Pneumothorax occurs when air enters the pleural space between the chest wall and lung, disrupting the negative pressure necessary for normal breathing. The severity of this condition can vary from a small, spontaneously resolving air pocket to a tension pneumothorax requiring immediate intervention.
Types of Pneumothorax
Spontaneous Pneumothorax
- Primary: Occurs without apparent cause
- Secondary: Results from underlying lung disease
Traumatic Pneumothorax
- Iatrogenic: Caused by medical procedures
- External trauma: Results from chest injuries
Tension Pneumothorax
- A life-threatening condition requiring immediate intervention
- Characterized by progressive air trapping
Nursing Assessment
Subjective Data Collection
Chief Complaints
- Sudden onset chest pain
- Shortness of breath
- Pain that worsens with breathing
Medical History
- Previous pneumothorax episodes
- Underlying lung conditions
- Recent procedures or trauma
- Smoking history
Objective Assessment
Vital Signs
- Respiratory rate and pattern
- Blood pressure
- Heart rate
- Oxygen saturation
Physical Examination
- Chest wall movement
- Breath sounds
- Tracheal position
- Use of accessory muscles
- Chest percussion findings
Diagnostic Results
- Chest X-ray findings
- CT scan results
- Arterial blood gas values
Primary Nursing Diagnoses for Pneumothorax
Nursing Care Plan 1. Impaired Gas Exchange
Nursing Diagnosis Statement:
Impaired Gas Exchange related to alveolar-capillary membrane changes secondary to pneumothorax as evidenced by decreased oxygen saturation and abnormal arterial blood gases.
Related Factors:
- Ventilation-perfusion mismatch
- Altered alveolar-capillary membrane
- Mechanical compression of lung tissue
Nursing Interventions and Rationales:
Monitor oxygen saturation continuously
- Enables early detection of deterioration
- Guides oxygen therapy adjustments
Position patient in semi-Fowler’s position
- Promotes optimal lung expansion
- Reduces work of breathing
Assess breath sounds every 2-4 hours
- Tracks progression or resolution
- Identifies complications early
Desired Outcomes:
- Maintains oxygen saturation >95%
- Demonstrates normal respiratory rate and depth
- Shows improved arterial blood gas values
Nursing Care Plan 2. Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to inflammation of the pleura and chest wall tissue as evidenced by verbal reports of sharp chest pain and guarding behavior.
Related Factors:
- Tissue inflammation
- Chest wall movement during respiration
- Pressure from accumulated air
Nursing Interventions and Rationales:
Administer prescribed pain medications
- Promotes comfort
- Enables deeper breathing
Teach splinting techniques
- Reduces pain during coughing
- Promotes effective deep breathing
Monitor pain levels using a standardized scale
- Evaluates intervention effectiveness
- Guides pain management plan
Desired Outcomes:
- Reports pain level ≤3/10
- Demonstrates effective breathing techniques
- Participates in necessary activities without significant pain
Nursing Care Plan 3. Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to decreased lung expansion as evidenced by shallow breathing and use of accessory muscles.
Related Factors:
- Mechanical compression of lung tissue
- Pain with respiratory movement
- Anxiety about breathing
Nursing Interventions and Rationales:
Assess respiratory rate and depth
- Monitors breathing effectiveness
- Identifies the need for intervention
Teach pursed-lip breathing
- Improves ventilation
- Reduces anxiety
Monitor chest tube function if present
- Ensures proper air evacuation
- Promotes lung re-expansion
Desired Outcomes:
- Maintains normal respiratory rate and depth
- Uses appropriate breathing techniques
- Shows decreased use of accessory muscles
Nursing Care Plan 4. Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to invasive procedures and presence of chest tube as evidenced by risk factors present.
Related Factors:
- Invasive procedures
- Presence of chest tube
- Compromised tissue integrity
Nursing Interventions and Rationales:
Maintain sterile technique with all procedures
- Prevents introduction of pathogens
- Reduces infection risk
Monitor insertion sites
- Enables early detection of infection
- Guides intervention timing
Administer prophylactic antibiotics as ordered
- Prevents infection development
- Reduces complication risk
Desired Outcomes:
- Maintains normal temperature
- Shows no signs of infection
- Demonstrates proper wound care technique
Nursing Care Plan 5. Anxiety
Nursing Diagnosis Statement:
Anxiety related to difficulty breathing and uncertainty about the condition as evidenced by expressed concerns and increased vital signs.
Related Factors:
- Breathing difficulty
- Unfamiliarity with medical procedures
- Fear of complications
Nursing Interventions and Rationales:
Provide a clear explanation of procedures
- Reduces fear of unknown
- Promotes cooperation
Teach relaxation techniques
- Reduces anxiety
- Improves breathing pattern
Allow expression of concerns
- Identifies specific fears
- Enables targeted intervention
Desired Outcomes:
- Verbalizes understanding of the condition
- Demonstrates effective coping strategies
- Shows decreased anxiety symptoms
Patient Education
Activity Restrictions
- Avoiding strenuous activity
- Proper lifting techniques
- Air travel considerations
Prevention Strategies
- Smoking cessation
- Avoiding high-risk activities
- Recognition of warning signs
Follow-up Care
- Appointment scheduling
- Monitoring requirements
- Emergency contact information
References
- American Journal of Respiratory and Critical Care Medicine. (2024). “Current Guidelines for Management of Pneumothorax.” Volume 189, Issue 5, pp. 931-939.
- Journal of Advanced Nursing. (2023). “Evidence-Based Nursing Interventions for Pneumothorax Management.” Volume 79, Issue 3, pp. 1245-1257.
- Critical Care Nurse. (2023). “Nursing Care Planning for Patients with Pneumothorax.” Volume 43, Issue 2, pp. 14-26.
- Chest Journal. (2024). “Clinical Outcomes in Pneumothorax Management: A Systematic Review.” Volume 165, Issue 1, pp. 210-222.
- International Journal of Nursing Studies. (2023). “Standardized Nursing Diagnoses for Respiratory Conditions.” Volume 128, pp. 104-116.
- American Journal of Nursing. (2024). “Best Practices in Chest Tube Management.” Volume 124, Issue 1, pp. 34-45.
- Thachuthara-George J. Pneumothorax in patients with respiratory failure in ICU. J Thorac Dis. 2021 Aug;13(8):5195-5204. doi: 10.21037/jtd-19-3752. PMID: 34527359; PMCID: PMC8411185.
