Ch 26: Pneumothorax, Hemothorax, Flail Chest

absent lung sounds on affected side?

lung is not inflated

hyperresonance

• low-pitched, booming sound

• due to trapped air

tension pneumothorax

deviated trachea

flail chest

• breathing in = chest falls

• breathing out = chest rises

• uneven movement on one side

Pneumothorax

Presence of air or gas in the pleural space that causes lung collapse

Pneumothorax
Risk Factors

• Blunt chest trauma

• Penetrating chest wounds

• Closed/occluded chest tube

• Older adult clients have decreased pulmonary reserves due to normal lung changes, including decreased lung elasticity and thickening alveoli

• Chronic obstructive pulmonary disease (COPD)

Pneumothorax
Expected Findings

• Hyperresonance on persucssion due to trapped air

• Anxiety

• Pleuritic pain

• Respiratory Distress

  • Tachypnea

  • Tachycardia

  • Hypoxia

  • Cyanosis

  • Dyspnea

  • Use of accessory muscles

• Reduced or absent breath sounds on affected side

• Asymmetrical chest wall movement

• Subcutaneous emphysema (air accumulating in subq tissue)

Pneumothorax
Lab Tests

ABGs: Hypoxemia (PaOz less than 80 mm Hg)

Pneumothorax
Diagnostic Procedures

Chest X-Ray

Pneumothorax
Nursing Care

• Administer oxygen therapy.

• Auscultate heart and lung sounds and monitor vital signs every 4 hr.

• Document ventilator settings hourly if the client is receiving mechanical ventilation.

• Check ABGs, SaO2, CBC, and chest x-ray results.

• Position the client to maximize ventilation (semi-Fowler's = 35° to 40°).

• Provide emotional support to the client and family.

• Monitor chest tube drainage.

• Administer medications as prescribed.

• Encourage prompt medical attention when evidence of infection occurs.

• Set up referral services (home health, respiratory services) to provide portable oxygen if needed.

Pneumothorax
Medications

• Benzodiazepines (Sedatives)

  • Lorazepam, Midazolam

  • NURSING ACTIONS:

    • Monitor VS

      • hypotension, respiratory distress

    • Amnesiac effects

    • Paradoxical effects (euphoria, rage

  • CLIENT EDUCATION:

    • Amnesic effects

    • Causes drowsiness

• Opioid Agonist (Pain)

  • Morphine sulfate, Fentanyl

  • Moderate to severe pain

  • Act on mu & kappa receptors

  • Pain relief, respiratory depression, euphoria, sedation, <GI motility

  • NURSING ACTIONS:

    • Caution asthma, emphysema

    • Assess pain q4h

    • Respiratory depression

      • 12 min/less

    • Monitor VS (hypotension, bradypnea)

    • N/V

    • Level of sedation (drowsiness, LOC)

    • Monitor constipation

    • Encourage fluid intake

    • Monitor I&O

  • CLIENT EDUCATION:

    • Fent patch

      • takes several hours to take effect

    • Drink plenty of fluids

    • Follow PCA instructions

Benzodiazepines (Sedatives)

• Lorazepam, Midazolam

• NURSING ACTIONS:

  • Monitor VS

    • hypotension, respiratory distress

  • Amnesiac effects

  • Paradoxical effects (euphoria, rage

• CLIENT EDUCATION:

  • Amnesic effects

  • Causes drowsiness

Opioid Agonist (Pain)

• Morphine sulfate, Fentanyl

• Moderate to severe pain

• Act on mu & kappa receptors

• Pain relief, respiratory depression, euphoria, sedation, <GI motility

• NURSING ACTIONS:

  • Caution asthma, emphysema

  • Assess pain q4h

  • Respiratory depression

    • 12 min/less

  • Monitor VS (hypotension, bradypnea)

  • N/V

  • Level of sedation (drowsiness, LOC)

  • Monitor constipation

  • Encourage fluid intake

  • Monitor I&O

• CLIENT EDUCATION:

  • Fent patch

    • takes several hours to take effect

  • Drink plenty of fluids

  • Follow PCA instructions

Pneumothorax
Therapeutic Procedures

• CHEST TUBE INSERTION

  • are inserted in pleural space to drain fluid, blood, or air

  • re-establish negative pressure

  • facilitate lung expansion

  • restore normal intrapleural pressure

  • NURSING ACTIONS:

    • Obtain informed consent, gather supplies, monitor the client's status (vital signs, SaOz, chest tube drainage), report abnormalities to the provider, and administer pain medications.

    • Continually monitor vital signs and the client's response to the procedure.

    • Monitor chest tube placement, function of chest drainage system, and dressing.

  • CLIENT EDUCATION:

    • Deep breathe to promote lung expansion.

    • Take rest periods as needed.

    • Use proper hand hygiene to prevent infection.

    • Participate in coughing, deep breathing, and use of incentive spirometry.

    • Obtain immunizations for influenza and pneumonia.

    • Recovery from a pneumothorax/hemothorax can be lengthy.

    • Talk with family or other support people to express feelings about the condition and recovery.

    • If applicable, consider smoking cessation.

    • Follow up with the provider as instructed, and report the following to the provider.

      • Upper respiratory infection

      • Fever

      • Cough

      • Difficulty breathing

      • Sharp chest pain

Pneumothorax
Complications

• DECREASED CARDIAC OUTPUT

  • Amount of blood pumped by the heart decreases as intrathoracic pressure rises

  • Hypotension develops

  • NURSING ACTIONS:

    • Administer IV fluids and blood products as prescribed.

    • Monitor heart rate and rhythm.

    • Monitor intake and output (chest tube drainage).

• RESPIRATORY FAILURE

  • Inadequate gas exchange due to lung collapse

  • NURSING ACTIONS:

    • Prepare for mechanical ventilation.

    • Continue respiratory assessment.

DECREASED CARDIAC OUTPUT

• Amount of blood pumped by the heart decreases as intrathoracic pressure rises

• Hypotension develops

• NURSING ACTIONS:

  • Administer IV fluids and blood products as prescribed.

  • Monitor heart rate and rhythm.

  • Monitor intake and output (chest tube drainage).

RESPIRATORY FAILURE

• Inadequate gas exchange due to lung collapse

• NURSING ACTIONS:

  • Prepare for mechanical ventilation.

  • Continue respiratory assessment.

Hemothorax

Expected Findings

• Dull percussion

• Anxiety

• Pleuritic pain

• Respiratory Distress

  • Tachypnea

  • Tachycardia

  • Hypoxia

  • Cyanosis

  • Dyspnea

  • Use of accessory muscles

• Reduced or absent breath sounds on affected side

• Asymmetrical chest wall movement

• Subcutaneous emphysema (air accumulating in subq tissue)

Hemothorax

Diagnostic Procedures

• Chest X-Ray

• Thoracentesis

  • to confirm

  • surgical perforation of chest wall & pleural space with a large-bore needle

  • NURSING ACTIONS:

    • Ensure that informed consent has been obtained.

    • Assist with client positioning and specimen transport.

    • Monitor status (vital signs, SaO2, injection site).

    • Assist the client to the edge of the bed and to lean over a bedside table.

  • CLIENT EDUCATION:

    • Remain still during the procedure (no moving, coughing, or deep breathing).

    • Discomfort will be felt when the local anesthetic solution is injected. When the needle is inserted into the pleural space, some pressure can be felt, but no pain.

Hemothorax

Accumulation of blood in the pleural space

Tension Pneumothorax

• Occurs when air enters the pleural space during inspiration through a one-way valve and is not able to exit upon expiration

• Trapped air causes pressure on heart & lungs

• Air & pressure rise = mediastinal shift

Spontaneous Pneumothorax

• Occur when there has been no trauma

• Small bleb on lung ruptures & air enters pleural space

Tension Pneumothorax

Expected Findings

• Tracheal deviation

• Anxiety

• Pleuritic pain

• Respiratory Distress

  • Tachypnea

  • Tachycardia

  • Hypoxia

  • Cyanosis

  • Dyspnea

  • Use of accessory muscles

• Reduced or absent breath sounds on affected side

• Asymmetrical chest wall movement

• Subcutaneous emphysema (air accumulating in subq tissue)

Flail Chest

• Occurs when at least two neighboring ribs (usually left) sustain multiple fractures

  • Causes instability of the chest wall & paradoxical chest wall movement

  • Significant limitation in chest wall expansion

• Result of free-floating rib segments

Flail Chest

Expected Findings

• Unequal chest expansion (the unaffected side of the chest will expand, while the affected

• side can appear to diminish in size or remain stationary)

• Paradoxical chest wall movement (inward movement of segment during inspiration,

• outward movement of segment during expiration)

• Tachycardia

• Hypotension

• Dyspnea

• Cyanosis

• Anxiety

• Chest pain

Flail Chest

Risk Factors

Multiple rib fractures from blunt chest trauma (often caused by motor-vehicle crash or as a result of cardiopulmonary resuscitation on older adults)

Flail Chest

Nursing Care

• Administer humidified oxygen.

• Monitor vital signs and SaO2.

• Review findings of pulmonary function tests, periodic chest x-rays, and ABGs.

• Assess lung sounds, color, and capillary refill.

• Promote lung expansion by encouraging deep breathing and proper positioning.

• Maintain mechanical ventilation in the event of severe injury to establish adequate gas exchange and stabilize the injury. (Flail chest is usually stabilized by positive-pressure ventilation.)

• Suction trachea and endotracheal tube as needed.

• Administer pain medication. Patient-controlled analgesia or an epidural block commonly is used.

• Administer IV fluids as prescribed.

• Monitor intake and output.

• Offer support and reassurance by explaining all procedures.