Nursing diagnosis of a patient with pneumothorax

May 7, 2024
A 25 years old male patient, admitted to emergency then transfer to the surgical department, The
patient complains of discomfort in the right side of the chest and difficulty breathing) Dyspnea ) . The
patient with free PSH PMH, and NKDA allergy, patient prepper for operation (NPO). Pre operation V/S
under observe.

Medical diagnosis: pneumothorax

Order: CBC, Chest x-ray.

The results for CBC : WBC IS high(10.8) and the rest is within the normal range.

Medication: -in emergency rocephin 1g 1x2

- Post operation (29/4/2024) perfalgan 1g I.V PRN

I.V.F: free

)29/4/2024): Chest tube procedure- Between ribs

Wound care: The wound is it clean, No discharge in the wound, No oozing in the wound.

Post operation: apply nebulizer

- Arovent neb. 1x4

- Bodecart neb. 1x2

Patient condition stat: conscious and oriented, Patient under observation.

Nursing Diagnosis:

Impaired Gas Exchange related to decreased lung expansion secondary to pneumothorax.

Goals:

1. Optimize Gas Exchange:

 Goal: Patient will demonstrate improved oxygenation and ventilation as evidenced by

normal arterial blood gas (ABG) values and respiratory parameters.

2. Pain Management:

 Goal: Patient will report pain level of ≤3 on a scale of 0-10 within 24 hours of initiating
interventions.

3. Prevention of Complications:

 Goal: Patient will remain free from complications related to pneumothorax and its
treatment, such as tension pneumothorax or infection.

4. Patient Education:
  Goal: Patient will demonstrate understanding of pneumothorax, its causes, symptoms,
and treatment, and will participate in self-care and management strategies.

Nursing Interventions:

1. Assessment:

 Conduct a thorough respiratory assessment, including respiratory rate, depth, and

effort, oxygen saturation levels, breath sounds, and chest wall movement.

 Monitor vital signs regularly to detect any signs of respiratory distress or deterioration.

2. Oxygen Therapy:

 Administer oxygen therapy as prescribed to maintain adequate oxygenation and relieve

hypoxia.

 Monitor oxygen saturation levels and titrate oxygen flow rate accordingly.

3. Positioning:

 Position the patient in a semi-Fowler's position or as directed by the healthcare provider

to optimize lung expansion and promote ventilation-perfusion matching.

4. Pain Management:

 Assess and manage pain using appropriate pharmacological and non-pharmacological

methods to promote comfort and facilitate deep breathing.

 Encourage relaxation techniques to alleviate anxiety, which can exacerbate pain and
respiratory distress.

5. Chest Tube Management:

 Assist with the insertion and monitoring of chest tubes as ordered by the physician to
facilitate lung re-expansion and evacuation of air or fluid from the pleural space.

 Monitor drainage output, assess for signs of complications (e.g., air leak, subcutaneous
emphysema), and ensure proper functioning of the chest drainage system.

6. Respiratory Support:

 Provide respiratory support as needed, including incentive spirometry, deep breathing

exercises, and coughing techniques to improve lung ventilation and prevent atelectasis.

 Educate the patient on the importance of pulmonary hygiene practices to prevent

respiratory complications.

7. Monitoring and Education:

 Educate the patient and family about pneumothorax, its causes, signs, and symptoms,
as well as the importance of adherence to treatment and follow-up care.
  Instruct the patient to report any worsening symptoms promptly, such as increased
shortness of breath, chest pain, or changes in respiratory status.

8. Psychosocial Support:

 Provide emotional support and reassurance to alleviate anxiety and promote coping
mechanisms during hospitalization and recovery.

 Collaborate with the healthcare team to address any psychosocial concerns or barriers
to care.

Evaluation:

 Regularly reassess the patient's respiratory status, oxygenation, pain level, and response to
interventions.

 Evaluate the effectiveness of the nursing care plan in achieving desired outcomes, such as
improved gas exchange, pain relief, and prevention of complications.

 Modify the care plan as needed based on the patient's condition, response to treatment, and
any changes in clinical status.

 Evaluate patient's understanding of pneumothorax and ability to participate in self-care and

management.