Pneumothorax or collapsed lung is caused by air leaking into the pleural cavity. In a normal lung, negative pressure exists between the visceral and parietal pleura or the pleural space. This pleural space contains minimal fluid that serves as lubrication when the tissues move. When air enters the pleural space, changes to the pressure will cause the lungs to partially or completely collapse.
This condition can be classified as open (with air entering through an opening in the chest wall) or closed (without any open wound). A pneumothorax usually causes sudden and severe chest pain along with difficulty breathing.
The different types of pneumothorax include the following:
- Spontaneous Pneumothorax – This condition occurs when there is a rupture of air-filled sacs on the lung surface. Risk factors for developing this type include COPD, lung diseases, pneumonia, smoking, a family history, and previous history of pneumothorax.
- Iatrogenic Pneumothorax – This occurs due to a puncture or laceration of the lungs during a medical procedure like a pleural biopsy or catheter insertion.
- Tension Pneumothorax – This type occurs when the air enters the pleural space and cannot escape. This often results from trauma such as from a stab or gunshot wound or internally from a fractured rib.
A collapsed lung can be confirmed through a chest x-ray, which will show air or fluid in the pleural space and reduced lung volume. Breath sounds are usually decreased or absent when the affected area is auscultated.
The Nursing Process
Since patients with pneumothorax often exhibit respiratory distress, the patient’s hemodynamic stability should be considered in the management of the condition. If the patient is stable and only has minimal air or fluid accumulation in the pleural space, no treatment may be necessary as the condition will resolve spontaneously.
With severe pneumothorax, immediate medical care is required. The most definitive treatment includes the insertion of a chest tube connected to a water-sealed drainage system. The nurse plays an essential role in the management of a pneumothorax with a priority on maintaining the airway, breathing, and circulation.
Nursing Care Plans Related to Pneumothorax
Impaired Gas Exchange Care Plan
When air enters the pleural space this causes positive intrapleural pressure and lung compression, which ultimately results in impaired gas exchange.
Nursing Diagnosis: Impaired Gas Exchange
- Ventilation-perfusion imbalance
- Decreased functional lung tissue
- Chest trauma
- Ineffective breathing pattern
As evidenced by:
- Abnormal arterial pH
- Altered respiratory depth
- Altered respiratory rhythm
- Nasal flaring
- The patient will exhibit improved ventilation and adequate oxygenation with ABGs within normal parameters
Impaired Gas Exchange Assessment
1. Assess lung sounds.
Pneumothorax will often present as decreased or absent airflow on one side of the chest, decreased chest wall movement on the affected side, and hyperresonance when the chest walls are percussed.
2. Assess respiratory rate and rhythm.
Alterations in respiratory rate and rhythm can indicate the progression of respiratory distress and more severe lung involvement.
3. Evaluate imaging studies.
A chest x-ray can confirm pneumothorax and the severity of the condition. CT scan or ultrasound may also be used.
Impaired Gas Exchange Interventions
1. Apply oxygen as ordered.
Air can reabsorb into the pleural space and supplemental oxygen can increase reabsorption.
2. Monitor ABG levels.
This enables healthcare providers to monitor the progress of the condition and determine the patient’s respiratory status.
3. Assist with chest tube thoracostomy.
Chest tubes are essential as they help drain air and fluid from the pleural space. This will help reduce lung compression.
4. Encourage deep breathing exercises.
Patients with a pneumothorax will need to relieve pressure on the lungs to enable optimal lung expansion. While it may be painful, encourage the patient to perform deep breathing exercises and use a device such as an incentive spirometer to inflate the lung and prevent atelectasis.
Acute Pain Care Plan
Symptoms of pneumothorax typically include sudden chest pain and dyspnea. The pain is described as sharp and worsens with deep breathing or coughing.
Nursing Diagnosis: Acute Pain
- Chest injury
As evidenced by:
- Distraction behavior
- Expressive pain behavior
- Guarding behavior
- Positioning to ease pain
- Hesitancy to take a deep breath/shallow breathing
- The patient will report a reduction in pain when breathing
- The patient will demonstrate an even respiratory rate without expressions of pain
Acute Pain Assessment
1. Conduct a comprehensive pain assessment.
Chest pain in pneumothorax is described as a sudden, severe, stabbing pain that radiates to the shoulders and worsens with inspiration. Pneumothorax can happen with or without visible signs of injury to the chest.
2. Monitor the effectiveness of analgesics.
Patients may be reluctant to take normal breaths due to pain with inspiration. Assess pain control following the administration of medications to ensure adequate ventilation.
Acute Pain Interventions
1. Encourage the use of a chest splint when breathing or coughing.
Chest pain in pneumothorax can negatively affect the patient’s breathing. With the use of a chest splint or pillow, the chest is supported making breathing more comfortable.
2. Assist the patient in a position of comfort.
Allow for lung expansion by supporting a high-Fowler’s position.
3. Administer analgesics as indicated.
Pain medication can help alleviate pain in pneumothorax. Anticipate pain such as prior to movement or breathing exercises and premedicate accordingly.
4. Provide diversional activities.
Rest is required when recovering from a pneumothorax. Offer the patient other activities such as reading, visiting with friends or family, music, and movies.
Ineffective Breathing Pattern Care Plan
Pneumothorax causes the build-up of air in the pleural space, adding unnecessary pressure to the lungs. This can lead to ineffective breathing patterns as the lungs are unable to expand normally when breathing.
Nursing Diagnosis: Ineffective Breathing Pattern
- Asymmetrical lung expansion
- Body position that inhibits lung expansion
As evidenced by:
- Abdominal paradoxical respiratory pattern
- Altered chest excursion
- Altered tidal volume
- Decreased expiratory pressure
- Decreased inspiratory pressure
- Accessory muscle use
- The patient will maintain an oxygen saturation of 94% or greater
- The patient will demonstrate an effective breathing pattern evidenced by respiratory rate and depth within expected limits
Ineffective Breathing Pattern Assessment
1. Assess the chest tube drainage system.
The nurse should regularly assess the chest tube and drainage system. Assess for dislodgement, leaks, or kinks in the tubing.
2. Assess the patient’s respiratory function.
Closely monitor for changes in the patient’s breathing pattern which would signal respiratory distress or the development of infection such as pneumonia.
3. Review imaging tests.
Patients may receive routine chest x-rays to monitor the progress of the pneumothorax. If the nurse feels there has been a change in the patient’s respiratory status, a chest x-ray can be requested.
Ineffective Breathing Pattern Interventions
1. Assist with thoracentesis.
The healthcare provider may perform a thoracentesis by inserting a needle in the pleural space to drain air or fluid. This can aid in improving the patient’s breathing pattern.
2. Encourage ambulation.
For patients who are able to ambulate safely, doing so will result in quicker improvement and a shorter hospital stay.
3. Consult with respiratory therapy.
If observing changes in the patient’s respiratory status or concerns with a chest tube system, a respiratory therapist can assist in troubleshooting and assessing.
4. Maintain the closed-drainage system.
The chest tube drainage system must always be kept below the drainage site, usually on the floor. If suction is used, ensure it is on at the prescribed level. Document drainage as required per facility protocol. Bubbling in the air leak chamber may signal a leak. Attempt to locate and remedy the leak or notify the healthcare provider.
References and Sources
- Collapsed Lung (Pneumothorax). Cleveland Clinic. Reviewed: May 11, 2021. From: https://my.clevelandclinic.org/health/diseases/15304-collapsed-lung-pneumothorax
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Pneumothorax. John Hopkins Medicine. 2022. From: https://www.hopkinsmedicine.org/health/conditions-and-diseases/pneumothorax
- Pneumothorax. McKnight CL, Burns B. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441885
- Pneumothorax. Richard W. Light, MD, Vanderbilt University Medical Center. Updated: September 2022. From: https://www.msdmanuals.com/professional/pulmonary-disorders/mediastinal-and-pleural-disorders/pneumothorax