Pneumothorax Nursing Care and Management: Study Guide

Pneumothorax is air in the pleural space collapsing the lung. The pressure that should hold the lung inflated is lost, and in tension pneumothorax that trapped air keeps building until it shifts the mediastinum and chokes off venous return. Recognize it fast, maintain airway, breathing, and circulation, and get the lung reinflated by evacuating the pleural air.

What Is Pneumothorax?

Pneumothorax, a collapsed lung, is a collection of air in the spaces around the lungs that puts pressure on the lung so it cannot fully expand. It occurs when the parietal or visceral pleura is breached and the pleural space, normally under negative pressure, is exposed to positive atmospheric pressure. A spontaneous pneumothorax occurs with rupture of a bleb. An open pneumothorax occurs when an opening through the chest wall lets positive atmospheric pressure into the pleural space. Diagnosis is made by chest x-ray film.

Classification

A simple or spontaneous pneumothorax occurs when air enters the pleural space through a breach of the parietal or visceral pleura. A traumatic pneumothorax occurs when air escapes from a laceration in the lung or a wound in the chest wall. A tension pneumothorax occurs when air is drawn into the pleural space from a lacerated lung or through a small opening or wound in the chest wall and cannot escape.

Pathophysiology

Negative pressure maintains lung inflation. When either pleura is breached, air enters the pleural space, and once positive pressure is present the lung or a portion of it collapses.

Causes

Spontaneous pneumothorax may occur in an apparently healthy person without trauma when an air-filled bleb ruptures. Blunt trauma such as rib fractures, invasive thoracic procedures that inadvertently puncture the pleura, and penetrating chest or abdominal trauma such as stab or gunshot wounds all cause traumatic pneumothorax.

Clinical Manifestations

Signs depend on size and cause. Pain is usually sudden and may be pleuritic. The patient may have only minimal respiratory distress with slight chest discomfort and tachypnea, or develop dyspnea from the pain and central cyanosis from severe hypoxemia. In simple and tension pneumothorax, chest expansion is decreased and breath sounds are diminished or absent. The trachea stays midline in simple pneumothorax but shifts away from the affected side in tension pneumothorax.

Assessment and Diagnosis

Thoracic CT is more sensitive than x-ray for detecting thoracic injuries, lung contusion, hemothorax, and pneumothorax, and early CT may influence management. Chest x-ray reveals air or fluid accumulation in the pleural space and may show a shift of mediastinal structures such as the heart. ABGs vary with the degree of compromised lung function, altered breathing mechanics, and the ability to compensate; PaCO2 is occasionally elevated, PaO2 may be normal or decreased, and oxygen saturation is usually decreased. Thoracentesis showing blood or serosanguineous fluid indicates hemothorax, and hemoglobin may be decreased, indicating blood loss.

Medical Management

Management depends on cause and severity. A small chest tube is inserted near the second intercostal space to drain fluid and air; for patients with jeopardized gas exchange, chest tube insertion may be necessary to achieve lung re-expansion. The priority is to maintain airway, breathing, and circulation, and the most important interventions focus on reinflating the lung by evacuating the pleural air. A small, minimally symptomatic primary spontaneous pneumothorax may seal and re-expand on its own.

Maintain a closed chest drainage system. Tape all connections and secure the tube at the insertion site with adhesive bandages. Regulate suction per the chest tube system directions; suction generally does not exceed 20 to 25 cm H2O negative pressure. Monitor the unit for kinks or bubbling, which can indicate an air leak, but never clamp a chest tube without a physician's order, since clamping can cause tension pneumothorax. Autotransfusion takes the patient's own blood drained from the chest, filters it, and transfuses it back into the vascular system. Antibiotics are usually prescribed to combat infection from contamination. A patient with possible tension pneumothorax should immediately receive a high concentration of supplemental oxygen to treat the hypoxemia.

Surgical Management

If more than 1500 ml of blood is aspirated initially by thoracentesis, the rule is to open the chest wall surgically. Thoracotomy opens the chest to remove blood or air trapped in the pleural space.

Nursing Management

Nursing Assessment

Assess tracheal alignment, chest expansion, breath sounds, and chest percussion.

Nursing Diagnosis

Acute pain related to positive pressure in the pleural space. Ineffective breathing pattern related to respiratory distress. Ineffective peripheral tissue perfusion related to severe hypoxemia. Anxiety related to difficulty breathing.

Nursing Care Planning and Goals

Relieve pain, achieve adherence to the prescribed pharmacologic regimen, establish a normal effective respiratory pattern with no cyanosis, increase perfusion, and reduce anxiety to a manageable level.

Nursing Interventions

Instruct the patient to inhale and strain against a closed glottis to reexpand the lung and eject air from the thorax. Plug an open wound by sealing it with gauze impregnated with petrolatum. Use pulse oximetry to monitor oxygen saturation.

Evaluation

Pain is relieved, the patient adheres to the pharmacologic regimen, a normal effective respiratory pattern is established with no cyanosis, perfusion increases, and anxiety drops to a manageable level.

Discharge and Home Care Guidelines

Handle the incision site aseptically to avoid infection. Take prescribed analgesics and antibiotics consistently. Keep followup appointments so the physician can assess the surgical site and respiratory status. Alternate rest and activity to avoid overexhaustion and difficulty breathing.

Documentation Guidelines

Document the client's description and acceptable level of pain, prior medication use, respiratory pattern, breath sounds, and use of accessory muscles, laboratory values, use of respiratory aids or supports, pulses and BP, the nature, extent, and duration of the problem, level of anxiety, and description and awareness of feelings. Record the plan of care, teaching plan, response to interventions and teaching, attainment or progress toward desired outcomes, modifications to the plan of care, and long term needs.