Assessment

HISTORY. Ask about chest pain; determine its onset, intensity, and location. Ask if the patient has shortness of breath or difficulty in breathing or fatigue. Elicit a history of COPD or emphysema or if the patient has had a thoracotomy, thoracentesis, or insertion of a central line. Ask if the patient smokes cigarettes.

For patients who have experienced chest trauma, establish a history of the mechanism of injury by including a detailed report from the prehospital professionals, witnesses, or significant others. Specify the type of trauma (blunt or penetrating). If the patient has been shot, ask the paramedics for ballistic information, including the caliber of the weapon and the range at which the person was shot. If the patient was in a motor vehicle crash, determine the type of vehicle (truck, motorcycle, car), the speed of the vehicle, the victim's location in the car (driver vs. passenger), and the use, if any, of safety restraints. Determine if the patient has had a recent tetanus immunization.

PHYSICAL EXAMINATION. The severity of the symptoms depends on the extent of any underlying disease and the amount of air in the pleural space. Examine the patient's chest for a visible wound that may have been caused by a penetrating object. Patients with an open pneumothorax also exhibit a sucking sound on inspiration.

Inspect the patient with pneumothorax for cyanosis, nasal flaring, asymmetrical chest expansion, dyspnea, tachypnea, and intercostal retractions. Observe whether the patient has a flail chest, a condition in which the patient has paradoxical chest movement with the chest wall moving outward during expiration and inward during inspiration. On palpation, note any tracheal deviation toward the unaffected side, subcutaneous emphysema (also known as crepitus; a dry, crackling sound caused by air trapped in the subcutaneous tissues), or decreased to absent tactile fremitus over the affected area. Percussion may elicit a hyperresonant or tympanitic sound. Auscultation reveals decreased or absent breath sounds over the affected area and no adventitious sounds other than a possible pleural rub.

Examine the thorax area, including the anterior chest, posterior chest, and axillae, for contusions, abrasions, hematomas, and penetrating wounds. Note that even small penetrating wounds can be life-threatening if vital structures are perforated. Observe the patient carefully for pallor. Take the patient's blood pressure and pulse rate, noting the early signs of shock or massive bleeding, such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill. Continue to monitor the vital signs frequently during periods of instability to determine changes in the condition or the development of complications.

PSYCHOSOCIAL. Patients with a pneumothorax may be confused, anxious, or restless. They may be concerned about their pain and dyspnea and could be in a panic state. Determine the patient's past ability to manage stressors, and discuss with the significant others the most adaptive mechanisms to use. Note that approximately one-half of all traumatic injuries are associated with alcohol and other drugs of abuse.

Diagnostic Highlights

Abnormality with Test Normal Result Condition

Explanation

Chest x-ray Clear lung fields Lung collapse with air between chest wall and visceral pleura

Lungs are not filled with air but rather are collapsed

Other Tests: Complete blood count, plasma alcohol level, arterial blood gases, rib x-rays, computed tomography (CT) scan

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