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Nursing Care Plan for Pneumothorax/Hemothorax

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Pathophysiology

A pneumothorax occurs when air collects in the pleural space around the lung. A hemothorax occurs when blood collects in the pleural space around the lung. This blood or air collection puts pressure on the lung tissue. This pressure makes the lung unable to expand, therefore it causes the lung to collapse. A collapsed, non-expandable lung cannot take in air and therefore cannot participate in oxygenation and gas exchange. A tension pneumothorax occurs when the pressure is so great that it puts pressure on the heart and major blood vessels – therefore decreasing cardiac output – this is a medical emergency.

Etiology

A pneumothorax can be spontaneous – caused by no obvious injury – due to a ruptured bleb or distended alveoli (as in COPD or positive pressure ventilation). It could also be caused by penetrating trauma (stab, gunshot wound). Hemothorax can be caused by penetrating trauma as well or could be due to a bleeding vessel or lesion around the lung.

Desired Outcome

To achieve reinflation of the lung by removing the blood or air. To restore appropriate oxygenation and gas exchangeability.

Pneumothorax/Hemothorax Nursing Care Plan

Subjective Data:

  • Sudden difficulty breathing
  • Shortness of breath
  • Restless/anxious

Objective Data:

  • Diminished or absent breath sounds over the affected area
  • Decreased or asymmetrical chest expansion on the affected side
  • Increased RR
  • Dullness on percussion (hemothorax)
  • Hyperresonance on percussion (pneumo)
  • Tracheal deviation to unaffected side (tension pneumothorax)

Nursing Interventions and Rationales

  • Auscultate Breath Sounds
  Breath sounds may be diminished or absent over the hemo/pneumo. A thorough assessment can identify the problem before it progresses. This will also help to determine if the lung has appropriately reinflated after the intervention.  
  • Assess respiratory status (rate)
  Patients may have rapid, shallow breathing due to collapsed lung  
  • Assess chest expansion
  Chest expansion may be asymmetrical due to collapsed lung. This is especially prominent in a tension pneumothorax which is a medical emergency.  
  • Assess hemodynamics and VS
  Tension pneumothorax can cause a significant decrease in cardiac output and is a medical emergency. Early intervention is the key to good outcomes.  
  • Place in high fowler’s position or position of comfort. Good-lung down positioning.
  High-fowler’s position can improve respiratory effort and improve oxygenation. Good lung down positioning helps to improve perfusion to good lung and promote reinflation of bad lung.  
  • Assess oxygenation and provide supplemental O2 as appropriate
  A collapsed lung cannot participate in oxygenation or gas exchange, therefore supplemental oxygen is typically required.  
  • Administer analgesics
  Pain can cause patients to breathe too shallow – putting them at risk for atelectasis. Pain relief can encourage deeper breathing.  
  • Educate patient on chest expansion exercises (IS, TCDB)
  Rapid, shallow breathing, plus a collapsed lung, means a high risk for atelectasis and pneumonia. Deep breathing exercises like Incentive Spirometry and Turn, Cough, Deep Breathe, can help reinflate the lungs.  
  • Prepare patient for Chest Tube Insertion or Thoracentesis. Provide appropriate post-procedure care.
  Chest tubes are placed to remove the air or blood from the pleural space. Thoracentesis is performed to drain fluid or blood from the pleural space. Both procedures will allow for the reinflation of the lung. Check facility policy for post-procedure monitoring. Review Chest Tube Management and Thoracentesis lesson for more details.  
  • If open, sucking chest wound – apply an occlusive dressing, taped on 3-sides
  Three-sided dressing creates a one-way valve. This would allow air to escape, but not re-enter. This helps to prevent the pneumothorax from worsening into a tension pneumothorax.  

References

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  • Question 1 of 3

The nurse is caring for a client who has developed a tension pneumothorax. The provider asks the nurse to gather the necessary supplies. Which of the following will the nurse obtain?

  • Question 2 of 3

A nurse is caring for a client admitted to the emergency department. The client has just been diagnosed with a hemothorax. What is the priority nursing intervention at this time?

  • Question 3 of 3

Which of the following is a common finding in an open pneumothorax?

Module 0 – Nursing Care Plans Course Introduction
Module Obstetrics (OB) & Pediatrics (Peds) Care Plans

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