NursingBulletin:

Notes on
PNEUMOTHORAX AND
MASTERY QUESTIONS
 Pleurae fluid disorders: all treated
with water seal chamber
Fluid Disorder: Color

Air Pneumothorax: no fluid

Trapped Air
Blood
Fluid between pleural lining
(exudates or transudates)
Pus between pleural lining
Lymphatic fluid
drainage
Tension Pneumothorax: a
nursing and medical
emergency
Hemothorax: bloody or
brownish color
Pleural Effusion: clearer
yellowish color
Empyema: yellowish or
greenish color
Chylothorax: milky white color
 Pneumothorax:
Opening that connect the outside
air with intrapleural space; result
is that air flows into intrapleural
space; this eliminates the
pressure gradient between the
thoracic cavity and the
atmosphere, and the lungs cannot
inflate
• Collapse of a lung resulting from
disruption of the negative
pressure of air in the pleural
cavity; may be associated with
fractured rib
• Reduces the surface area for
gaseous exchange and leads to
hypoxia and retention of carbon
dioxide (hypercarbia)
 Types of Pneumothorax:
• Spontaneous: thought to occur when a
weakened area of the lung (bleb) ruptures; air
then moves from the lung to the intrapleural
space causing collapse; highest incidence is
in men 20 to 40 years of age.

• Open: laceration (e.g., a stab wound) through

the chest wall into the intrapleural space. Hole
in the chest wall, communicates with the lung

• Hemothorax: collection blood within the

pleural cavity.
 Types of Pneumothorax
• Hydrothorax: accumulation of fluid in the pleural
cavity.

• Tension: buildup of pressure as air accumulates

within the pleural space; the pressure increase
likely to induce a mediastinal shift.
• Closed pneumothorax: air is forced into the
pleural space with a continued pressure
build up. Hole in lung, chest wall intact
• Shifts mediastinum away from the affected
side with results of a compressed heart
• Cardiac and respiratory arrest if not treated
 : Mediastinal Shift may occur toward the uninvolved side as a
result of increased pressure within the pleural space; this involves
the trachea, esophagus, heart, and great vessels.
Complications of Pnuemothorax
• Low Blood oxygen levels
• Respiratory Failure
• Cardiac Arrest
• Shock
Clinical Findings
• Subjective:
– Chest pain, usually described as sharp and increasing on
exertion
– Dyspnea and drowsiness
• Objective:
– Rapid, shallow respirations (nonsymmetric)
– Breath sounds on the affected side will be diminished or
absent
– Chest x-rat examination will reveal extent of the
pneumothorax
– Tachycardia
– Tachypnea
– Hypotension
– Decreased chest expansion unilaterally
– Cyanosis
– Hypotension
– Tracheal deviation to the affected side wit tension
pnemothorax
Assessment
1. Auscultation of lung fields for diminished or
absent breath sounds
2. Chest percussion for hyperresonance
3. Check motion during inhalation for inequality
4. Baseline Vital Signs
5. Skin for changes in color
6. Auscultate breath sounds to observe for signs
of pneumothorax when the client is on PEEP
(lung tissue that is frail may not withstand
increased intrathoracic pressure, and
pneumothorax occurs)
7. Monitor ABG (Respiratory Acidosis)
Diagnosis: Impaired Gas Exchange
Goal: to relieve the pressure on the lung,
allowing it to re-expand, and to prevent
recurrences.
 Implementations
• Maintain constant supervision until stable
• Maintain patency of
• chest tubes
• Place in high-Fowler’s position
• Offer fluids frequently
• Monitor vital signs, particularly respirations
• Apply dressing over an open chest wound
• Oxygen as prescribed
• Chest tube placement
• Monitor for chest tube system
 Indications for CTT
• If fluid, such as blood, or air, gets into the pleural
space, the lung can collapse, preventing
adequate air exchange. Chest tubes are used to
treat conditions that can cause the lung to
collapse, such as:
• air leaks from the lung into the chest
(pneumothorax)
• bleeding into the chest (hemothorax)
• after surgery or trauma in the chest
(pneumothorax or hemothorax)
• lung abscesses or pus in the chest (empyema).
 Chest Tube Insertion
• Chest tubes are inserted to drain blood, fluid, or air and
allow full expansion of the lungs. The tube is placed in the
pleural space.

• The area where the tube will be inserted is numbed (local

anesthesia). The patient may also be sedated.
• The chest tube is inserted between the ribs into the chest
and is connected to a bottle or canister that contains sterile
water. Suction is attached to the system to encourage
drainage. A stitch (suture) and adhesive tape is used to keep
the tube in place.
• The chest tube usually remains in place until the X-rays
show that all the blood, fluid, or air has drained from the
chest and the lung has fully re-expanded. When the chest
tube is no longer needed, it can be easily removed, usually
without the need for medications to sedate or numb the
patient. Medications may be used to prevent or treat
infection (antibiotics).
 Types of Chest Tube Drainage
1. Three-chamber system: includes one chamber
that serves to collect drainage, one that acts as
water-seal, and one that has levels of water to
control the amount of suction regardless of the
amount of negative pressure applied.
2. Commercially prepared plastic unit designed
for closed chest suction: combines the features
of the other systems and may or may not be
attached to suction (e.g., PleurEvac)
 Nursing Care for pt with CTT:
• Ensure that the tubing is not kinked; tape
all connections to prevent separation
• Do not milk the tube
• Maintain the drainage system below the
level of the chest; mark and monitor
drainage
• Turn the client frequently, making sure the
chest tubes are not compressed.
• Observe for fluctuation of fluid in tube; the
level will rise on inhalation and fall on
exhalation; if there are no fluctuations,
either the lung has expanded fully or the
chest tube is clogged
 Nursing Care for pt with CTT:
• Place two clamps at your bedside for use if the
underwater-seal bottle is broken; clamps are used
judiciously and only in emergency situations

• Encourage coughing and deep breathing every 2

hours, splinting the area as needed

• After lung re-expansion is verified by chest x-ray,

instruct the client to exhale or strain (Valsalva’s
Maneuver) as the tube is withdrawn by the
physician; apply a gauze dressing immediately
and firmly secure the tape to make an airtight
dressing
 Complications of CTT
• Complications of tube thoracostomy
include death, injury to lung or
mediastinum, hemorrhage (usually from
intercostal artery injury), neurovascular
bundle injury, infection, bronchopleural
fistula, and subcutaneous or
intraperitoneal tube placement
 Pneumothorax Mastery Questions
1. A client with emphysema experiences a
sudden episode of shortness of breath. The
physician diagnoses a spontaneous
pneumothorax. The nurse is aware that the
probable cause of the spontaneous
pneumothorax is a:
a. pleural friction rub
b. tracheoesophageal fistula
c. rupture of subpleural bleb
d. puncture wound of the chest wall
Pneumothorax Mastery Questions
2. When a spontaneous pneumothorax is
suspected in a client with a history of
emphysema, the nurse should call the
physician and:
a. administer 60% O2 via Venturi mask
b. Place the client on the unaffected side
c. Give O2 2L per minute via nasal cannula
d. Prepare for IV administration of
electrolytes
Pneumothorax Mastery Questions
3. When teaching a client about a spontaneous
pneumothorax, the nurse bases the explanation
on the understanding that:
a. The heart and great vessels shift into the
affected side
b. The other lung will collapse if not treated
immediately
c. Inspired air will move from the lung into the
pleural space
d. There is a greater negative pressure within
the chest cavity
 Pneumothorax Mastery Questions
4. Following a spontaneous pneumothorax,
the client becomes extremely drowsy
and the pulse and respirations increase.
The nurse should suspect:
a. hypercapnia
b. hypokalemia
c. an elevated pO2
d.respiratory alkalosis
Pneumothorax Mastery Questions
5. When assessing an individual with a
spontaneous pneumothorax, the nurse
should expect dyspnea and:
a. hematemesis
b. unilateral chest pain
c. increased chest motion
d. mediastinal shift towards the involved side
 Pneumothorax Mastery Questions
6. When a client suffers a complete
pneumothorax, there is danger of
mediastinal shift. If such a shift occurs, it
may lead to:
a. Infection of the subpleural lining
b. Decreased filling of the right heart
c. Rupture of the pericardium or aorta
d. Increased volume of the unaffected lung
 Pneumothorax Mastery Questions
7. The physician inserts a chest tube in a client who
has been stabbed in the chest and attaches it to a
closed drainage system. When caring for the client,
the nurse should:
a. Apply a thoracic binder to prevent tension on the
tube
b. Observe for fluctuations in the water-seal chamber
c. Clamp the tubing to prevent a rapid decline in
pressure
d. Administer morphine sulfate, because the client will
be agitated
 Pneumothorax Mastery Questions
8. Complete lung expansion before the
removal of the chest tubes is evaluated
by:
a. Return of normal tidal volume
b. Absence of additional drainage
c. Decreased adventitious sounds
d. Comparison of chest radiographs
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