural space
b. Intrathoracic pressure changes induced by increased pleural
space volumes and reduced lung capacity, causing respiratory
distress and gas exchange problems and producing 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
III. Etiology
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 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
mainstem 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)
a. Morbidity: Primary spontaneous pneumothorax affects
9,000 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
secondary spontaneous pneumothorax, occurring in
intervals of 1.5 to 2 years.
c. Mortality: Rate is 15% for those with secondary pneumothorax.

Care Setting
Client is treated in inpatient medical or surgical unit.

Nursing Priorities
1. Promote or maintain lung reexpansion for adequate oxygenation
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.

NURSING DIAGNOSIS: ineffective Breathing Pattern

May be related to
Decreased lung expansion due to air or fluid accumulation
Musculoskeletal impairment
Pain and anxiety
Inflammatory process
Possibly evidenced by
Dyspnea, tachypnea
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.

ACTIONS/INTERVENTIONS
Respiratory Monitoring
Independent
Identify etiology or precipitating factors, such as spontaneous
collapse, trauma, malignancy, infection, and complication
of mechanical ventilation.
Evaluate respiratory function, noting rapid or shallow respirations,
dyspnea, reports of “air hunger,” development of
cyanosis, and changes in vital signs.
Monitor for synchronous respiratory pattern when using
mechanical ventilator. Note changes in airway pressures.
Auscultate breath sounds.
Note chest excursion and position of trachea.
Assess fremitus.
Ventilation Assistance
Assist client with splinting painful area when coughing, or
during deep breathing.
Maintain position of comfort, usually with head of bed
elevated. Turn to affected side. Encourage client to sit up as
much as possible.
Maintain a calm attitude, assisting client to “take control” by
using slower, deeper respirations.
Tube Care: Chest
Once chest tube is inserted:
Determine if dry seal chest drain or water seal system is
used.
If water seal system is used:
Check suction control chamber for correct amount of suction,
as determined by water level, wall or table regulator,
at correct setting.
Check fluid level in water-seal chamber; maintain at prescribed
level.
Observe for bubbling in water-seal chamber.
Evaluate for abnormal or continuous water-seal chamber
bubbling.
Determine location of air leak (client or system centered) by
clamping thoracic catheter just distal to exit from chest.
Place petrolatum gauze or other appropriate material around
the insertion as indicated.
Clamp tubing in stepwise fashion downward toward
drainage unit if air leak continues.
Seal drainage tubing connection sites securely with lengthwise
tape or bands according to established policy.
Monitor water-seal chamber “tidaling.” Note whether change
is transient or permanent.
Position drainage system tubing for optimal function; for
example, shorten tubing or coil extra tubing on bed, making
sure tubing is not kinked or hanging below entrance to
drainage container. Drain accumulated fluid as necessary.
Note character and amount of chest tube drainage, whether
tube is warm and full of blood and whether bloody fluid
level in water-seal bottle is rising.
Evaluate need for gentle “milking” of chest tube per protocol.
If thoracic catheter is disconnected or dislodged:
Observe for signs of respiratory distress. If possible, reconnect
thoracic catheter to tubing and suction, using clean
technique. If the catheter is dislodged from the chest,
cover insertion site immediately with petrolatum dressing
and apply firm pressure. Notify physician at once.
After thoracic catheter is removed:
Cover insertion site with sterile occlusive dressing. Observe
for signs or symptoms that may indicate recurrence of
pneumothorax, such as shortness of breath and reports
of pain. Inspect insertion site, noting character of
drainage.
Collaborative
Assist with and prepare for reinflation procedures; for example,
simple aspiration, Heimlich valve, and chest tube placement
with chest tube drainage unit (CDU).
Obtain postplacement x-rays and review serial chest x-rays.
Ventilation Assistance
Monitor and graph serial ABGs and pulse oximetry. Review
vital capacity and tidal volume measurements.
Administer supplemental oxygen via cannula, mask, or
mechanical ventilation, as indicated.
Administer analgesics and sedatives, as indicated.

RATIONALE
Understanding the cause of lung collapse is necessary for
proper chest tube placement and choice of other therapeutic
measures.
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.
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.
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.
Chest excursion is unequal until lung reexpands. Trachea
deviates from affected side with tension pneumothorax.
Voice and tactile fremitus (vibration) is reduced in fluid-filled
or consolidated tissue.
Supporting chest and abdominal muscles makes coughing
more effective and less traumatic.
Promotes maximal inspiration; enhances lung expansion and
ventilation in unaffected side.
Assists client to deal with the physiological effects of hypoxia,
which may be manifested as anxiety or fear.
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 in order 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 (Atrium, 2007b).
Maintains prescribed intrapleural negativity, which promotes
optimum lung expansion and fluid drainage. Note: Dry-seal
setups are also used with an automatic control valve (AVC),
which provides a one-way valve seal similar to that
achieved with the water-seal system.
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 evaluating
whether the chest drainage system is functioning appropriately.
Note: Underfilling the water-seal chamber leaves it
exposed to air, putting client at risk for pneumothorax
or tension pneumothorax. Overfilling, a more common
mistake, prevents air from easily exiting the pleural space,
thus preventing resolution of pneumothorax and possibly
creating a tension pneumothorax.
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.
With suction applied, this indicates a persistent air leak that
may be from a large pneumothorax at the chest insertion
site (client centered) or chest drainage unit (system centered).
If bubbling stops when catheter is clamped at insertion site,
leak is client centered at insertion site or within the client.
Usually corrects insertion site air leak.
Isolates location of a system-centered air leak. Note: As a rule,
clamping for a suspected leak is the only time that chest
tube should be clamped.
Prevents or corrects air leaks at connector sites.
The water-seal chamber serves as an intrapleural manometer
(gauges intrapleural pressure); therefore, fluctuation, or
tidaling, reflects pressure differences between inspiration
and expiration. Tidaling of 2 to 6 cm during inspiration 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.
Improper position, kinking, or accumulation of clots and fluid
in the tubing changes the desired negative pressure and
impedes air or fluid evacuation. Note: If a dependent loop
in the drainage tube cannot be avoided, lifting and draining
it every 15 minutes will maintain adequate drainage in the
presence of a hemothorax.
Useful in evaluating resolution of pneumothorax or development
of hemorrhage requiring prompt intervention. Note:
Some drainage systems are equipped with an autotransfusion
device, which allows for salvage of shed blood.
May be indicated to maintain drainage in the presence of fresh
bleeding, large blood clots, or purulent exudates (empyema).
Caution is necessary to prevent undue discomfort or
injury, such as invagination of tissue into catheter eyelets
and rupture of small blood vessels.
Pneumothorax may recur, requiring prompt intervention to
prevent fatal pulmonary and circulatory impairment.
Early detection of a developing complication, such as recurrence
of pneumothorax or presence of infection, is
essential.
Treatment goals include air evacuation, lung reinflation, and
prevention of recurrence. Although simple aspiration or
Heimlich one-way valve procedures may be useful for small
uncomplicated pneumothorax with little or no drainage,
chest tube placement is the treatment of choice for traumatic
hemopneumothoraces. CDUs include a collection
chamber, a water-seal chamber, and a suction-control regulator.
A dry suction system can also be used. Note: Tension
pneumothorax requires immediate needle depression,
followed by chest tube placement.
Placement of tube(s) is determined by the cause of the problem;
for example, anterior chest near apex of lung, or one
tube at the apex and one at posterior fifth to sixth intercostal
space. X-rays confirm proper placement and monitor
progress of reexpansion of lung.
Assesses status of gas exchange and ventilation and need for
continuation or alterations in therapy.
Aids in reducing work of breathing; promotes relief of respiratory
distress and cyanosis associated with hypoxemia.
Given to manage pleuritic pain and reduce anxiety and tachycardia
associated with impaired respiratory function, especially
when client is on a ventilator.