Med-Surg · chapter 11 · Gas Exchange, Airway Management, and Respiratory System Disorders
Disorders of the Lower Respiratory System: Pneumothorax
The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 3 practice questions with the reasoning.
Key points
Pneumothorax mechanism
Air can enter the pleural space when there is trauma through the chest wall, or if there is a rupture of the inner (visceral) pleural layer.
Effect on oxygenation
The accumulation of air increases pressure, causing the lung to collapse and deflate. As a result of collapse and deflation, the lung area available for oxygenation and ventilation is dramatically decreased.
Tension pneumothorax shift
In addition to causing a major amount of lung collapse, the large volume of air exerts high pressure; this can force the heart and trachea to shift.
Respiratory disease risks
Pneumothorax can occur as a result of many medical conditions, especially respiratory diseases such as COPD, asthma, cystic fibrosis, pneumonia, and tuberculosis.
Smoking and COPD risks
Patients with COPD have a significantly higher incidence of pneumothorax when compared with non-COPD patients. For heavy smokers, the risk of pneumothorax is 102 times higher when compared with nonsmokers (McKnight Burns, 2023).
Common symptoms
Respiratory distress is a common clinical manifestation of pneumothorax. Patients commonly report a rapid onset of dyspnea, cough, and intense chest pain that is worse with movement.
Assessment findings
Vital sign abnormalities can include an increased respiratory rate, decreased oxygen saturation, and increased heart rate. Physical assessment findings can include unequal chest expansion and decreased or absent breath sounds.
Tension signs
With tension pneumothorax, low blood pressure, cyanosis, and tracheal deviation (trachea in a non-midline position) can occur (McKnight Burns, 2023).
Diagnosis urgency
Prompt diagnosis of pneumothorax is essential to prevent the possibility of life-threatening complications. Imaging and physical assessment are utilized to identify signs of pneumothorax.
Emergency treatment timing
However, tension pneumothorax is an emergency, and treatment needs to be initiated immediately, without waiting for imaging (McKnight Burns, 2023).
Nursing care focus
Nursing care for a patient with pneumothorax focuses on prompt identification of potential respiratory and circulatory compromise. Anticipating and preparing for potential treatment interventions are key nursing roles.
Occlusive dressing use
If there is an open chest wound from a penetrating trauma, or if a chest tube becomes dislodged, the nurse must be ready to apply a three-sided occlusive dressing, which allows trapped air to escape while preventing more air from entering.
Needle decompression purpose
A needle is inserted between ribs into the pleural space, which allows the air that has accumulated in the pleural space to escape out of the body.
Evaluation outcomes
The most important outcomes related to pneumothorax center on improved oxygenation and lung reexpansion. The nurse monitors pulse oximetry, oxygen requirement, and lung sounds.
Terms to know
- pleural space
- The pleural space is the area between the inner (visceral) pleural layer and the outer (parietal) pleural layer.
- Pneumothorax
- Pneumothorax occurs when air enters the pleural space.
- thoracostomy tube
- A thoracostomy tube, also referred to as a chest tube, is a tube inserted through the skin into the pleural space, to drain air, fluid, or blood.
- Mechanical pleurodesis
- Mechanical pleurodesis involves abrading the parietal pleura, causing the inflammatory response to patch up the break in the pleural space.
- Chemical pleurodesis
- Chemical pleurodesis involves instilling chemicals into the pleural space, with the irritation creating an inflammatory response.
Practice questions
Stuck on select-all-that-apply? How to take them one option at a time.
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Every question here, with the answer
At 1410, a patient with pneumothorax develops low blood pressure, cyanosis, and tracheal deviation. While the team prepares to intervene, which entry best documents the immediate care priority?
- Suspected tension pneumothorax; preparing for immediate needle decompression without waiting for imaging.
- Suspected tension pneumothorax; awaiting blood gas results to determine whether decompression is indicated.
- Suspected tension pneumothorax; preparing for chest x-ray before proceeding with decompression.
- Suspected tension pneumothorax; monitoring the response to oxygen before preparing for decompression.
Answer: Suspected tension pneumothorax; preparing for immediate needle decompression without waiting for imaging.
The section associates these findings with tension pneumothorax and identifies immediate needle decompression as its treatment. Waiting for imaging, a response to oxygen, or blood gas results would delay the required emergency intervention.
At 1900, you are documenting the response to treatment for a patient with pneumothorax and a chest tube. Which information most directly supports your evaluation of the patient's oxygenation and respiratory status over the shift? Select all that apply.
- Integrity of the dressing at the chest tube insertion site.
- Security of the connection between the chest tube and drainage device.
- Changes in the patient's oxygen requirement.
- Lung sounds on reassessment compared with earlier findings.
- Pulse oximetry readings over the shift.
Answer: Changes in the patient's oxygen requirement., Lung sounds on reassessment compared with earlier findings., Pulse oximetry readings over the shift.
The section specifically identifies pulse oximetry, oxygen requirement, and lung sounds as measures to monitor when evaluating respiratory improvement. Dressing integrity and secure tubing connections are important chest-tube care observations, but they do not directly demonstrate improvement in oxygenation or respiratory findings.
At 1000, shortly after a chest tube is connected to treat a pneumothorax, you observe bubbles in the drainage device's water-seal/air-leak monitor. Which note best interprets this observation?
- Bubbles observed in the water-seal/air-leak monitor, indicating a need to increase the prescribed suction.
- Bubbles observed in the water-seal/air-leak monitor, consistent with expected air movement through the drainage system.
- Bubbles observed in the water-seal/air-leak monitor, indicating a break in the drainage system.
- Bubbles observed in the water-seal/air-leak monitor, confirming that adequate wall suction is applied.
Answer: Bubbles observed in the water-seal/air-leak monitor, consistent with expected air movement through the drainage system.
Bubbles are expected in this area as air from a pneumothorax moves through the drainage system; the section describes bubbles as unexpected when the device is evacuating fluid. Adequate wall suction is assessed using the bellows, not bubbling, and the observation does not establish a need to increase prescribed suction.
Where every quote comes from
Section 11.6 Disorders of the Lower Respiratory System: Pneumothorax of Medical-Surgical Nursing by Christy Bowen, Bridget Carey, Jessica Palozie, Maren Reinholdt, OpenStax, 2024. Read the whole section free at openstax.org.
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