A patient presents with a suspected tension pneumothorax. After notifying the physician, what is the nurse's priority action to stabilize the patient's condition?

B) Prepare for needle decompression

A) Increase the flow of supplemental oxygen

B) Prepare for needle decompression

C) Assist the patient into a semi-Fowler's position

D) Administer anxiolytic medication to reduce anxiety

A 55-year-old male patient’s condition deteriorates with signs of respiratory distress, including tracheal deviation to the left, diminished breath sounds on the right, and hyperresonance on percussion of the right thorax. Which immediate nursing intervention is the most critical to address the suspected condition?

B) Prepare the patient for urgent needle decompression of the chest.

A) Increase the flow rate of supplemental oxygen via nasal cannula to 6 liters per minute.

B) Prepare the patient for urgent needle decompression of the chest.

C) Position the patient in a high Fowler's position to improve ventilation.

D) Administer a bronchodilator to alleviate respiratory distress.

After the chest tube insertion, the nurse observes the development of subcutaneous emphysema in the patient. Which of the following actions is the most appropriate immediate nursing intervention?

C) Assess the chest tube system for any kinks or obstructions

A) Reposition the patient to a semi-Fowler's position to facilitate drainage

B) Notify the healthcare provider immediately about the development of subcutaneous emphysema

C) Assess the chest tube system for any kinks or obstructions

D) Increase the oxygen flow rate to improve oxygenation and ease breathing

A patient who recently underwent chest tube insertion for a pneumothorax now exhibits subcutaneous emphysema around the neck and upper chest. What is the most appropriate initial nursing action?

B) Reassess the chest tube for patency and secure connections.

A) Increase the patient's oxygen flow rate.

B) Reassess the chest tube for patency and secure connections.

C) Elevate the head of the bed to 45 degrees.

D) Notify the physician immediately about the subcutaneous emphysema.

A patient with a chest tube insertion for pneumothorax continues to demonstrate respiratory distress and subcutaneous emphysema. The chest X-ray shows a correctly positioned chest tube but a persistent pneumothorax. What is the nurse's priority intervention in this situation?

C) Administer a high-flow oxygen therapy to improve oxygen saturation.

A) Increase the suction pressure on the chest tube.

B) Prepare for possible insertion of a second chest tube.

C) Administer a high-flow oxygen therapy to improve oxygen saturation.

D) Notify the healthcare provider about the potential need for surgical intervention.

A patient with a chest tube following a pneumothorax is experiencing persistent subcutaneous emphysema and reduced but ongoing pneumothorax despite correct chest tube placement. The patient has a respiratory rate of 30 breaths per minute and fluctuating oxygen saturation between 88% and 90%. Which nursing intervention is most appropriate to prioritize at this time?

A) Increase the oxygen flow rate to improve oxygen saturation.

B) Encourage the patient to perform incentive spirometry every hour.

C) Monitor and document the amount and characteristics of chest tube drainage.

D) Prepare for potential surgical intervention by ensuring consent is signed and available.

A patient with a pneumothorax has just undergone a change in management with increased suction pressure on the existing chest tube and the insertion of a second chest tube. Post-intervention, the patient's respiratory rate decreased but oxygen saturation remains at 89-92% on high-flow oxygen. Which nursing intervention is most appropriate at this time?

D) Reassess and monitor the chest tube drainage system for any leaks.

A) Decrease the flow rate of oxygen to prevent oxygen toxicity.

B) Initiate incentive spirometry every hour to promote lung expansion.

C) Prepare the patient for urgent surgical consultation.

D) Reassess and monitor the chest tube drainage system for any leaks.

A patient with a bilateral pneumothorax secondary to suspected blebs or bullae is being managed with chest tubes and high-flow oxygen. The suction pressure on the existing chest tube was increased, and a second chest tube was inserted. Despite these interventions, the patient's oxygen saturation remains between 89% and 92% on high-flow oxygen. What is the next priority nursing action?

A) Reassess the chest tube placement and functioning to ensure proper decompression of the pleural space.

B) Increase the flow rate of oxygen to improve oxygenation.

C) Prepare the patient for immediate surgical intervention.

D) Administer bronchodilators to improve lung expansion.

A patient with recurrent pneumothoraces and subcutaneous emphysema is being considered for surgical intervention. Which nursing intervention is most critical while awaiting the interdisciplinary team's decision?

B) Monitor for signs of tension pneumothorax and report immediately

A) Administer bronchodilators to improve lung function

B) Monitor for signs of tension pneumothorax and report immediately

C) Educate the patient on postoperative care for pleurodesis

D) Encourage the patient to perform incentive spirometry every hour

A patient with recurrent pneumothoraces has been found to have multiple small blebs and bullae on a high-resolution CT scan. The healthcare team is considering surgical interventions such as bullectomy or pleurodesis. As the nurse caring for this patient, which priority intervention should be implemented to monitor for complications during this period?

B) Monitor the patient's chest tube output and assess for any changes.

A) Administer antibiotics prophylactically to prevent infection.

B) Monitor the patient's chest tube output and assess for any changes.

C) Encourage frequent deep breathing exercises to prevent atelectasis.

D) Increase the patient's oxygen flow rate to maintain saturation above 95%.

pneumothorax - Nursing Case Study

Pathophysiology

• Primary mechanism: Intrapleural space air accumulation disrupts negative pressure, leading to collapsed lung and impaired gas exchange. This occurs due to spontaneous rupture of alveoli or traumatic injury to chest wall or lung.

• Secondary mechanism: As the lung collapses, the mediastinum may shift towards the unaffected side, potentially compressing vital structures such as the heart and great vessels, compromising cardiac function and circulation.

• Key complication: Tension pneumothorax can develop if air continues to accumulate, drastically increasing intrathoracic pressure, leading to severe respiratory distress and cardiovascular compromise, requiring emergency intervention to prevent life-threatening consequences.

Patient Profile

Demographics:

35-year-old male, construction worker

History:

• Key past medical history: Smoker for 15 years, history of asthma

• Current medications: Albuterol inhaler as needed, over-the-counter ibuprofen for occasional back pain

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden onset of sharp chest pain and shortness of breath

• Key symptoms: Chest pain on the right side, increased difficulty breathing, dry cough, fatigue, anxiety

• Vital signs: Blood pressure 105/65 mmHg, heart rate 115 beats per minute, respiratory rate 28 breaths per minute, oxygen saturation 89% on room air, temperature 37.5°C (99.5°F)

Section 1

Change in Patient Status:

Shortly after the initial assessment, the patient's condition began to deteriorate. His oxygen saturation dropped further to 85% despite being placed on supplemental oxygen via nasal cannula at 3 liters per minute. The patient became increasingly tachypneic, with a respiratory rate climbing to 34 breaths per minute. His heart rate rose to 130 beats per minute, and he exhibited pronounced jugular venous distention, indicating potential cardiovascular compromise. The patient's anxiety escalated as he struggled to catch his breath, and he reported feeling light-headed and dizzy.

A focused physical examination revealed significant tracheal deviation to the left, diminished breath sounds on the right side, and hyperresonance upon percussion of the right thorax. These findings suggested the development of a tension pneumothorax, a life-threatening complication that requires immediate intervention. The nurse promptly communicated these changes to the attending physician, emphasizing the urgency of the situation and the need for rapid decompression to relieve intrathoracic pressure and restore adequate ventilation and perfusion.

The healthcare team prepared for an emergent needle decompression, while simultaneously arranging for a chest tube insertion to provide sustained relief and prevent recurrence. This swift response aims to stabilize the patient, prevent further cardiopulmonary compromise, and create a pathway for recovery. As these interventions were being initiated, the nurse remained vigilant, monitoring for any additional changes in the patient's status and preparing to manage potential post-procedural complications.

Section 2

Following the emergent needle decompression, the patient's condition showed initial signs of stabilization. His respiratory rate began to decrease to 28 breaths per minute, and his heart rate settled slightly at 110 beats per minute. Oxygen saturation improved to 90% on the nasal cannula, providing a tentative indication that the immediate threat of tension pneumothorax was being alleviated. However, the patient's clinical picture remained precarious. The decision to proceed with chest tube insertion was critical to ensure ongoing decompression and to prevent recurrence of tension physiology.

As the chest tube was inserted on the right side, there was an immediate rush of air, confirming the presence of pneumothorax and relieving some of the intrathoracic pressure. Post-procedural assessment showed a more central tracheal position, and breath sounds on the right side, though still diminished, were slightly more audible. The patient's anxiety levels decreased, and he reported feeling somewhat less breathless. Despite these positive developments, the nurse noted a new complication: the patient exhibited signs of subcutaneous emphysema around the neck and upper chest, indicating air had escaped into the subcutaneous tissues.

This new finding necessitated further clinical reasoning and vigilance. While often benign, subcutaneous emphysema can sometimes indicate persistent air leaks or improper chest tube placement. The healthcare team ordered a chest X-ray to assess the chest tube's position and evaluate the extent of subcutaneous air. Lab tests, including arterial blood gases, were also conducted to monitor the patient's oxygenation status and acid-base balance. The nurse remained attentive to the patient's vital signs and comfort level, ready to advocate for additional interventions if necessary, while communicating closely with the medical team about the patient's evolving condition.

Section 3

Following the chest tube insertion and identification of subcutaneous emphysema, the team urgently reviewed the chest X-ray results, which revealed that the chest tube was positioned correctly and appropriately decompressing the pleural space. However, the X-ray also showed a persistent pneumothorax, albeit reduced in size, and extensive subcutaneous air spread across the right thorax and neck. Arterial blood gas analysis indicated a pH of 7.35, pCO2 of 48 mmHg, pO2 of 65 mmHg, and HCO3- of 26 mEq/L, suggesting a respiratory acidosis with some compensatory metabolic response, indicating that the patient's respiratory function was still compromised.

Despite the initial procedural success in stabilizing the patient, the persistence of pneumothorax and widespread subcutaneous emphysema signaled to the healthcare team that an ongoing air leak might be present. The patient’s respiratory rate remained elevated at 30 breaths per minute, and his oxygen saturation fluctuated between 88% and 90%, indicating that the current interventions were insufficient to address all underlying issues. Given these findings, the team considered escalating treatment, including adjusting the chest tube's suction pressure or considering the use of a second chest tube if warranted by further deterioration.

In light of these new developments, the nursing staff increased their surveillance, focusing on signs of worsening respiratory distress or further cardiovascular compromise. They initiated continuous pulse oximetry and frequent vital sign monitoring, remaining vigilant for any signs of tension physiology recurring. A collaborative team meeting was held to discuss the potential need for surgical intervention should conservative measures fail to resolve the air leak. The nurse also prioritized patient education, explaining the situation and the steps being taken to manage it, ensuring the patient remained informed and as comfortable as possible during the ongoing treatment.

Section 4

As the team continued to closely monitor the patient's condition, new diagnostic results were obtained, which provided further insight into the ongoing challenges. A follow-up chest X-ray revealed that while the initial pneumothorax had decreased in size, there was now evidence of a secondary, small pneumothorax developing on the contralateral side. This unexpected finding suggested the possibility of a more complex underlying pathology, such as bilateral blebs or bullae, which might be contributing to the persistent air leaks. Additionally, the subcutaneous emphysema had marginally increased, now extending into the supraclavicular area, indicating that the air was still tracking through tissue planes.

In response to these findings, the healthcare team decided to adjust the current treatment plan. The suction pressure on the existing chest tube was increased to enhance pleural space decompression, and a decision was made to insert a second chest tube on the affected side to address the new pneumothorax. Concurrently, a high-resolution CT scan was ordered to assess for potential underlying causes such as lung parenchymal disease or structural abnormalities contributing to the air leaks. Throughout these interventions, the nursing staff remained diligent in their assessments, ensuring that the patient was hemodynamically stable, and continued to educate the patient about the situation and the rationale behind each intervention.

The patient’s clinical status presented a mixed picture. Although his respiratory rate decreased to 26 breaths per minute post-intervention, his oxygen saturation remained on the lower end, fluctuating between 89% and 92% on high-flow oxygen. Arterial blood gas analysis showed slight improvement with a pH of 7.38, pCO2 of 46 mmHg, pO2 of 70 mmHg, and HCO3- of 27 mEq/L, indicating partial amelioration of the respiratory acidosis. These results highlighted the importance of continued vigilance and reassessment, as well as the need for potential surgical consultation if the air leaks persisted despite the current management strategies.

Section 5

As the patient continued to be closely monitored, new diagnostic results were obtained from the high-resolution CT scan. The scan revealed the presence of multiple small blebs and bullae bilaterally, which were likely contributing to the persistent and recurrent air leaks. These findings suggested a possible underlying condition such as emphysema or a genetic predisposition to bleb formation, requiring further investigation by a respiratory specialist. Additionally, there were signs of mild atelectasis in the right lower lobe, likely due to compromised lung expansion from the pneumothoraces and subcutaneous emphysema.

In response to these findings, the healthcare team recognized the need for a multidisciplinary approach, involving pulmonology and thoracic surgery for comprehensive evaluation and management of the patient's condition. The decision was made to maintain the current chest tube management while the patient was evaluated for potential surgical intervention, such as bullectomy or pleurodesis, to prevent future pneumothoraces. Meanwhile, the nursing staff continued to prioritize effective pain management and respiratory support, ensuring that the patient remained comfortable and stable.

The patient's clinical status showed some improvement following these interventions. His respiratory rate stabilized at 24 breaths per minute, and his oxygen saturation increased slightly to 93% on high-flow oxygen. While these improvements were encouraging, the nursing team remained vigilant for any signs of further deterioration or new complications, such as tension pneumothorax or increased subcutaneous emphysema, which would require immediate intervention. The focus remained on frequent reassessment and timely communication with the interdisciplinary team to ensure the best possible outcome for the patient.