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Pneumothorax Nursing Care Plan: Ineffective Breathing Pattern

December 2011 Nurse Licensure Examination Results
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I. Pathophysiology

Partial or complete collapse of lung due to accumulation of air (pneumothorax), blood (hemothorax), or other fluid (pleural effusion) in the pleural space
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
Complications include hypoxemia, respiratory failure, and cardiac arrest.

II. Classification

Primary spontaneous pneumothorax
Secondary spontaneous pneumothorax
Iatrogenic pneumothorax
Traumatic pneumothorax

III. Etiology

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
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
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
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)

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.
Recurrence rate: Is about 40% for both primary and secondary spontaneous pneumothorax, occurring in intervals of 1.5 to 2 years.
Mortality: Rate is 15% for those with secondary pneumothorax.

Care Setting

Client is treated in inpatient medical or surgical unit.

Nursing Priorities

Promote or maintain lung reexpansion for adequate oxygenation and ventilation.
Minimize or prevent complications.
Reduce discomfort and pain.
Provide information about disease process, treatment regimen, and prognosis.

Discharge Goals

Adequate ventilation and oxygenation maintained.
Complications prevented or resolved.
Pain absent or controlled.
Disease process, prognosis, and therapy needs understood.
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.