Chapter 22: Pneumothorax, Hemothorax, and Flail Chest

Nursing Interventions for the client with Pneumothroax/Hemothorax

-Administer O2 therapy -Auscultate heart and lung sounds and monitor vital signs every 4 hrs -Check ABG's, SaO2, CBC, and chest Xray results -Position client to maximize ventilation (High-Fowler's = HOB 90*) -Monitor chest tube drainage -Encourage prompt medical attention when evidence of infection occurs -Instruct client to deep breath to promote lung expansion -Set up referral services (home health, respiratory services) to provide portable O2 if needed

Nursing Interventions for the client with a Flail Chest

-administer humidified O2 -monitor Vital Signs and SaO2 -review finding of pulmonary functinon tests (PFTs), periodic chest xrays, and ABG's -auscultate lung sounds, color, and capillary refill -promote lung expansion by encouraging deep breathing and proper postioning -assist with the care of suctioning trachea endotracheal tube as needed -administer pain medication, PCA or epidural block is commonly used -ensure access to IV fluids as prescribed -Monitor I&O -Offer support and reassurance by explaining all procedures

Expected Findings for client with Pneumothorax/Hemothorax

-anxiety -pain Physical Findings: -Manifestations of Respiratory Distress: -tachypnea -tachycardia -hypoxia -cyanosis -dyspnea -use of accessory muscles -Tracheal deviation to the unaffected side (tension pneumothorax) -Reduced or absent sounds on the affected side -Asymmetrical chest wall movement -Hyperresonance on percussion due to trapped air (pneumothorax) -Dull percussion (hemothorax) -Subcutaneous emphysema (air accumulating in subcutaneous tissue)

Risk Fx : Pneumothorax & Hemothorax

-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

Client Education regarding Pneumothorax/Hemothorax

-take rest periods as needed -get vaccinations (influenza & pneumonia) -recovery from a pneumothorax/hemothorax can be lengthy -do not smoke -follow-up care is important, report the following to the HCP: -upper respiratory infection -fever -cough -difficulty breathing -sharp chest pain

Expected Findings for the client with Flail Chest

-unequal chest expansion (the unaffected side of the chest will expand, while the affected side can appear to diminish in size to remain stationary) -Paradoxical Chest Movement (inward movement of segment during inspiration, outward movement pf segment during expiration) -tachycardia -hypotension -dyspnea -cyanosis -anxiety -chest pain

Medications used for Pneumothorax/Hemothorax

1) Benzodiazepines (sedatives) : can be used to decrease anxiety -Lorazepam -Midazolam Nursing Actions: -Monitor Vital Signs (Benzodiazepines can cause hypotension and respiratory distress) -Monitor paradoxical effects (Euphoria, rage) Client Education: -Medications have amnesic effects and can cause drowsiness 2) Opioid Agonists (pain medication) : used to treat moderate to severe pain Can also cause: -pain relief -respiratory depression -euphoria -sedation -decrease in GI motility -Morphine Sulfate -Fentanyl Nursing Actions: -Use cautiously in clients with Asthma and Emphysema -due to risk of respiratory depression -Check client's pain level every 4 hrs -Remind client taking fentanyl patch, that initial patch takes several hours to take effect -a short acting pain medication is administered for breakthrough pain -If respirations are < 12/min, stop the medication and notify HCP immediately -Monitor for signs of Hypotension & Bradypnea -Observe for Nausea and Vomiting -Check level of sedation (drowsiness, LOC) -Monitor for Constipation -Encourage fluid intake and activity (related to decrease in GI motility/avoid constipation) -Monitor I&O and fluid retention (common in clients who have an enlarged prostate) Client Education: -Clients who do not have fluid restrictions due to other conditions should drink plenty of fluids to prevent constipation -Use a patient-controlled analgesia (PCA) pump if applicable -the client is the only person who should push the button -the safety lockout mechanism administration on the PCA prevents overdosing

Therapeutic Procedures for client with Pneumothorax/Hemothorax

1) Chest Tube Insertion: inserted in the pleural space to drain fluid, blood, or air; re-establish a negative pressure; facilitate lung expansion ; and restore normal intrapleural pressure Nursing Action: -Verify informed consent has been obtained -Monitor Status -Vital Signs -SaO2 -Chest tube drainage -Report abnormalities to the HCP and administer pain medications -Continually monitor vital signs and client's response to the procedure -Monitor chest tube placement, function, and dressing

Dx Procedures for Pneumothorax/Hemothorax

1) Chest Xray: -used to confirm pneumothorax and hemothorax 2) Thoracentesis : surgical perforation of the chest wall and pleural space with a large-bore needle -can be used to confirm Hemothorax Nursing Action: -Ensure informed consent has been obtained -Make sure the client understands the importance of remaining still during the procedure (no moving, coughing, or deep breathing) -Assist with client positioning and specimen transport -Assist the client to the edge of the bed and lean over a bedside table (Orthopneic Position) -Inform the client they will feel discomfort when local anesthetic solution is injected *-When the needle is inserted into the lung, some pressure can be felt, but no pain

Complications associated to Pneumothorax/Hemothorax

1) Decreased Cardiac Output : -the amount of blood pumped by the heart decreases as intrathoracic pressure rises -hypotension develops Nursing Action: -assist with the care of client receiving IV fluids and blood products -monitor heart rate and rhythm -monitor I&O (chest tube drainage) 2) Respiratory Failure : -inadequate gas exchange due to lung collapse Nursing Action: -assist in preparing for mechanical ventilation -monitor respiratory status

ABG findings for a client with Pneumothorax/Hemothorax

ABG's : Hypoxemia : PaO2 < 80m Hg -Normal Range : 80-100m Hg

Risk Fx for Flail Chest

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

Interprofessional Team for the client with Pneumothorax/Hemothorax

Respiratory Services: should consulted for : -ABG's -breathing tx -suctioning for airway management Pulmonary Services: should be consulted for: -chest tube management -pulmonary care Pain Management Services: should be consulted if pain persists or is uncontrolled Rehabilitation Care : consulted for : -if client has prolonged weakness and needs assistance with an increasing level of activity

Spontaneous Pneumothorax

a small bleb on the lung ruptures and air enters the pleural space -can occur when there has been no trauma

Hemothorax

an accumulation of blood in the pleural space Expected Finding: -Dull Percussion

Flail Chest

inability of the injured side of the chest to expand adequately upon inhalation and contract upon exhalation -one side of the chest is typically affected due to multiple rib fractures

Flail Chest

occurs when at least two neighboring ribs, usually on one side of the chest, sustain multiple fractures causing instability of the chest wall and paradoxical chest wall movement -this results in significant limitation in chest wall expansion

Pneumothorax

the presence of air or gas in the pleural space that causes lung collapse Expected Finding: -Hyperresonance on percussion due to trapped air

Tension Pneumothorax

when air enters the pleural space during inspiration through a one-way valve and is not able to exit upon expiration The trapped air causes pressure on the heart and lung -As a result: -increase in pressure compresses blood vessels and limits venous return, leading to a decrease in cardiac output -air pressure continues to rise in the pleural cavity, which causes a mediastinal shift -death can result if not treated immediately Expected Finding: -Tracheal deviation to the unaffected side