A patient with suspected tension pneumothorax presents with tracheal deviation, jugular venous distention, and hypotension. Despite supplemental oxygen, oxygen saturation remains low. What is the nurse's immediate priority action?

B) Perform needle decompression

A) Increase the oxygen flow rate

B) Perform needle decompression

C) Prepare for chest tube insertion

D) Administer intravenous fluids

A nurse is caring for a patient with signs of a tension pneumothorax. Which clinical manifestation most strongly indicates the need for immediate intervention?

B) Tracheal deviation to the left

C) Respiratory rate of 32 breaths per minute

A patient with a newly inserted chest tube for a pneumothorax is exhibiting signs of respiratory distress, anxiety, and confusion, with a confirmed persistent air leak. The patient's potassium level is 3.2 mEq/L. What is the priority nursing action at this time?

B) Notify the healthcare provider about the persistent air leak and hypokalemia.

A) Increase the patient's oxygen flow rate to improve oxygenation.

B) Notify the healthcare provider about the persistent air leak and hypokalemia.

C) Administer potassium replacement as ordered to correct hypokalemia.

D) Adjust the suction level on the chest tube drainage system to control the air leak.

A patient who recently had a chest tube insertion for a pneumothorax is now showing signs of a persistent air leak, as indicated by continuous bubbling in the water seal chamber. The patient also exhibits increased anxiety, confusion, and mild hypokalemia. What is the priority nursing intervention in this situation?

C) Notify the healthcare provider for potential surgical evaluation due to the persistent air leak.

A) Increase the suction on the chest drainage system to enhance lung re-expansion.

B) Administer supplemental potassium to address the hypokalemia.

C) Notify the healthcare provider for potential surgical evaluation due to the persistent air leak.

D) Provide reassurance and emotional support to reduce the patient's anxiety.

A patient with respiratory distress is showing signs of increasing lethargy and a decreased Glasgow Coma Scale (GCS) score. The arterial blood gas analysis shows respiratory acidosis. Which nursing intervention is most appropriate to address the underlying cause of the patient's condition?

A) Administer intravenous sodium bicarbonate to correct the acidosis.

C) Increase the concentration of supplemental oxygen to improve oxygen saturation.

D) Administer a diuretic to manage potential fluid overload contributing to respiratory distress.

A patient in the intensive care unit is experiencing increasing lethargy and a reduced level of consciousness with a Glasgow Coma Scale score reduction from 14 to 11. An arterial blood gas analysis reveals respiratory acidosis with a pH of 7.32 and PaCO2 of 50 mmHg. Which clinical intervention should the nurse prioritize to address the patient's current respiratory status?

A) Increase the flow rate of supplemental oxygen via nasal cannula.

C) Administer an intravenous diuretic to reduce fluid overload.

D) Prepare the patient for emergent intubation and mechanical ventilation.

A patient with a history of pneumothorax is being treated with non-invasive positive pressure ventilation (NIPPV) and potassium replacement. After an initial improvement, the patient exhibits asymmetric chest expansion and decreased breath sounds on the right side. Which immediate nursing intervention is most appropriate to address the suspected tension pneumothorax?

C) Prepare for needle decompression

B) Increase the NIPPV pressure settings

C) Prepare for needle decompression

D) Initiate high-flow oxygen therapy

A patient has undergone needle decompression and chest tube insertion for a pneumothorax. Following these interventions, the arterial blood gas shows a pH of 7.32 and a pCO2 of 48 mmHg. Which nursing intervention is most appropriate to address the respiratory acidosis in this patient?

A) Encourage deep breathing exercises and incentive spirometry

B) Administer sodium bicarbonate to correct the acidosis

C) Increase the patient's oxygen flow rate

D) Prepare the patient for immediate re-intubation

A patient with a history of recurrent pneumothorax has just undergone chest tube insertion and is showing signs of mild respiratory acidosis. The CT scan reveals subpleural blebs. Which nursing intervention is most appropriate to address the patient's current respiratory status and prevent future complications?

A) Educate the patient on deep breathing exercises to improve lung expansion.

B) Administer supplemental oxygen to manage hypoxemia.

C) Encourage smoking cessation to reduce the risk of recurrent pneumothorax.

D) Prepare the patient for immediate surgical intervention to resect the blebs.

Pneumothorax - Nursing Case Study

Pathophysiology

• Primary mechanism: Pneumothorax occurs when air enters the pleural space, disrupting the negative pressure that normally keeps the lungs inflated, leading to partial or complete lung collapse.

• Secondary mechanism: The air can enter the pleural space through a breach in the visceral pleura (due to lung injury or disease) or the parietal pleura (from trauma or medical intervention), allowing atmospheric pressure to equalize with pleural pressure.

• Key complication: As the lung collapses, gas exchange is impaired, potentially leading to hypoxemia. In tension pneumothorax, air trapped in the pleural space increases pressure, compressing mediastinal structures, which can cause cardiovascular compromise and requires urgent medical intervention.

Patient Profile

Demographics:

45-year-old male, construction worker

History:

• Key past medical history: Chronic obstructive pulmonary disease (COPD), smoker for 20 years

• Current medications: Albuterol inhaler, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden onset of sharp chest pain and difficulty breathing

• Key symptoms: Shortness of breath, decreased breath sounds on the right side, anxiety, cyanosis (bluish skin tint)

• Vital signs: Blood pressure 100/65 mmHg, heart rate 110 bpm, respiratory rate 28 breaths per minute, oxygen saturation 88% on room air, temperature 37.2°C (98.9°F)

Section 1

Change in Patient Status:

Following the initial assessment and stabilization efforts, the patient's condition showed signs of deterioration, indicating a progression towards a tension pneumothorax. Despite supplemental oxygen at 10 liters via a non-rebreather mask, his oxygen saturation remained suboptimal at 85%. The patient became increasingly agitated and reported worsening dyspnea. Upon reassessment, the patient's trachea was noted to be deviated to the left, a classic sign of mediastinal shift due to increased intrathoracic pressure on the affected side. Additionally, jugular venous distention was observed, suggesting compromised venous return and potential cardiovascular involvement.

The patient's vital signs reflected this change, with a further drop in blood pressure to 90/60 mmHg, indicating possible obstructive shock. The heart rate increased to 120 bpm as the body attempted to compensate for the reduced cardiac output. Respiratory rate remained elevated at 32 breaths per minute, reflecting respiratory distress and the body's effort to improve ventilation. Given these findings, the clinical team recognized the urgent need for decompression to relieve the pressure in the pleural space and prevent further hemodynamic instability.

The primary intervention of needle decompression was swiftly performed in the second intercostal space at the midclavicular line on the right side. This resulted in an immediate rush of air, confirming the presence of a tension pneumothorax. The patient's vital signs began to stabilize gradually, with improved oxygen saturation and a decrease in heart rate. However, the team prepared for chest tube insertion to ensure continuous drainage and prevent recurrence. This intervention was critical in addressing the acute complication and stabilizing the patient's condition, emphasizing the importance of prompt recognition and treatment in such scenarios.

Section 2

Following the initial successful intervention, the patient was closely monitored for any further changes in status. About an hour post-chest tube insertion, the clinical team noticed a new development. The patient's respiratory rate remained elevated at 30 breaths per minute, and although his oxygen saturation had improved to 92%, he continued to exhibit signs of respiratory distress. Additionally, the patient began to exhibit an increased level of anxiety and confusion, which prompted further investigation.

A repeat chest X-ray was conducted to assess the efficacy of the chest tube placement and ensure proper lung re-expansion. The imaging revealed a new complication: a persistent air leak, suggesting a bronchopleural fistula. This finding indicated that there was still ongoing communication between the pleural space and the bronchial tree, preventing complete lung re-expansion. The air leak was confirmed by observing continuous bubbling in the water seal chamber of the chest drainage system.

In light of these findings, the team had to deliberate on the next steps to address this complication. The persistent air leak required careful management to prevent further respiratory compromise while allowing time for spontaneous healing or considering surgical intervention. The patient's electrolyte levels were also assessed, revealing mild hypokalemia with a potassium level of 3.2 mEq/L, which could impact cardiac and muscle function, necessitating prompt correction. The clinical team planned to adjust the patient's management plan to address these issues, including potential adjustments in ventilatory support and electrolyte replacement, highlighting the need for ongoing vigilance and adaptability in managing complex cases.

Section 3

As the clinical team continued to monitor the patient, they noted a subtle but concerning change in his status. The patient, who had initially exhibited anxiety and confusion, now presented with increasing lethargy and a reduced level of consciousness. His Glasgow Coma Scale (GCS) score decreased from 14 to 11, indicating a moderate decline in neurological status. This change prompted the team to consider the potential underlying causes, including hypoxia, electrolyte imbalances, or even neurological complications secondary to hypoxemia.

The patient's vital signs showed a heart rate of 115 beats per minute, blood pressure of 100/65 mmHg, and increased accessory muscle use during respiration, suggesting ongoing respiratory distress despite supplemental oxygen and chest tube intervention. Additionally, an arterial blood gas (ABG) analysis was performed, revealing a pH of 7.32, PaCO2 of 50 mmHg, and HCO3- of 24 mEq/L, consistent with respiratory acidosis. This finding, combined with the patient's neurological decline, raised concerns about inadequate ventilation and prompted consideration for escalated respiratory support.

In response to these developments, the clinical team decided to initiate non-invasive positive pressure ventilation (NIPPV) to improve alveolar ventilation and reduce the work of breathing. Concurrently, intravenous potassium replacement was started to address the hypokalemia, with careful monitoring to avoid overcorrection. The team emphasized the importance of frequent reassessment, including neurological evaluations and continuous monitoring of respiratory status, to ensure timely identification and management of any further complications, setting the stage for the next phase of the patient's care journey.

Section 4

As the clinical team continued to monitor the patient following the initiation of non-invasive positive pressure ventilation (NIPPV) and potassium replacement, they observed an initial improvement in respiratory effort and a slight increase in the patient's alertness. However, within the next few hours, a nurse noted a new and concerning development: the patient exhibited asymmetric chest expansion with decreased breath sounds on the right side, suggesting a possible complication. A repeat chest X-ray was swiftly ordered, revealing a significant re-accumulation of air in the pleural space on the right, consistent with a tension pneumothorax, which was compressing the mediastinum and further compromising respiratory function.

In response to this acute change, the team prepared for an urgent needle decompression followed by chest tube reinsertion to relieve the pressure. The patient's blood pressure had dropped to 90/60 mmHg, his heart rate increased to 125 beats per minute, and he showed signs of increased respiratory distress, despite the ongoing NIPPV support. These findings pointed to the urgency of the situation, underscoring the critical need for intervention to prevent further cardiovascular compromise and deterioration of the patient's condition.

The team quickly performed the needle decompression, which provided immediate but temporary relief. This was followed by the insertion of a second chest tube, which resulted in the stabilization of vital signs and an improvement in the patient's oxygenation. With the immediate crisis averted, the team focused on close monitoring and reassessment to ensure the efficacy of the interventions and to watch for any additional complications. This incident highlighted the importance of vigilant assessment and prompt action in managing pneumothorax and its potential complications, setting the stage for further evaluation of underlying causes and long-term management strategies.

Section 5

Following the stabilization of the patient's immediate condition with the needle decompression and chest tube insertion, the clinical team turned their attention to further diagnostic assessments to understand the underlying causes and to preempt future complications. A comprehensive set of laboratory tests and imaging studies were ordered, including arterial blood gases, a complete blood count, serum electrolytes, and a CT scan of the chest. The arterial blood gas analysis revealed a persistent mild respiratory acidosis, with a pH of 7.32 and pCO2 of 48 mmHg, indicating ongoing respiratory compromise despite the interventions. The complete blood count showed a mild leukocytosis with a white blood cell count of 13,000/mm³, suggesting a possible inflammatory or infectious process. Electrolyte levels were largely within normal limits, apart from a slightly low calcium level of 8.0 mg/dL, which warranted monitoring but was not immediately critical.

The CT scan provided further insights, revealing not only the re-expanded right lung but also areas of subpleural blebs, particularly in the upper lobes. These findings suggested an underlying bullous lung disease, which could predispose the patient to recurrent pneumothoraxes. This discovery prompted the team to consider the need for a more definitive surgical intervention, such as pleurodesis or bleb resection, to prevent future episodes. The presence of subpleural blebs also raised questions about the patient's smoking history and occupational exposure, leading to further inquiries into his lifestyle and work environment.

With these new diagnostic results, the clinical team prepared to discuss the findings with the patient and his family, emphasizing the importance of addressing potential modifiable risk factors and considering surgical options. Meanwhile, the patient's status remained under close observation, with continuous monitoring of his respiratory and cardiovascular function. The team also initiated a referral to a pulmonologist for a more specialized assessment of the underlying lung pathology, setting the stage for a multidisciplinary approach to his long-term management. This phase of care highlighted the complexity of pneumothorax management and the necessity for comprehensive evaluation and planning to prevent recurrence and ensure optimal patient outcomes.