What is the priority intervention for tension pneumothorax?

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Lecture on Pneumothorax
Pneumothorax NCLEX Review
Pathophysiology of Pneumothorax
Types of Pneumothorax to remember for the NCLEX exam
Signs & Symptoms of Pneumothorax:
Nursing Interventions for Pneumothorax:

This is an NCLEX review for pneumothorax. Patients who have a pneumothorax are experiencing a collapse lung due to air leaking into the intrapleural space.

In the previous review, I covered other respiratory disorders. So, if you are studying for NCLEX or your nursing lecture exams be sure to check out that section.

When taking care of a patient with a pneumothorax it is very important the nurse knows how to recognize the typical signs and symptoms seen in this condition, how it is diagnosed, nursing interventions, and patient education.

Don’t forget to take the pneumothorax quiz.

In this NCLEX review for pneumothorax, you will learn the following:

-Definition of pneumothorax -Pathophysiology of pneumothorax -Different types (closed, open, and tension pneumothorax) -Signs and Symptoms

-Nursing Interventions

Lecture on Pneumothorax

Pneumothorax NCLEX Review

Definition: the collapsing of a lung due to air accumulating in the pleural space (the space between the visceral and parietal pleura which is also called the intrapleural space). Learn more about lung anatomy and physiology.

Key Points to Remember about Pneumothorax:

It can be a partial or total collapse of the lung (mainly affects one lung).
Causes include but not limited to: spontaneous (without warning), trauma to the chest (blunt or penetrating), lung disease, medical procedures (central line placement, mechanical ventilation).
It is diagnosed with a chest x-ray, ultrasound, or CT scan.
A small pneumothorax usually resolves on its own.
A large pneumothorax usually requires treatment like a chest tube to remove air from intrapleural space or needle aspiration (as with a tension pneumothorax).

Pathophysiology of Pneumothorax

The visceral pleura (attaches to the lungs) and parietal pleura (attaches to the chest wall) are separated by a small amount of serous fluid and this space is called the intrapleural space. In a pneumothorax, this is where the air collects that causes the lung to collapse.

The intrapleural space allows the visercal and parietal pleura to glide over one another during inhalation and exhalation which creates a negative pressure. The negative pressure acts like suction to keep the lungs inflated.

Therefore, if air enters the intrapleural space it causes a buildup of pressure (remember under normal condition the lungs like negative pressure) which decreases the ability of the lungs to recoil and pushes the lung away from the chest which leads to collapse.

Types of Pneumothorax to remember for the NCLEX exam

Open Pneumothorax: an opening in the chest wall (from a gun shot, stabbing etc.) that causes a passage between outside air and the intrapleural space. This allows air to pass back and forth during inspiration and expiration. Therefore, the body will shunt air through the chest wall opening instead of the trachea .

Remember, normally you have air passing through trachea (not the chest wall) to the lungs while breathing. Because of this you may hear a “sucking sound” This type of pneumothorax is also known as a sucking chest wound.
Nursing intervention for an open chest wound: place a sterile occlusive dressing over the opening and tape it on 3 sides (leaving the 4th side free from tape). This prevents the wound from being occluded. This type of dressing will allow exhaled air to leave the opening but seal over the opening when inhaling (hence preventing a tension pneumothorax).

Closed Pneumothorax: when air leaks into the intrapleural space without any outside wound (hence the chest wall and pleural stay intact). Example of what can cause this: a rib fracture where the sharp, bony part of the bone punctures the lung causing air to be released into the intrapleural space. Another common cause of closed pneumothorax is called spontaneous pneumothorax:

Spontaneous Pneumothorax: a defect in the alveolar wall and visceral pleura where air enters into the intrapleural space. An example: pulmonary bleb (sac-like blister that develops on the visceral pleura that ruptures and leaks air into the pleural space). This causes pressure to build up in the intrapleural space and causes the lung to collapse. It known as a “spontaneous” pneumothorax because the pneumothorax was NOT caused by an injury.
Patients can have multiple pulmonary blebs and they don’t have to rupture immediately. Exact cause of rupture is not totally understood but things that can increase the rupture of a bleb include: change in air pressure, taking a sudden, deep breath, or smoking

Two classifications of Spontaneous Pneumothorax:

Primary spontaneous pneumothorax: occurs in people without lung disease and they tend to be young <30 years of age and tall and thin.
Secondary spontaneous pneumothorax: occurs in people with lung disease (copd, asthma, cytic fibrosis).

Tension pneumothorax: a complication of a pneumothorax (can happen with open or closed pneumothorax). This is a medical emergency. It happens when the opening to the intrapleural space creates a one-way valve…where air collects into the space but never leaves. This causes major compression on the lungs and heart. The patient will have a mediastinum shift, increased intrathoracic pressure and decreased venous return.

Patho of tension pneumothorax: AIR CANNOT ESCAPE the intrapleural space -> there is shift of the mediastinum as pressure builds in the space -> patient tries to compensate by increasing breathing (tachypnea) to maintain oxygen level but this doesn’t work, patient will have hypoxia -> there will be compression on the vena cava (remember the vena cava normally drains blood to the heart but it can’t now) ->suppose to draining blood back to the heart…the heart then has nothing to pump…hence decreased cardiac output
Anatomy changes with a tension pneumothorax: mediastinal shift causes heart, trachea, esophagus, and vessels to shift to the UNAFFECTED side and this will compress the unaffected lung and venous vessels.
Major Signs and Symptoms of Tension Pneumothorax:
- Major: Tachycardia, Tachypnea, Hypotension and Hypoxia
- As well as: Respiratory distress, jugular venous distention, tracheal deviation (LATE SIGN)
If a patient is on mechanical ventilation w/ PEEP (positive end-expiratory pressure) they are at risk for a tension pneumothorax due to barotrauma which causes buildup of pressure in the intrapleural space from rupture of the visceral pleura.
Treatment for tension pneumothorax: needle decompression: …a needle is inserted into the intrapleural space to remove air…..performed by physician.

Signs & Symptoms of Pneumothorax:

Remember the mnemonic: COLLAPSED

Chest pain (sharp and sudden and worst on inspiration), Cyanosis

Overt tachycardia and tachypnea

Low blood pressure

Low SpO2

Absent lung sounds on affected side

Pushing of trachea to unaffected side (tension pneumo.)

Subcutaneous emphysema (escaping carbon dioxide collecting in the skin…crunchy bulges on the skin), Sucking sound with open pneumothorax

Expansion of chest rise and fall unequal

Dyspnea

Nursing Interventions for Pneumothorax:

Monitor breath sounds (equal sounds on both sides), equal rise and fall of the chest, vital signs (HR, blood pressure, oxygen saturation), and patient effort of breathing, subq emphysema (can be found on the face, abdomen, armpits, neck (affects breathing), administering oxygen as ordered
Maintain chest tube drainage system if placed by physician:
- Assessing for air leaks in the system, keep it secure
- Troubleshooting if drain comes out or system breaks
  - Water seal chamber: may have intermittent bubbling as air is drained from the pleural space. The water seal chamber fluctuates as the patient breathes in and out. If it stops fluctuating there may be a kink somewhere or the lung has re-expanded. NOT normal to have excessive bubbling in the water seal chamber (air leak somewhere).
Keep HOB of the bed elevated…Fowler’s position

References

What Are Pleurisy and Other Pleural Disorders? – NHLBI, NIH. (2011). Nhlbi.nih.gov. Retrieved 6 December 2016, from https://www.nhlbi.nih.gov/health/health-topics/topics/pleurisy