Tension pneumothorax and nursing care

Nursing assessment

Mrs. Jane Dow is an elder in-patient in a hospital and recently went through an open cholecystectomy for gallstones. She had just shifted from the ward and the nurse initiated her vital assessment. On current presentation, the nurse assessed the patient is still drowsy, confirmed by her GCS (14). The patient now complains about the pain on the right side of the ribs (5/10) with breathing difficulty. The nurse provided 2 liters of oxygen via the nasal prongs to manage her impaired oxygen levels and vitals. The nurse also initiated auscultation where the nurse found a limited air entry on the right chest. To manage patient condition nurse will ensure a comprehensive assessment, which will support the care plan.

ABG assessment

As the patient reflects acute respiratory complications, the nurse will begin with arterial blood gas analysis. This assessment will detect the flow of pulmonary exchange and ventilatory control. The analysis can be performed by taking out blood samples from the arterial. Nurses play a vital role in assessing The test will determine the arterial oxygen and carbon dioxide levels. The ABGs assessment confirms the presence of lowers oxygen levels (Pao2) and carbon dioxide ( Paco2) as well based on the degree of varied lung function and impaired breathing systems. oxygen saturation was also lowered (Montero-Salinas et al., 2021). ABLs and need to keep safe documentation of all the results and even inform the doctors in case of emergency. The results will determine if the patient needs external oxygen for managing respiratory distress.

X-ray

The nurse will coordinate with a radiologist to ensure the presence of any trapped air or fluid. It is a simple, non-invasive, and cost-effective procedure to identify the reason behind current clinical signs and symptoms. The respiratory distress along with the pain in the right side of the ribs can be assessed further by imaging. Upper chest radiography shows a white visceral pleura which is opposite to the chest wall. It also reflects a loss of vascular lung marking between the chest and pleura. Moreover, a deep sulcus was visible between the chest cavity. An X-ray will also reveal air or fluid accumulation on the pleural space, a clear representation of pulmonary tension (Raman et al., 2019).

Ultrasound-

This imaging assessment will show a dilated veins of the neck are poorly sensitive. Concerning the tension physiology, the ultrasounds reflect dilated inferior vena cava and mediastinal shift. Lung slide, B-lines or comet tail abnormalities, A-lines, as well as the lung pointing sign all are ultrasound indications that really can aid in the identification of a typical pulmonary tension (Inocencio et al., 2017). The to-and-fro motion of the pleural cavity on the area (pleura) that occurs during breathing is known as lung sliding. It is a vibrant sign that shows a horizontal motion along the pleural line when observed on ultrasound. In the case of pulmonary tension and, the A-line usually appears at the lung apex. Moreover, in the case of air entrapment between visceral and parietal pleura lines and no to-and-fro movement on the pleura line is visible on ultrasound. This is usually observed when the body is under low oxygen levels. The accuracy of ultrasonography is greater than those of typical upright anterior-posterior computed x-rays. The ultrasound will support the detection of pulmonary tension along with hypoxia and impaired respiratory flow.

Blood test-

In this case, the patient complains of pain beneath the ribs and chest. On further evaluation from comprehensive assessment, impaired ABGs result in a typical case of pulmonary tension and impaired pulmonary flow (Sajadi-Ernazarova & Martin, 2020). All these signs can make it difficult for the lungs to function and might collapse if not diagnosed timely. As the patient underwent an invasive procedure (Open cholecystectomy) for a long owing to surgery, which may increase the risk of infection. During infection, the airway cab is filled with fluid inside the lungs, which can lead to a hypoxic condition. A blood test can confirm the presence of an infectious agent, triggering infection (Tarhani et al., 2020). It is a simple and convenient procedure and can support the presence of the underlying reason for lung impairment and pulmonary tension, A culture can be initiated which will assess the presence of infection. The blood test will also show the increased level of WBCs which also reflects a clear case of infection.

CT scan

A CT scan is a confirming test where all the results will show a clear representation of the possibility of pneumothorax. Air entrapment is evident in commutated test imaging. Air trapping is a term used during lung CT to indicate a reduction in pulmonary parenchyma reduction, which is most apparent with a less increase in attenuation after exhalation acquisition (Sajadi-Ernazarova & Martin, 2020). This presentation must be distinguished from decreased hypoperfusion attenuation caused by localized increased pulmonary vascular resistance. This testing will provide a differential diagnosis of pulmonary tension and will help the healthcare professionals to come to a single conclusion regarding continuous pathology of the signs of symptoms to design an effective care plan.

Pathophysiology

In this case, the patient has had recent surgery and soon after that, the patient complains about chest pain The vitals were showing a low O2 level (PaO2 = 70 mmHg) and a low CO2 level (PaCO2 = 18mmHg). It is clearly explaining that the lungs are not working in their natural phase and the pulmonary exchanges are being impacted. Moreover, her abdominal wound and had drained into the wound with a small amount of dark blood. The surgery is sometimes related to pleural trauma and under the presence of anesthesia may lead to tension pneumothorax. It is a distinct condition associated with Pneumothorax wherein air flows the intra-pleural region but could escape it (Musa et al., 2021). It puts great pressure on the lung wall, thereby increases chest pressure, which further triggers less amount of blood towards the heart. It is often characterized by shortness of breath and rapid breathing (Jalota & Sayad, 2020). An arterial blood sample assessment confirms the lack of adequate oxygen and CO2 levels. It can happen naturally or during anesthesia, especially when external pressurized ventilation is utilized during surgery (Jalota & Sayad, 2020).  A tension pneumothorax is predicted, and percussion of the lungs will suspect the damaged side, which is frequently visible on the chest.

Nursing critical care

The tension pneumothorax requires immediate attention for the safety of the patient. In this case, the doctor inserted a long needle into the chest. It is a safe procedure typically opted in an emergency to decompress a tension pneumothorax and is usually preferred when tube thoracostomy cannot be done (Gurney, 2019). In this case, it was done after confirming tension pneumothorax from an arterial blood gas test. The most common complications that are associated with Needle Thoracostomy include bleeding, reoccurrence of pneumothorax, pain, hypoxia, or risk of infection.

Individuals with fat or muscular chest walls may require a larger catheter and needle to access the pleural region for decompression. Moreover, a delicate balance must be found, as a longer needle may raise the risk of preventable damage, bleeding, and other hemorrhagic complications. Furthermore, a combination of parameters bleeding may lead to Needle Thoracostomy malfunctioning by creating a blood clot inside the lumen of the catheter. The nurse can assess the bleeding from a radiograph which must reflect a high suspicion for vascular injury (Naik et al., 2017). Moreover, the needle Thoracostomy can sometimes lead to a pulmonary laceration in case of the needle shifts from its original position, which can and can trigger the air to leak out of the lung and reach the pleural space. When the blood vessels are torn it is called lead to bleeding. The most effective way to manage this condition is by keeping a safe chest needle tubing drainage position (Li et al., 2018). The nurse can use sterile tape to fix the needle properly along with the catheter. Positioning of the patient is also an effective management approach to keep the needle at a fixed position (Naik et al., 2017). Maintain a comfortable sleeping position, which usually involves elevating the head of the bed. Make a 180-degree turn to the affected side. Even more than possible, encourage the patient to be in the recommended position.

In some cases, the insertion sites also show bleeding and in this case, the nurse should apply pressure to the exits site and fix it with the strip. The nurse can also place dressing over the exit spot to control drainage (Weichenthal et al., 2018). To evaluate bleeding nurses can also check coagulation tests. Continuous monitoring on drain chamber to make sure no excess bleed loss. Persistent pleuritic chest pain on the left side, breathlessness, pale face, and hypotension The presence of symptoms similar to the Needle Thoracostomy might lead to progressive atelectasis (Li et al., 2018).

Reoccurrence of pneumothorax is also a complication that nurse needs to address. It typically occurs when the tubing gets clogged, which can reverse the effect of Needle Thoracostomy and can again cause tension pneumothorax. Although, the re-occurrence of pneumothorax needs ot be avoided by correct nursing monitoring and care. It is usually evidenced by respiratory distress and impaired vitals as well. The nurse can manage this condition to avoid reduce the risk of hypoxia (Hallifax & Janssen, 2019). Keep an eye out for other signs of pulmonary distress. Reattach the catheter to the tubing. While performing this procedure the healthcare professional must need ot perform to handle the equipment with safe hands. They must ensure to sanitize hands before and after performing the procedure  Cover the catheter with petrolatum bandage and apply firm pressure if indeed the catheter becomes dislodged from the chest The nurse even needs to inform the doctor in case the situation gets unmanageable (Burch, 2020). Moreover, keeping track of vitals especially the respiratory rate to control pulmonary and circulatory impairment. Reoccurrence of pneumothorax is also associated with pulmonary distress and all the complications of tension pneumothorax will be resumed (Ayres et al., 2021). One of the risk signs is hypoxia, which contributes to a large proportion of mortality within hospitals setting, The nurse must identify the early sign of pneumothorax and managing the risk of hypoxia.

Pain is a factor that is always associated with a surgical procedure. In this case, the patient was treated with a Needle Thoracostomy, which can trigger additional. However the doctor did not recommend a pharmacological treatment but in case the pain elevated the nurse must be aware of the PRN (like opioids or metformin) to manage the condition (Burch, 2020). The nurse must control pain as it can increase not only the physical but the psychological health burden on the patient as well. Skilled nurses with effective decision-making and critical thinking must ensure a safe PRN administration for the safety of the patient (Hallifax & Janssen, 2019). The competent nurse can differentiate the pain due to pulmonary tension or the recent application of Needle Thoracostomy. A pain assessment scale can be used to evaluate the effectiveness of the medication. The Abbey scale can be useful in this case, as it will cover all the physical and psychological aspects of pain and later process results.

Infection, also termed as wound infection is closely associated with needle Thoracostomy. Recurrence rates for empyema caused by thoracostomy have indeed been recorded as low as 1% and as much as 25% (Hallifax & Janssen, 2019). According to studies, the risk of empyema is greater when pulmonary edema occurs before thoracostomy. The development of pleural infection facilitates sepsis colonization from the respiratory tract, culminating in empyema. Characterized by inflammation to necrotizing tissue inflammation are all potential infections just at needle wounds (Snyder et al., 2017). The risk of chronic granulomatous soft tissue infection is higher with needle thoracostomy draining for empyema thoracic. Appropriate skin preparations help to avoid infection in the wound area. Medications are frequently helpful against infection (Rebmann & Carrico, 2017). Infection prevention is more of nursing as humans can increase the risk of contamination leading to severe infections. They need to ensure extreme hygiene and safety for the safety of both themselves and the patient as well (Rebmann & Carrico, 2017).

References

Ayres, M., Hwang, A., Oubre, J., Smith, L., & Raudat, C. (2021). Management of anterior tension pneumothorax in a trauma patient with prior pleurodesis. Critical Care Medicine, 49(1), 672.

Burch, A. (2020). Management of the Patient with Spontaneous Pneumothorax. Medsurg Nursing, 29(3). 1-14.

Gurney, D. (2019). Tension pneumothorax: What is an effective treatment?. Journal of Emergency Nursing, 45(5), 584-587.

Hallifax, R., & Janssen, J. P. (2019). Pneumothorax—time for new guidelines?. In Seminars in respiratory and critical care medicine. UK: Thieme Medical Publishers.

Inocencio, M., Childs, J., Chilstrom, M. L., & Berona, K. (2017). Ultrasound findings in tension pneumothorax: a case report. The Journal of emergency medicine, 52(6), 217-220.

Jalota, R., & Sayad, E. (2020). Tension pneumothorax. UK: StatPearls

Li, X., Su, X., Chen, B., Yao, H., Yu, Y., Leng, X., & Zhu, C. (2018). Multidisciplinary team approach on a case of bilateral tension pneumothorax. Journal of thoracic disease, 10(4), 2528.

Montero-Salinas, A., Pérez-Ramos, M., Toba-Alonso, F., Quintana-DelRío, L., Suanzes-Hernández, J., Sobrido-Prieto, M., & Martínez-Isasi, S. (2021). Analysis of Arterial Blood Gas Values Based on Storage Time Since Sampling: An Observational Study. Nursing Reports, 11(3), 517-521.

Musa, J., Zielinski, M., Hernandez, M. (2021). Tension pneumothorax decompression with colorimetric capnography: Pilot case series. Gen Thorac Cardiovasc Surg, 2, 1-14.

Naik, N. D., Hernandez, M. C., Anderson, J. R., Ross, E. K., Zielinski, M. D., & Aho, J. M. (2017). Needle decompression of tension pneumothorax with colorimetric capnography. Chest, 152(5), 1015-1020.

Raman, D., Sharma, M., Moghekar, A., Wang, X., & Hatipoğlu, U. (2019). Utilization of thoracic ultrasound for confirmation of central venous catheter placement and exclusion of pneumothorax: a novel technique in real-time application. Journal of Intensive Care Medicine, 34(7), 594-598.

Rebmann, T., & Carrico, R. (2017). Consistent infection prevention: vital during routine and emerging infectious diseases care. OJIN: The Online Journal of Issues in Nursing, 22(1). 1-14.

Sajadi-Ernazarova, K. R., Martin, J., & Gupta, N. (2020). Acute pneumothorax evaluation and treatment. UK: StatPearls

Snyder, C. L. (2017). Diseases of the Pleural Space. In Fundamentals of Pediatric Surgery New York: Springer.

Tarhani, F., Nezami, A., & Heidari, G. (2020). Evaluating the usefulness of lab-based tests for the diagnosis of pneumonia. International Journal of General Medicine, 13, 243-254.

Weichenthal, L. A., Owen, S., Stroh, G., & Ramos, J. (2018). Needle thoracostomy: do change needle length and location change patient outcome?. Prehospital and Disaster Medicine, 33(3), 237-244.

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