Pneumothorax Nursing Care Plans Diagnosis and Interventions
Pneumothorax NCLEX Review and Nursing Care Plans
A pneumothorax, also known as having a collapsed lung, is one of the most commonly occurring pulmonary disorders that primarily affect lung recoil and, therefore, ventilation.
Pneumothorax is typically characterized by the commonly seen signs and symptoms of a respiratory disorder such as difficulty of breathing and chest pain, and depending on the severity of the condition, a pneumothorax can be potentially fatal enough to be considered a medical emergency.
A patient’s pneumothorax can be classified into different types depending on its cause and pathophysiology and different risk factors depending on the type of pneumothorax, although all types are generally diagnosed and treated the same way.
Signs and Symptoms of Pneumothorax
The lungs are able to function normally due to the negative pressure relative to the outside air pressure that the closed chest cavity maintains. This difference in pressure is what enables the lungs to retain their elasticity in order to recoil and allow air to escape upon exhalation.
A pneumothorax occurs when atmospheric air is somehow able to enter through a breach and accumulate into the pleural space, resulting in a rise in intrathoracic pressure and reducing pulmonary vital capacity.
The breach can open the chest wall, pulmonary airway or the alveoli to the pleural cavity, and the difference in pressure between the two spaces at this point will cause the air in the environment or the alveoli to fill the pleural space in an effort to equalize the pressure difference.
Causes of this breach in the pleural cavity can vary, but the common causes are usually the following: a rupture of a pleural bleb, traumatic injury to the pleural wall or the structures supporting thoracic cavity, invasive procedures where the thoracic cavity is accidentally punctured.
Signs and symptoms of pneumothorax are generally the same throughout the different types of the condition, although manifestation and severity may differ depending on the pneumothorax’s cause and size:
- Chest pain described as sudden and affecting the thoracic area
- Shortness/difficulty of breathing. The severity of the difficulty of breathing is usually correlational to the pneumothorax’s size
- Signs of hypoxemia, such as central cyanosis
- Decreased or uneven expansion of the chest wall
- Diminished or absent breath sounds
- Tracheal deviation, or the misalignment of the trachea from its central position in the neck area. In cases of severe (tension) pneumothorax, the trachea may shift away from where the chest cavity breach is located.
Types of Pneumothorax
A. Types of Pneumothorax based on the causative factor
- Non-traumatic Pneumothorax. Also known as spontaneous pneumothorax, it is a type where there is no visible injury that can be attributed to the pressure imbalance in the pleural cavity leading to pulmonary collapse.
- Primary, spontaneous pneumothorax. This is a type of pneumothorax wherein the cause is not any visible injury or underlying disease, but instead a sudden rupturing of subpleural, apical blebs, which are thinly walled sacs of air usually found in the apex part of the lungs. The ruptured blebs become the breach through which air seeps into the pulmonary cavity.
- Secondary spontaneous pneumothorax. This pneumothorax is not caused by an injury, but can be connected to an underlying disease such as chronic obstructive pulmonary disease (COPD), tuberculosis or cystic fibrosis.
- Traumatic Pneumothorax. This is a type of pneumothorax that is caused by any type of injury, such as blunt trauma from a heavy blow to the chest, or penetrating chest injuries such as a stab or bullet wound.
- Tension Pneumothorax. This is a type of pneumothorax that is considered a life-threatening medical emergency, manifested by jugular vein distention, tracheal deviation, and hemodynamic instability due to a decrease in venous return and cardiac output.
- Iatrogenic Pneumothorax. This is a type of pneumothorax wherein the chest wall breach occurred as a result of an injury from an invasive diagnostic procedure or therapy such as thoracocentesis or lung biopsy; or more commonly, a mechanical ventilator related injury.
B. Types of Pneumothorax according to pathophysiology
- Open pneumothorax. This is a type of pneumothorax wherein the atmospheric air is able to enter and exit the pulmonary cavity freely, as in with an open, penetrating chest injury.
- Closed pneumothorax. This is a type of pneumothorax wherein air, upon entering, is not able to exit the pulmonary cavity during exhalation. This can occur if the original point of entry for the atmospheric air is closed, and there is no other way for the air to exit.
Causes of Pneumothorax
There are several possible causes for a pneumothorax, which will be one of the main basis of classifying the type of pneumothorax the patient has:
- A ruptured bleb, which is attributed to the development of primary spontaneous pneumothorax
- Traumatic injury, whether blunt or penetrating (stabbing or puncturing) to the chest or abdomen, the cause of traumatic pneumothorax
- Accidental puncturing while undergoing diagnostic or therapeutic procedures, which is the cause of iatrogenic pneumothorax
- Underlying diseases, which is the cause for secondary spontaneous pneumothorax
Risk Factors to Pneumothorax
There are different factors that can predispose a patient to pneumothorax. Again, some risk factors are more predisposed to a specific type of pneumothorax:
- Male gender, predominantly those ranging from 10-30 years old
- Presence of pulmonary diseases such as COPD, chronic asthma, tuberculosis or pneumonia
- Smoking history. The more a patient smokes, the higher their risk for pneumothorax becomes.
- Congenital bleb formation
- Tall patients, wherein their height can cause pressure differences in the lung apex that can cause blebs to possibly rupture
- Genetic predisposition
Diagnosis of Pneumothorax
- Chest x-ray. The primary method of diagnosing pneumothorax. A chest xray can reveal accumulation of air or fluid in the pleural space as well as show any deviation or misalignment of chest structures, most notably the thorax.
- CT Scan. While chest x-ray is usually sufficient enough for diagnosis in most cases, a CT Scan of the thoracic cavity may be ordered for better visualization. A CT scan is more sensitive than an X-ray, and can better identify chest injuries and other accompanying chest injuries such as lung contusion. It is also useful in identifying the cause of a spontaneous pneumothorax.
- Arterial Blood Gas (ABG). This test is used to determine oxygen, carbon dioxide and acid-base imbalances in the body, which can be variable depending on the severity of the patient’s pneumothorax, their current breathing mechanics, and the body’s ability to use compensatory mechanisms in the presence of potential respiratory imbalances. Most affected values are PaO2 and PaCO2.
Treatment for Pneumothorax
Therapeutic interventions for pneumothorax will vary depending on the severity of the lung collapse and the resulting symptoms:
Catheter or chest tube treatment. This involves placing a catheter or chest tube as the primary treatment for pneumothorax and other types of collapsed lung.
- A catheter or tube is inserted at an area adjacent to the second intercostal space, which is where the air will escape. This will help the lungs re-expand and improve ventilation and gas exchange.
Treatment involving a chest tube can be further subdivided into two types:
- Simple aspiration: the method of inserting the catheter to aspirate the trapped air in the pleural cavity. The catheter can be removed immediately after aspiration, or can be maintained while observing the patient to ensure complete evacuation of atmospheric air. Success rates of this treatment is higher in primary spontaneous pneumothorax.
- Note that, if a chest catheter that will remain inserted in the patient’s thoracic cavity, it will be considered a chest tube despite its relatively small size.
- Chest tube placement: the use of chest tube drainage is recommended for patients with large pneumothorax or if the pneumothorax is not treatable by simple aspiration, and is recommended for in-patient basis treatment in most cases. Although not primarily recommended for use in pneumothorax patients, chest tube suction systems may be used in conjunction with tube placement if in case lung re-expansion is not attained by the tube placement alone. Chest tubes are intended to stay in place until there is an established lung re-expansion and confirmed absence of any air leaks based on diagnostic test findings.
- Oxygen therapy. Especially for patients with pneumothorax, high flow oxygen is recommended and should be given for patients with symptoms of hypoxia. Care should be taken if using high flow oxygen on patients with affected underlying conditions such as COPD, who will be at risk for hypercarbia.
- Medications. Drugs may be prescribed to manage accompanying symptoms, prevent infection or manage air leaks.
- Surgery. Although rare, pneumothorax patients with confirmed persistent air leaks may have to undergo surgery to stop the leaks and prevent recurrence of the pneumothorax.
Prevention of Pneumothorax
There is no definite way to prevent development of pneumothorax, and in some cases, it may even be unavoidable. However, there are certain ways that can lessen the risk of having the condition:
- Avoid activities that can increase risk for chest injuries such as contact sports, or wear protective equipment to possibly lessen impact of blunt force on the thoracic area.
- Avoid smoking, or if currently a smoker, join a smoking cessation program.
- Promptly treat any pulmonary infections that can predispose the patient to pneumothorax, such as pneumonia or tuberculosis.
- Having certain conditions, such as COPD or having a family history of primary spontaneous pneumothorax, may mean that developing pneumothorax is unavoidable. Advise the patient to monitor their symptoms and to notify their healthcare provider in case of difficulty of or pain during breathing.
Nursing Diagnosis for Pneumothorax
Nursing Care Plan for Pneumothorax 1
Nursing Diagnosis: Ineffective Breathing Pattern related to decreased lung expansion, muscular or skeletal impairment, inflammation and/or pain secondary to pneumothorax, as possibly evidenced by difficulty of breathing, irregular or abnormal respiratory rate, or use of accessory muscles for breathing.
Desired Outcome: The patient will be able to establish and maintain an efficient breathing pattern within normal limits, maintain oxygenation levels (i.e. oxygen saturation, ABG) within normal limits, and avoid presenting signs and symptoms of hypoxia.
|Pneumothorax Nursing Interventions||Rationale|
|Establish a baseline database for the patient’s vital signs and respiratory status. Determine the cause and the precipitating factors of the patient’s ineffective breathing pattern.||Since there are several types and underlying causes for pneumothorax , understanding the pathophysiology of the disease can help guide the nurse’s creation of care plans and implementation of proper interventions.|
|Assess for the quality of the patient’s respiratory function, taking note of abnormal breathing patterns such as heavy respirations, gasping, difficulty of breathing, and signs of hypoxia such as cyanosis or finger clubbing.||A patient at risk for or currently exhibiting ineffective breathing patterns is at risk for respiratory distress. In addition, further, unwanted changes in the patient’s vital signs may be an indication of increased stress, pain, or a patient progressing to shock due to hypoxia.|
|Assist the patient in a comfortable position, with the head of bed typically elevated. Advise the patient to turn to the affected side as tolerated, and to change positions regularly.||Positioning the patient with their head of bed elevated will help promote optimal lung inspiration and improve expansion. Turning to the affected side promotes adequate ventilation at the unaffected side as well.|
|If the patient is with a chest tube, ensure that: the chest tube therapy system is intact and functional, there is an adequate amount of suction in the suction chamber, fluid in the water seal chamber is maintained at prescribed level, and the presence of bubbling in the water seal chamber is within normal limits.||The chest tube drainage is inserted to ensure that air in the pleural cavity can be evacuated while preventing further accumulation of atmospheric air into said cavity. Gentle bubbling is indicative of the chest tube system working as intended. Absence of bubbling, excessive bubbling, an inadequately filled water seal chamber or breaks in the system should be reported promptly, as they are indicative of either a large pneumothorax or an ineffective continuous chest tube treatment.|
|Be ready to administer supplemental oxygen as indicated.||In the event of hypoxia or respiratory distress, having readily available oxygen can help relieve distress and promote normalization of oxygen levels.|
Nursing Care Plan for Pneumothorax 2
Nursing Diagnosis: Acute Pain related to muscle or bone injury or lung tissue damage secondary to pneumothorax as evidenced by grunting or exertion while breathing or changing position, possible difficulty of breathing or ineffective breathing pattern, facial grimace, complaints of discomfort, and other symptoms of pain.
Desired Outcome: The patient will be able to verbalize a reduction of their pain or that their pain is under control, be able to follow and maintain an effective pain management plan, display improved vital signs and lesser physiologic manifestations attributable to pain, and patient’s breathing pattern is within normal limits and expected quality.
|Pneumothorax Nursing Interventions||Rationale|
|Establish the patient’s baseline database regarding pain. Note the quality, intensity and any precipitating factors that may trigger or worsen the pain.||Identifying the patient’s type of pain and/or what causes the patient pain or discomfort can help the nurse develop an appropriate pain management plan in collaboration with the other members of the healthcare team.|
|Assist the patient in changing positions or splinting the chest when coughing or breathing.||Ensure that the patient is in a comfortable position at all times to avoid turning posture into an aggravating factor to the pain. In case that the patient’s pain is negatively affecting their breathing, provide support to relieve the pain and promote maintenance of normal breathing function.|
|Provide diversionary activities and non-pharmacologic methods of pain management such as engaging in diversionary activities, meditation and guided imagery, and other relaxation techniques.|
|Provide pharmacologic pain management as prescribed. Preferably, provide these medications before the patient engages in any physically demanding activity.||Since some forms of pneumothorax are secondary to conditions that are known to be painful (e.g. rib fractures), the patients may be prescribed pain medication as needed to help relieve discomfort. Providing pain medication in preparation for certain physically demanding therapeutic interventions can help prepare the patient for the procedure and prevent pain from developing or worsening during these activities.|
|Evaluate the effectiveness of any pain management modality used, and modify the care plan as needed.||Evaluating the patient’s response to the pain management care modalities is a good indication of the treatment plan’s effectiveness, and is a good basis for changing the plan to make it more effective and appropriate for the patient.|
Nursing Care Plan for Pneumothorax 3
Nursing Diagnosis: Knowledge Deficit/ Deficient Knowledge related to the lack of educational resources or learning opportunities; cognitive limitations, or misinformation regarding their current disease secondary to pneumothorax, as evidenced by lack of or inadequate understanding regarding their condition, confusion regarding prescribed treatments, and poor compliance to the care plan.
Desired Outcome: The patient will be able to verbalize and demonstrate understanding of their disease condition, possible cause/s, risk factors and ways to prevent a recurrence or manage symptoms; demonstrate understanding behind the necessity of the current care plan’s interventions, and be able to comply with the care plan ordered.
|Pneumothorax Nursing Interventions||Rationale|
|Assess the patient’s pneumothorax type, its most probable cause, and other risk factors that could have predisposed them to having pneumothorax, such as a genetic condition, playing contact sports, smoking history, or having an ongoing pulmonary infection.||Knowing what are the most likely causes of the patient’s pneumothorax can help the nurse better plan how to prevent a recurrence, developing a care plan that is more appropriate to the patient’s condition.|
|Discuss with the patient information regarding their pneumothorax and how they have most likely developed the condition, taking into consideration the patient’s ability to comprehend the information being given. Provide the patient supplementary information sources such as flyers, brochures or websites regarding pneumothorax.||Giving pertinent information to the patient regarding their disease gives them better understanding of their pneumothorax and what having it could mean for them in the short- and long-term. This will help them plan realistic expectations and goals while taking their current limitations in mind.|
|Encourage the patient to comply with their current treatment plan, and that any reason that could stop the patient from adhering to their treatment plan should be discussed for possible adjustment to the therapeutic modality or the treatment plan altogether.||Developing any patient’s therapeutic care plan is done alongside the patient, their caregivers, and the rest of the healthcare team.|
By providing them with health education regarding their disease, the patient will be able to understand their treatment modalities better and may improve their active participation in the development of their care plan
Nursing Care Plan for Pneumothorax 4
Risk for Trauma
Nursing Diagnosis: Risk for Trauma related to ongoing disease and dependence on an external device to manage their condition secondary to pneumothorax, as evidenced by the presence of a continuous chest tube drainage system in place.
Desired Outcome: The patient will be able to avoid incidents of further trauma or injury by maintaining a safe environment and recognizing the need for further guidance or assistance in preventing pneumothorax or chest tube drain related complications.
|Pneumothorax Nursing Interventions||Rationale|
|Advise the patient regarding the function of their chest drainage system, its purpose and how it should be monitored to ensure that the system is working properly.||Enabling the patient to understand the function of their chest tube helps alleviate their anxiety and encourage them to cooperate in maintaining the integrity of the unit.|
|Remind the patient to avoid damaging the tube, including lying on it or attempting to pull it out.||Disconnecting a chest tube can trigger recurrence of symptoms by providing a means of entry for atmospheric air into the pleural cavity. Lying on the tube may increase risk for accumulation of obstruction that can also damage the tube.|
|Anchor the chest tube to the chest wall. Ensure that there is enough extra free tubing when the patient is to be moved or turned.||Helps prevent accidental dislodging of the chest tube as well as reduce incidence of pain or discomfort associated with tugging or movement of the chest tube during position changes.|
Nursing Care Plan for Pneumothorax 5
Nursing Diagnosis: Risk for Infection secondary to presence of external device connected to the patient’s body, or underlying disease condition secondary to pneumothorax.
Desired Outcome: The patient will be able to avoid acquiring infections secondary to the presence of their chest tube or their underlying disease that caused their pneumothorax as well as demonstrate understanding of how they can protect themselves from developing infections.
|Pneumothorax Nursing Interventions||Rationale|
|Advise the patient to avoid tampering with their chest tube device and to be especially careful of pulling or frequently moving the tube.||Avoid further irritation or damage to the skin in contact with the chest tube that could lead to further impaired skin integrity and risk infection.|
|If with underlying pulmonary condition, advise the patient to comply with antibiotic regimen and to remain alert for signs of worsening infection such as fever, chills, or cough.||Certain chronic infections or diseases can predispose a patient to develop pneumothorax.|
|Ensure that the chest tube insertion site is kept clean and dressed appropriately. Advise the attending physician if the dressing is soiled or if there are signs of leaks or ineffective suctioning in the chest tube unit.||Maintaining the integrity of the chest tube dressing and unit ensures that the system will not serve as a portal for microorganisms to cause infection, and that the chest tube is functioning optimally.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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Very informative and educative