DEFINITION:
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|DEFINITION: pneumothorax: a complete or partial collapse of a lung as result of|RELATED DIAGNOSTIC TESTS: |
|an accumulation of air in the pleural space. May be closed or open. Closed – most|Chest x-ray, abg values, oximetry, CBC |
|commonly spontaneous pneumothorax caused by rupture of small blebs on visceral | |
|pleural space. | |
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|ETIOLOGY: |MEDICAL MANAGEMENT: |
|Cause is unknown but occurs most often in male cigarette smokers with a tendency |Prescribe meds, order labs as needed, order/perform procedures as needed, |
|to recur. Other causes include injury to lungs from mechanical vent, insertion of|monitor for discharge, educate pt re: necessary procedures/treatments needed, |
|subclavian catheter, perforation of esophagus, injury from broken ribs, ruptured |insert chest tube |
|blebs or bullae in a patient with copd. | |
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|PATHOPHYSIOLOGY: |NURSING MANAGEMENT: |
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|Air and fluid in the pleural space caused by a rupture in the visceral pleura or |Admin meds as ordered, mon i/o’s and labs, enc fluids, provide dressing change |
|the pariental pleura and chest wall. air pressure in the pleural space pushes |and chest tube suctioning as needed, eval pain. loc, vs, mon o2 sat, coordinate|
|against the already recoiled lung, causing compression atelectasis,and against |care w/ PT and RT, advocate and educate as needed, tc&db pt q 2-4hrs as ordered|
|the mediastinum, compressing and displacing the heart and great vessels. | |
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|SIGNS & SYMPTOMS: |HEALTH DEVIATION SELF-CARE REQUISITES: |
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|Dyspnea, < movement of involved chest wall, diminished or absent breath sounds on|Adl, o2, ambulation, social isolation, med management, sleep disturbance, vital|
|the affected side, hyperresonance to percussion, mild tachycardia, respiratory |signs, elimination pattern |
|distress (shallow, rapid, resp and air hunger), chest pain and cough, no breath | |
|sounds over affected area, hypotensioin, mediastinal displacement and trachea | |
|shifts to unaffected side. | |
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|REFERENCE PAGES: | |
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|Pg 643-651; med-surg nursing; lewis, heitkemper, dirksen | |
|Pg 20-25; med-surg nursing care; swearingen, ross | |
|Pg 1167-1168; pathophysiology; mccance, huether | |
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