Nursing Care Plan Hemothorax / Pneumothorax

CARE SETTING

Inpatient medical or surgical unit.

RELATED CONCERNS

1. Cardiac surgery: postoperative care
2. Chronic obstructive pulmonary disease (COPD) and asthma
3. Psychosocial aspects of care
4. Pulmonary tuberculosis (TB)
5. Ventilatory assistance (mechanical)
6. Patient Assessment Database
7. Findings vary, depending on the amount of air and/or fluid accumulation, rate of accumulation, and underlying lung function.

ACTIVITY/REST

May report: 
Dyspnea with activity or even at rest

CIRCULATION

May exhibit: 

1. Tachycardia; irregular rate/dysrhythmias
2. S3 or S4/gallop heart rhythm (heart failure secondary to effusion)
3. Apical pulse reveals point of maximal impulse (PMI) displaced in presence of mediastinal shift (with tension pneumothorax)
4. Hamman’s sign (crunching sound correlating with heartbeat, reflecting air in mediastinum)
5. BP: Hypertension/hypotension
6. JVD

EGO INTEGRITY

May exhibit: 
Apprehension, irritability

FOOD/FLUID

May exhibit: 
Recent placement of central venous IV/pressure line (causative factor)

PAIN/DISCOMFORT

May report 
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)

May exhibit: 

1. Guarding affected area
2. Distraction behaviors
3. Facial grimacing

RESPIRATION

May report: 

1. Difficulty breathing, “air hunger”
2. Coughing (may be presenting symptom)
3. History of recent chest surgery/trauma; chronic lung disease, lung inflammation/infection (empyema/ effusion); diffuse interstitial disease (sarcoidosis); malignancies (e.g., obstructive tumor)
4. Previous spontaneous pneumothorax; spontaneous rupture of emphysematous bulla, subpleural bleb (COPD)

May exhibit: 

1. Respirations: Rate increased/tachypnea
2. Increased work of breathing, use of accessory muscles in chest, neck; intercostal retractions, forced abdominal expiration
3. Breath sounds decreased or absent (involved side)
4. Fremitus decreased (involved site)
5. Chest percussion: Hyperresonance over air-filled area (pneumothorax); dullness over fluidfilled area (hemothorax)
6. Chest observation and palpation: Unequal (paradoxic) chest movement (if trauma, flail); reduced thoracic excursion (affected side)
7. Skin: Pallor, cyanosis, diaphoresis, subcutaneous crepitation (air in tissues on palpation)
8. Mentation: Anxiety, restlessness, confusion, stupor
9. Use of positive pressure mechanical ventilation/positive end-expiratory pressure (PEEP) therapy

SAFETY

May report: 

1. Recent chest trauma (e.g., fractured ribs, penetrating wound)
2. Radiation/chemotherapy for malignancy
3. Presence of central IV line

TEACHING/LEARNING

May report: 

1. History of familial risk factors: Tuberculosis, cancer
2. Recent intrathoracic surgery/lung biopsy
3. Evidence of failure to improve
4. Discharge plan DRG projected length of inpatient stay: 6.5 days
5. considerations: Temporary assistance with self-care, homemaker/maintenance tasks
6. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. 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.
2. Chest x-ray: Reveals air and/or fluid accumulation in the pleural space; may show shift of mediastinal structures (heart).
3. 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.
4. Thoracentesis: Presence of blood/serosanguineous fluid indicates hemothorax.
5. Hb: May be decreased, indicating blood loss.

NURSING PRIORITIES

1. Promote/maintain lung re-expansion for adequate oxygenation/ventilation.
2. Minimize/prevent complications.
3. Reduce discomfort/pain.
4. Provide information about disease process, treatment regimen, and prognosis.

DISCHARGE GOALS

1. Adequate ventilation/oxygenation maintained.
2. Complications prevented/resolved.
3. Pain absent/controlled.
4. Disease process/prognosis and therapy needs understood.
5. Plan in place to meet needs after discharge.