Issaiah Nicolle L.

Cecilia October 15, 2020

3 NRS A Prof. Lacambra

Let’s begin with small leap.

PRIORITY CONCEPT: Gas exchange and Perfusion
RLE ACTIVITY 1
CRITICAL THINKING What Should You Do?
A victim of a gunshot wound to the chest sustained a penetrating injury. The emergency medical
response team applied a nonporous dressing over the victim’s sucking chest wound at the site of
the accident. On arrival at the, the victim is cyanotic, and the nurse notes subcutaneous
emphysema (crepitus) and tracheal deviation away from the affected side. What should the nurse
do?
The patient is experiencing a tension pneumothorax caused by penetrating trauma (gunshot
wound).
Pneumothorax is an accumulation of air in the thoracic cavity between the parietal and visceral
pleurae. It can occur when there is a buildup of intrathoracic pressure in the pleural space and air
cannot escape. The loss of negative intrapleural pressure results in collapse of the lung. The
possible cause of this is the covering of an open chest wound.
Signs and symptoms of a pneumothorax include cyanosis, sudden, sharp pain with breathing
or coughing on the affected side, tachycardia, tachypnea, dyspnea, hypotension, subcutaneous
emphysema as evidenced by crepitus on palpation, neck vein distention, hyperresonance to
percussion, tachycardia, sucking sound with open chest wound, anxiety, and restlessness. The
nurse will hear no sounds of air movement on auscultation on affected side. Meanwhile, tracheal
deviation away from the affected side indicates a tension pneumothorax, which is a medical
emergency. This is a medical emergency requiring possible needle decompression followed by
chest tube insertion with a chest drainage system with continuous negative pressure.to re-expand
the lung and remove air and fluid.

POSSIBLE NURSING DIAGNOSIS

 Impaired gas exchange related to decreased oxygen diffusion capacity.
 Ineffective breathing pattern related to decreased lung expansion due to air or fluid
accumulation.
 Ineffective peripheral tissue perfusion related to severe hypoxemia.
 Acute pain related to the positive pressure in the pleural space.
 Anxiety related to difficulty in breathing.
 PLANNING EVALUATION
NURSING GOAL / NURSING RATIONALE
ASSESSMENT DIAGNOSIS EXPECTED INTERVENTIONS
OUTCOME
Objective Ineffective SHORT TERM Immediately release the chest Tension pneumothorax SHORT TERM
 Cyanotic breathing GOAL wound dressing and contact occur due to covering of GOAL
 Dyspnea pattern related After 8 hours of the health care provider. an open chest wound. After 8 hours of
 Tacypnea to decreased nursing Thus, this chest wound nursing
lung expansion interventions, the dressing should be interventions, the
 Subcutaneous
due to air or patient will be removed immediately. patient
emphysema
fluid able to establish established an
(Crepitus) on
accumulation an improvement Evaluate respiratory function, Respiratory distress and improvement in
palpation in respiratory rate, noting rapid or shallow changes in vital signs respiratory rate,
 Neck vein depth, and pattern. respirations, dyspnea, reports occur because ofdepth, and
distention of “air hunger,” development physiological stress and pattern.
 Tracheal deviation LONG TERM of cyanosis, and changes in pain or may indicate
 Diminished or GOAL vital signs. development of shock LONG TERM
absent breath After a series of due to hypoxia or GOAL
sounds over the nursing hemorrhage. After a series of
affected area intervention, the nursing
patient will be Auscultate breath sounds. Breath sounds may be intervention, the
VS taken as follows: able to establish a diminished or absent in patient
T – 37.0 C normal and a lobe, lung segment, or established a
P – 105 bpm effective entire lung field normal and
RR – 32 cpm breathing pattern (unilateral). Atelectatic effective
BP – 90/50 mmhg within normal area will have no breath breathing pattern
O2 – 90% range. sounds, and partially within normal
collapsed areas range.
have decreased sounds.
Assess hemodynamics and Tension pneumothorax
vital signs. can cause a significant
decrease in cardiac
output and is a medical
emergency. Early
intervention is the key
to good outcomes.

Note chest excursion and Chest excursion is

position of trachea. unequal until lung re-
expands. Trachea
deviates from affected
side with tension
pneumothorax.

Administer oxygen as It can help to reduce the

prescribed. size of the
pneumothorax by
decreasing the alveolar
nitrogen partial
pressure. Aids in
reducing work of
breathing; promotes
relief of respiratory
distress and cyanosis
associated with
hypoxemia.
Place the client in a Fowler’s
position. Promotes maximal
inspiration; enhances
 lung expansion and
ventilation in unaffected
side.
Prepare for chest tube
placement, which will remain Tension pneumothorax
in place until the lung has requires immediate
expanded fully. Provide needle depression,
appropriate post-procedure followed by chest tube
care. placement. Chest tube
placement is the
treatment of choice for
traumatic
hemopneumothoraxes.
Monitor the chest tube
drainage system, assess for A chest drainage system
air leaks in the system and needs to be a
keep it secure. continuously closed
system to maintain the
negative pressure
necessary for normal
respiratory function.
Any air leak interrupts
this closed system.
Note character and amount of
chest tube drainage, whether Useful in evaluating
tube is warm and full of resolution of
blood and whether bloody pneumothorax or
fluid. development of
level in water-seal bottle is hemorrhage requiring
rising. prompt intervention.
Educate patient on chest Rapid, shallow
expansion exercises. breathing, plus a
collapsed lung, means a
high risk for atelectasis
and pneumonia. Deep
breathing exercises like
Incentive Spirometry
and Turn, Cough, Deep
Breathe, can help
reinflate the lungs