Nursing Care Plan (NCP) for Pneumothorax/Hemothorax

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Outline

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. 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. This pressure makes the lung unable to expand, therefore it causes the lung to collapse.

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 in order to restore appropriate oxygenation and gas exchangeability.

Pneumothorax/Hemothorax Nursing Care Plan

Subjective Data:

  • Dyspnea/Short of Breath
  • Restlessness/Anxiety
  • Sudden difficulty breathing 
  • Pleuritic Chest Pain (worse with inspiration)

Objective Data:

  • Diminished/Absent breath sounds over the affected side 
  • Asymmetrical/decreased chest expansion over the affected side 
  • Increased respirations 
  • Accessory Muscle Use 
  • Hyperresonance on percussion (pneumothorax)
  • Dullness on percussion (hemothorax)
  • Tracheal Deviation to unaffected side (tension pneumothorax)

Nursing Interventions and Rationales

Nursing Intervention (ADPIE) Rationale
Auscultate breath sounds  breath sounds may be diminished or absent over a pneumothorax/hemothorax. A thorough assessment can identify a problem before it worsens. Also, be sure to re-assess and listen after an intervention was done to make sure that the lung has reinflated. 
Assess Respiratory Rate  patients may present with shallow/rapid breathing due to a collapsed lung 
Assess for Chest Pain/administer analgesics  Pain can cause a patient to breathe more shallowly and can put them at risk for atelectasis. Pain relief can allow the patient to breathe more deeply. 
Assess for chest expansion  The chest can be asymmetrical due to a collapsed lung. This is especially prominent in a tension pneumothorax which is a medical emergency. 
Assess VS/hemodynamics  tension pneumothorax can cause a significant decrease in CO (low BP). Early intervention is key
Place patient in high fowler’s for better oxygenation/comfort  Approximately 90 degrees. Improves respiratory rate/effort. Better oxygenation. Good lung down positioning improves lung perfusion to the good lung and promotes reinflation of the bad lung. 
Using the IS/Flutter Valve/Deep Breathing/Cough/Turn Exercises  educate the patient the importance of using the incentive spirometer, flutter valve, and cough/deep breathing exercises that help reinflate the lungs. Collapsed lung/rapid/shallow breathing can increase risk for atelectasis and pneumonia. 
Assess oxygenation/Provide supplemental O2 if appropriate A collapsed lung cannot participate in oxygenation or gas exchange, therefore supplemental oxygen is typically required.
Prepare patient for chest tube insertion/Thoracentesis procedure  Provide proper post procedure care

Chest Tubes- help remove air or blood from the pleural space. 

Thoracentesis- drains fluid or blood from the pleural space. 

Both will allow the lungs to reinflate 

Writing a Nursing Care Plan (NCP) for Pneumothorax/Hemothorax

A Nursing Care Plan (NCP) for Pneumothorax/Hemothorax starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

  • https://emedicine.medscape.com/article/424547-overview
  • https://www.mayoclinic.org/diseases-conditions/pneumothorax/symptoms-causes/syc-20350367
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Transcript

Hey everyone. Today, we are going to be creating a nursing care plan for pneumothorax, hemothorax, and tension pneumothorax. So, let’s get started. So, let’s go over the 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. A tension pneumothorax occurs when the pressure is so great that it puts pressure onto the heart and the major blood vessels. Therefore, it will decrease the cardiac output, which is a medical emergency. Some nursing considerations you want to also take lung sounds, assess vital signs, and hemodynamics. You want to assess for chest pain, chest expansion, making sure the patients are in high fowler’s, deep breathing exercises, and preparing the patient for a chest tube or thoracentesis procedures. Some desired outcomes: you want to achieve the reinflation of the lung by removing the blood or the air to restore any sort of appropriate oxygenation and gas exchange ability. So as far as all these pressures together, this puts pressure onto the lung itself, which can make it difficult for the lungs to expand for the proper gas exchange and oxygenation to occur. Therefore, this will cause the lungs to collapse. 

So, three main types. I wanted to break this down for the first type that you see is a, what’s called a pneumothorax, a pneumothorax. This is going to be air in the pleural space, the second kind is hemothorax. So, this is going to be when there is blood in that pleural space. And lastly, tension pneumothorax. And this is when the pressure is so great that it puts pressure onto the heart or the main blood vessels. Therefore, it will decrease cardiac output. And this, once again, is a medical emergency. And I also wanted to note for you guys, there’s also what is called pleural effusions and pleural effusions are excess fluid in the pleural space.

So, we’re going to start the care plan. We’re going to first start out with going over once again, the subjective data and the objective data. So, one of the first things you’re going to see in a patient is going to be some shortness of breath, and you’re also going to see difficulty breathing. Along with the subjective data, there’s going to be some objective data. Some things you’re going to see here is they’re going to have some diminished, absent breath sounds over the affected side. Decreased chest expansion over the affected side, increased respirations accessory muscle use, and hyper resonance on percussion. And dullness on percussion, which is for a hemo, and tracheal deviation on the unaffected side for tension pneumo. 

So, some interventions that we’re going to do, you want to make sure that you’re going to be checking for some breath sounds, you want to make sure because there might be diminished or absent sounds depending on which one it is. So, a thorough assessment is needed to make sure that it’s not worsening or enable reassessment after an intervention is done, to make sure that the lung has reinflated. You’re also going to make sure that you’re going to be assessing vital signs or any hemo because the patient may present with any short of shallow breathing or rapid breathing when a lung collapses and with attention, you want to make sure that you’re checking with their blood pressure because it can cause a decrease in cardiac output, which is in medical emergency. You also want to assess chest pain and give pain medication as needed. They’re going to have some rapid shallow breathing and pain relief allows them to breathe more deeply. Assess for chest expansion. Collapsed lungs can cause the chest to be asymmetrical. So, the more prominent the tension pneumo, you want to make sure you place the patient in a high fowler’s position for better oxygenation and comfort. This will help improve respiratory rate and effort and improve the lung perfusion for the good lung and reinflate the bad lung. Some others that we want to look into are educating the patient on an incentive spirometer and a flutter valve, coughing, and deep breathing exercises. So, this is going to help reinflate a collapsed lung. Rapid shallow breathing can lead to things like atelectasis and pneumonia. You want to make sure you’re assessing their O2 and giving O2 as appropriate. So, since the collapsed lung can’t oxygenate properly for the gas exchange, you may have to give sub O2 to enable the patient to breathe better. You also want to prepare a patient for a chest tube insertion or a thoracentesis procedure. The chest tube will be able to help remove the air or fluid from the pleural space. And a thoracentesis is going to be able to drain the fluid from the pleural space. 

And here we’re going to see a picture of a chest tube. So, as you can see, this is the chamber. And if you have a hemothorax, there’s going to be blood. That’s going to fill into this chamber right here and it’s going to fill it up here. Let’s go down and up here. This is the water seal here. The suction here. This is what a chest tube looks like. 

And now we’re going to go over some key points here. So, some pathophysiology etiology. So, a pneumo is, once again, air in the pleural space, hemothorax is blood, and tension pneumo is when there’s so much pressure. It puts that strain on the heart and major blood vessels. The pneumo can be spontaneous, can also be caused by penetrating trauma. Some subjective and objective data you’ll see patients may have shortness of breath, restlessness anxiety, sudden difficulty breathing, pleuritic chest pain, and diminished or absent breath sounds over the affected side. And again, depending if it’s a pneumo or hemo, increased respirations accessory muscle use hyper resonance on percussion, dullness on percussion, and tracheal deviation. And once again, depending on what you hear is going to be dependent on if it’s a pneumo, hemo, or tension pneumothorax. You want to do an assessment of vital signs, O2, and position. So, assess for respiratory status, breath sounds, and blood pressure. Make sure you’re positioning the patient in high fowler’s for better gas exchange and oxygenation. We’re going to do thoracentesis, CT, and incentive spirometry. Make sure you’re educating the patient on the chest tubes. The thoracentesis procedure, how to use that incentive spirometer and a flutter valve properly. And then to use those cough, deep breathing, and turning exercises. And there you have it with that care plan. 

You guys did awesome. We love you guys. Go out, be your best self today and as always happy nursing.

 

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