Inpatient medical or surgical unit.
- Cardiac surgery: postoperative care
- Chronic obstructive pulmonary disease (COPD) and asthma
- Psychosocial aspects of care
- Pulmonary tuberculosis (TB)
- Ventilatory assistance (mechanical)
- Patient Assessment Database
- Findings vary, depending on the amount of air and/or fluid accumulation, rate of accumulation, and underlying lung function.
Dyspnea with activity or even at rest
- Tachycardia; irregular rate/dysrhythmias
- S3 or S4/gallop heart rhythm (heart failure secondary to effusion)
- Apical pulse reveals point of maximal impulse (PMI) displaced in presence of mediastinal shift (with tension pneumothorax)
- Hamman’s sign (crunching sound correlating with heartbeat, reflecting air in mediastinum)
- BP: Hypertension/hypotension
Recent placement of central venous IV/pressure line (causative factor)
Unilateral chest pain, aggravated by breathing, coughing, and movement (depending on Sudden onset of symptoms while coughing or straining (spontaneous pneumothorax) the size/area Sharp, stabbing pain aggravated by deep breathing, possibly radiating to neck, shoulders, involved): abdomen (pleural effusion)
- Guarding affected area
- Distraction behaviors
- Facial grimacing
- Difficulty breathing, “air hunger”
- Coughing (may be presenting symptom)
- History of recent chest surgery/trauma; chronic lung disease, lung inflammation/infection (empyema/ effusion); diffuse interstitial disease (sarcoidosis); malignancies (e.g., obstructive tumor)
- Previous spontaneous pneumothorax; spontaneous rupture of emphysematous bulla, subpleural bleb (COPD)
- Respirations: Rate increased/tachypnea
- Increased work of breathing, use of accessory muscles in chest, neck; intercostal retractions, forced abdominal expiration
- Breath sounds decreased or absent (involved side)
- Fremitus decreased (involved site)
- Chest percussion: Hyperresonance over air-filled area (pneumothorax); dullness over fluidfilled area (hemothorax)
- Chest observation and palpation: Unequal (paradoxic) chest movement (if trauma, flail); reduced thoracic excursion (affected side)
- Skin: Pallor, cyanosis, diaphoresis, subcutaneous crepitation (air in tissues on palpation)
- Mentation: Anxiety, restlessness, confusion, stupor
- Use of positive pressure mechanical ventilation/positive end-expiratory pressure (PEEP) therapy
- Recent chest trauma (e.g., fractured ribs, penetrating wound)
- Radiation/chemotherapy for malignancy
- Presence of central IV line
- History of familial risk factors: Tuberculosis, cancer
- Recent intrathoracic surgery/lung biopsy
- Evidence of failure to improve
- Discharge plan DRG projected length of inpatient stay: 6.5 days
- considerations: Temporary assistance with self-care, homemaker/maintenance tasks
- Refer to section at end of plan for postdischarge considerations.
- Thoracic CT: Studies show that CT is more sensitive than x-ray in detecting thoracic injuries, lung contusion, hemothorax, and pneumothorax. Early CT may influence therapeutic management.
- Chest x-ray: Reveals air and/or fluid accumulation in the pleural space; may show shift of mediastinal structures (heart).
- ABGs: Variable depending on degree of compromised lung function, altered breathing mechanics, and ability to compensate. PaCO2 occasionally elevated. PaO2 may be normal or decreased; oxygen saturation usually decreased.
- Thoracentesis: Presence of blood/serosanguineous fluid indicates hemothorax.
- Hb: May be decreased, indicating blood loss.
- Promote/maintain lung re-expansion for adequate oxygenation/ventilation.
- Minimize/prevent complications.
- Reduce discomfort/pain.
- Provide information about disease process, treatment regimen, and prognosis.
- Adequate ventilation/oxygenation maintained.
- Complications prevented/resolved.
- Pain absent/controlled.
- Disease process/prognosis and therapy needs understood.
- Plan in place to meet needs after discharge.