Last updated on December 28th, 2023
Here you will find three Pneumothorax nursing care plans based on a hypothetical case scenario. It will include three sample nursing care plans with NANDA nursing diagnoses, nursing assessment, expected outcome, nursing interventions, and rationales.
What is Pneumothorax?
Pneumothorax is called a collapsed lung. It occurs when the air escapes from the lungs but remains within the pleural cavity.
There are three main types of pneumothoraces. Namely, Simple Pneumothorax, Tension Pneumothorax, and Open Pneumothorax.
Causes of pneumothorax include:
- Traumatic injury to the lungs,
- Certain lung diseases such as CODP, asthma, tuberculosis, whooping cough, and cystic fibrosis
Additionally, primary spontaneous pneumothorax occurs without a specific underlying cause. People who are at risk of this type of pneumothorax are:
- Tall and thin otherwise healthy people
- Smokers
- Pregnancy
- Marfan syndrome
- Familial pneumothorax
The most common symptoms are sharp, severe, radiating chest pain with shortness of breath.
Pneumothorax Nursing Care Plan – Case Scenario
A 37-year old female presents to the ED after a motor vehicle accident with complaints of shortness of breath and chest pain. The patient reports that she was driving home when she was struck head-on by an oncoming vehicle. The patient was wearing her seatbelt and has no past medical history.
Upon assessment, the patient appears anxious and restless. Her heart rate is 125 BPM, blood pressure is 89/43 (57) mmHg, respiratory rate is 35 breaths per minute, and oxygen saturation is 87% on nonrebreather. Her fingertips and lips are cyanotic. Upon auscultation, no lung sounds can be heard on the right side of the patient’s chest.
An arterial blood gas is drawn and pH is 7.29, paCO2 is 56 mmHg, paO2 is 52 mmHg, HCO3 is 22 mEq/L, showing severe respiratory acidosis.
A stat chest x-ray is performed and shows 8th and 9th right-sided rib fractures and also states “peripheral space on the right side is radiolucent compared to the left lung, and no lung markings are seen peripheral to the line of the visceral pleural edge, suspect pneumothorax.”
The patient is admitted to the hospital for a right-sided pneumothorax.
#1 Nursing Care Plan for Pneumothorax – Impaired Gas Exchange
Nursing Assessment
Subjective Data:
- The patient reports shortness of breath and chest pain
Objective Data:
- Cyanotic fingertips and lips
- Tachypnea and hypoxemia
- Respiratory acidosis
- Rib fractures
Nursing Diagnosis
Impaired gas exchange related to decrease in functioning lung tissue as evidenced by hypoxemia and respiratory acidosis
Goal/Desired Outcome
Short-term goal: The patient will report an improvement in shortness of breath, be weaned down to 2L nasal cannula, and exhibit an improving acid-base balance by the end of the shift
Long-term goal: The patient’s lung will re-expand and will suffer no long-term respiratory complications
Nursing interventions with rationale for pneumothorax – Impaired gas exchange
| Nursing Interventions | Rationales |
| Prepare for chest tube placement | A chest tube will evacuate the air or fluid, allowing the lung to re-inflate |
| If a significant amount of blood (>1500 ml) is found in the pleural space, a thoracotomy may be recommended | A thoracotomy surgically opens the chest wall and can more effectively drain large amounts of air and blood from the pleural space |
| Monitor complete blood count and consider autotransfusion if needed | If the blood count is low, autotransfusion can filter blood expelled from the chest and reinfuse it into the patient’s circulation, avoiding the need for a traditional blood transfusion |
| Monitor oxygenation status | A worsening in hypoxemia may indicate the need for increased oxygen support, such as intubation |
| Instruct the patient to regularly strain or bear down against a closed glottis | Applying internal chest pressure can force air out of the pleural space and help inflate the lung |
#2 Sample Nursing Care Plan for Pneumothorax – Risk for Injury
Nursing Assessment
Subjective Data:
- The patient reports chest pain and shortness of breath
Objective Data:
- The patient is restless and anxious
- Hypoxemic on ABG
- Rib fractures and collapsed lung are confirmed on x-ray
Nursing Diagnosis
Risk for injury related to a collapsed lung and subsequent chest tube placement as evidenced by restlessness, anxiety, and hypoxemia
Goal/Desired Outcome
Short-term goal: The chest tube remains intact, with no air leak or crepitus noted by the end of the shift.
Long-term goal: The patient’s lung re-inflates and experiences no long-term side effects from chest tube placement
Nursing interventions with rationale for pneumothorax – Risk for injury
| Nursing Interventions | Rationales |
| Monitor the chest tube unit for any bubbling or kinks in the tubing | Bubbling can indicate an air leak. Kinking or clamping can cause a tension pneumothorax, do not clamp without a physician’s order |
| Tape all connections of the chest tube and maintain the prescribed level of suction | It’s important to maintain a closed system free from leaks. Suction can vary from -10 to -20 mmHg, and rarely exceeds -25 mmHg |
| Perform a fall risk evaluation and enact the proper safety interventions | The fact that the patient is attached to a chest tube unit, in addition to being restless, anxious, and hypoxemic, means she is at high risk for a fall |
| Change the chest tube dressing daily and as needed, monitoring the site for signs and symptoms of infection | Aseptic technique for dressing changes is important for infection prevention. Redness, warmth, and drainage can indicate an infection. |
| Palpate chest and neck for crepitus | Subcutaneous emphysema is a complication of chest tubes and indicates an air leak into subcutaneous tissue which can be life-threatening |
#3 Sample Nursing Care Plan for Pneumothorax – Acute Pain
Nursing Assessment
Subjective Data:
- The patient reports chest pain
Objective Data:
- The patient is restless and anxious
- Tachycardia and tachypnea
- Rib fractures confirmed on chest x-ray
Nursing Diagnosis
Acute pain related to complications from motor vehicle accident as evidenced by restlessness, anxiety, tachycardia, and tachypnea
Goal/Desired Outcome
Short-term goal: The patient will report a reduction of pain to an acceptable and tolerable level by the end of the shift
Long-term goal: The patient will have no acute or chronic pain issues
Nursing interventions with rationale for pneumothorax – Acute pain
| Nursing Interventions | Rationales |
| Manage pain with prescribed analgesics | Lidocaine should be administered locally with chest tube insertion. Intravenously, fentanyl and morphine are commonly prescribed to manage chest tube pain |
| Monitor oxygen status and the effects of analgesia | Opiates can depress the respiratory system and should be used judiciously. Naloxone should be used to reverse opiates if overdose or complications are noted |
| Utilize non-pharmacologic pain relief measures | Cold application and relaxation techniques have been shown to help relieve pain without the use of medications |
| Stabilize chest tube to the patient with the adhesive device | This prevents any pulling or accidental removal of the chest tube |
| Educate patient about interventions to help with rib fractures | Interventions such as sitting upright, or splinting the chest with a pillow while coughing has been shown to significantly lessen pain. It’s also important to educate the patient about the importance of taking deep breaths to prevent pneumonia. Tools such as an incentive spirometer can be helpful |
Conclusion
Here you have learnt how to create a pneumothorax nursing care plan including nursing assessment, NANDA nursing diagnosis, expected outcome, and nursing interventions with rationales.
Reference
Ackley, B., Ladwig, G., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing Diagnoses Handbook: An Evidence-based Guide to Planning Care (12th ed.). Elsevier.
Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.
Swearingen, P. (2016). ALL-IN-ONE CARE PLANNING RESOURCE (4th ed.). Elsevier/Mosby.
