A collapsed lung happens when air (pneumothorax), blood (hemothorax), or other fluids (pleural effusion) enters the pleural space, the area between the lung and the chest wall. 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.
Nursing Care Plans
Nursing care planning and management for patients with hemothorax or pneumothorax includes management of chest tube drainage, monitoring respiratory status, and providing supportive care.
Below are three (3) nursing care plans for patients with pneumothorax and hemothorax:
Risk for Trauma
Risk factors may include
- Concurrent disease/injury process
- Dependence on external device (chest drainage system)
- Lack of safety education/precautions
- Recognize need for/seek assistance to prevent complications.
- Correct/avoid environmental and physical hazards.
|Explain with patient purpose and function of chest drainage unit, taking note of safety features.||Information on how system works provides reassurance, reducing patient anxiety.|
|Advise patient to avoid lying and pulling on tubing.||Reduces risk of obstructing drainage and inadvertently disconnecting tubing.|
|Identify changes or situations that should be reported to caregivers such as change in sound of bubbling, sudden “air hunger” and chest pain, disconnection of equipment.||Timely intervention may prevent serious complications.|
|Anchor thoracic catheter to chest wall and provide extra length of tubing before turning or moving patient;||Prevents thoracic catheter dislodgment or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing.|
|Secure tubing connection sites;||Prevents tubing disconnection.|
|Pad banding sites with gauze or tape.||Protects skin from irritation and pressure.|
|Secure drainage unit to patient’s bed, stand or cart placed in low-traffic area.||Maintains upright position and reduces risk of accidental tipping and breaking of unit.|
|Implement safe transportation if patient is sent off unit for diagnostic purposes. Before transporting: check water-seal chamber for correct fluid level, presence or absence of bubbling; presence, degree and timing of tidaling. Ascertain whether or not chest tube can be clamped or disconnected from suction source.||Promotes continuation of optimal evacuation of fluid or air during transport. If patient is draining large amounts of chest fluid or air, tube should not be clamped or suction interrupted because of risk of reaccumulation of fluid or air, compromising respiratory status.|
|Observe thoracic insertion site, noting condition of skin, presence and characteristics of drainage from around the catheter. Change or reapply sterile occlusive dressing as needed.||Provides for early recognition and treatment of developing skin or tissue erosion or infection.|
|Observe for signs of respiratory distress if thoracic catheter is disconnected or dislodged.||Pneumothorax may recur or worsen, compromising respiratory function and requiring emergency intervention.|
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
Respiratory Care Plans
Care plans about respiratory system disorders:
- Asthma | 4 Care Plans
- Bronchiolitis | 5 Care Plans
- Chronic Obstructive Pulmonary Disease (COPD) | 5+ Care Plans
- Cystic Fibrosis | 5 Care Plans
- Hemothorax and Pneumothorax | 3 Care Plans
- Influenza (Flu) | 5 Care Plans
- Lung Cancer | 5 Care Plans
- Mechanical Ventilation | 6 Care Plans
- Near-Drowning | 5 Care Plans
- Pleural Effusion | 6 Care Plans
- Pneumonia | 8+ Care Plans
- Pulmonary Embolism | 4 Care Plans
- Pulmonary Tuberculosis | 5 Care Plans
- Tracheostomy | 5 Care Plans
Recommended books and resources:
- Nursing Care Plans: Diagnoses, Interventions, and Outcomes
- Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
- Nursing Diagnoses 2015-17: Definitions and Classification
- Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
- Manual of Psychiatric Nursing Care Planning
- Maternal Newborn Nursing Care Plans
- Delmar's Maternal-Infant Nursing Care Plans, 2nd Edition
- Maternal Newborn Nursing Care Plans