nursing bulletin notes on pneumothorax

NursingBulletin: Notes on

PNEUMOTHORAX AND MASTERY QUESTIONS

Pleurae fluid disorders: all treated with water seal chamber

Fluid Disorder: Color

Air Pneumothorax: no fluid drainage

Trapped Air Tension Pneumothorax: a nursing and medical emergency

Blood Hemothorax: bloody or brownish color

Fluid between pleural lining (exudates or transudates)

Pleural Effusion: clearer yellowish color

Pus between pleural lining Empyema: yellowish or greenish color

Lymphatic fluid Chylothorax: milky white color

Pneumothorax:

Opening that connect the outside air with intrapleural space; result is that air flows into intrapleural space; this eliminates the pressure gradient between the thoracic cavity and the atmosphere, and the lungs cannot inflate

• Collapse of a lung resulting from disruption of the negative pressure of air in the pleural cavity; may be associated with fractured rib

• Reduces the surface area for gaseous exchange and leads to hypoxia and retention of carbon dioxide (hypercarbia)

• Spontaneous: thought to occur when a weakened area of the lung (bleb) ruptures; air then moves from the lung to the intrapleural space causing collapse; highest incidence is in men 20 to 40 years of age.

• Open: laceration (e.g., a stab wound) through the chest wall into the intrapleural space. Hole in the chest wall, communicates with the lung

• Hemothorax: collection blood within the pleural cavity.

Types of Pneumothorax:

Types of Pneumothorax

• Hydrothorax: accumulation of fluid in the pleural cavity.

• Tension: buildup of pressure as air accumulates within the pleural space; the pressure increase likely to induce a mediastinal shift.

• Closed pneumothorax: air is forced into the pleural space with a continued pressure build up. Hole in lung, chest wall intact

• Shifts mediastinum away from the affected side with results of a compressed heart

• Cardiac and respiratory arrest if not treated

: Mediastinal Shift may occur toward the uninvolved side as a result of increased pressure within the pleural space; this involves

the trachea, esophagus, heart, and great vessels.

Complications of Pnuemothorax

• Low Blood oxygen levels

• Respiratory Failure

• Cardiac Arrest

• Shock

• Subjective: – Chest pain, usually described as sharp and increasing on

exertion– Dyspnea and drowsiness

• Objective:– Rapid, shallow respirations (nonsymmetric)– Breath sounds on the affected side will be diminished or

absent– Chest x-rat examination will reveal extent of the

pneumothorax– Tachycardia– Tachypnea– Hypotension– Decreased chest expansion unilaterally– Cyanosis– Hypotension– Tracheal deviation to the affected side wit tension

pnemothorax

Clinical Findings

Assessment1. Auscultation of lung fields for diminished or absent breath sounds2. Chest percussion for hyperresonance3. Check motion during inhalation for inequality4. Baseline Vital Signs5. Skin for changes in color6. Auscultate breath sounds to observe for signs of pneumothorax when the client is on PEEP (lung tissue that is frail may not withstand increased intrathoracic pressure, and pneumothorax occurs)7. Monitor ABG (Respiratory Acidosis)

Diagnosis: Impaired Gas Exchange

Goal: to relieve the pressure on the lung, allowing it to re-expand, and to prevent recurrences.

Implementations

• Maintain constant supervision until stable• Maintain patency of• chest tubes• Place in high-Fowler’s position• Offer fluids frequently• Monitor vital signs, particularly respirations• Apply dressing over an open chest wound • Oxygen as prescribed• Chest tube placement• Monitor for chest tube system

Indications for CTT

• If fluid, such as blood, or air, gets into the pleural space, the lung can collapse, preventing adequate air exchange. Chest tubes are used to treat conditions that can cause the lung to collapse, such as:

• air leaks from the lung into the chest (pneumothorax)

• bleeding into the chest (hemothorax) • after surgery or trauma in the chest

(pneumothorax or hemothorax) • lung abscesses or pus in the chest (empyema).

Chest Tube Insertion• Chest tubes are inserted to drain blood, fluid, or air and

allow full expansion of the lungs. The tube is placed in the pleural space.

• The area where the tube will be inserted is numbed (local anesthesia). The patient may also be sedated.

• The chest tube is inserted between the ribs into the chest and is connected to a bottle or canister that contains sterile water. Suction is attached to the system to encourage drainage. A stitch (suture) and adhesive tape is used to keep the tube in place.

• The chest tube usually remains in place until the X-rays show that all the blood, fluid, or air has drained from the chest and the lung has fully re-expanded. When the chest tube is no longer needed, it can be easily removed, usually without the need for medications to sedate or numb the patient. Medications may be used to prevent or treat infection (antibiotics).

Types of Chest Tube Drainage

1. Three-chamber system: includes one chamber that serves to collect drainage, one that acts as water-seal, and one that has levels of water to control the amount of suction regardless of the amount of negative pressure applied.

2. Commercially prepared plastic unit designed for closed chest suction: combines the features of the other systems and may or may not be attached to suction (e.g., PleurEvac)

Nursing Care for pt with CTT:• Ensure that the tubing is not kinked; tape all

connections to prevent separation• Do not milk the tube• Maintain the drainage system below the level

of the chest; mark and monitor drainage• Turn the client frequently, making sure the

chest tubes are not compressed.• Observe for fluctuation of fluid in tube; the

level will rise on inhalation and fall on exhalation; if there are no fluctuations, either the lung has expanded fully or the chest tube is clogged

Nursing Care for pt with CTT:

• Place two clamps at your bedside for use if the underwater-seal bottle is broken; clamps are used judiciously and only in emergency situations

• Encourage coughing and deep breathing every 2 hours, splinting the area as needed

• After lung re-expansion is verified by chest x-ray, instruct the client to exhale or strain (Valsalva’s Maneuver) as the tube is withdrawn by the physician; apply a gauze dressing immediately and firmly secure the tape to make an airtight dressing

Complications of CTT

• Complications of tube thoracostomy include death, injury to lung or mediastinum, hemorrhage (usually from intercostal artery injury), neurovascular bundle injury, infection, bronchopleural fistula, and subcutaneous or intraperitoneal tube placement

Pneumothorax Mastery Questions

1. A client with emphysema experiences a sudden episode of shortness of breath. The physician diagnoses a spontaneous pneumothorax. The nurse is aware that the probable cause of the spontaneous pneumothorax is a:a. pleural friction rubb. tracheoesophageal fistulac. rupture of subpleural blebd. puncture wound of the chest wall


2. When a spontaneous pneumothorax is suspected in a client with a history of emphysema, the nurse should call the physician and:

a. administer 60% O2 via Venturi mask

b. Place the client on the unaffected side

c. Give O2 2L per minute via nasal cannula

d. Prepare for IV administration of electrolytes


3. When teaching a client about a spontaneous pneumothorax, the nurse bases the explanation on the understanding that:

a. The heart and great vessels shift into the affected side

b. The other lung will collapse if not treated immediately

c. Inspired air will move from the lung into the pleural space

d. There is a greater negative pressure within the chest cavity


4. Following a spontaneous pneumothorax, the client becomes extremely drowsy and the pulse and respirations increase. The nurse should suspect:

a. hypercapnia

b. hypokalemia

c. an elevated pO2

d.respiratory alkalosis


5. When assessing an individual with a spontaneous pneumothorax, the nurse should expect dyspnea and:

a. hematemesis

b. unilateral chest pain

c. increased chest motion

d. mediastinal shift towards the involved side


6. When a client suffers a complete pneumothorax, there is danger of mediastinal shift. If such a shift occurs, it may lead to:

a. Infection of the subpleural lining

b. Decreased filling of the right heart

c. Rupture of the pericardium or aorta

d. Increased volume of the unaffected lung


7. The physician inserts a chest tube in a client who has been stabbed in the chest and attaches it to a closed drainage system. When caring for the client, the nurse should:

a. Apply a thoracic binder to prevent tension on the tube

b. Observe for fluctuations in the water-seal chamberc. Clamp the tubing to prevent a rapid decline in

pressured. Administer morphine sulfate, because the client will

be agitated


8. Complete lung expansion before the removal of the chest tubes is evaluated by:

a. Return of normal tidal volume

b. Absence of additional drainage

c. Decreased adventitious sounds

d. Comparison of chest radiographs

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nursing bulletin notes on pneumothorax

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