Primary Nursing Diagnosis

Impaired gas exchange related to decreased oxygen diffusion capacity

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Comfort level; Anxiety control

INTERVENTIONS. Airway insertion and stabilization; Airway management; Respiratory monitoring; Oxygen therapy; Mechanical ventilation; Anxiety reduction

Ü PLANNING AND IMPLEMENTATION Collaborative

The priority is to maintain airway, breathing, and circulation. The most important interventions focus on reinflating the lung by evacuating the pleural air. Patients with a primary spontaneous pneumothorax that is small with minimal symptoms may have spontaneous sealing and lung reexpansion. For patients with jeopardized gas exchange, chest tube insertion may be necessary to achieve lung re-expansion.

Maintain a closed chest drainage system; be sure to tape all connections, and secure the tube carefully at the insertion site with adhesive bandages. Regulate suction according to the chest tube system directions; generally, suction does not exceed 20 to 25 cm H2O negative pressure. Monitor a chest tube unit for any kinks or bubbling, which could indicate an air leak, but do not clamp a chest tube without a physician's order because clamping may lead to tension pneumothorax. Stabilize the chest tube so that it does not drag or pull against the patient or against the drainage system. Maintain aseptic technique, changing the chest tube insertion site dressing and monitoring the site for signs and symptoms of infection such as redness, swelling, warmth, and drainage.

Oxygen therapy and mechanical ventilation are prescribed as needed. Surgical interventions include removing the penetrating object, exploratory thoracotomy if necessary, thoracentesis, and thoracotomy for patients with two or more episodes of spontaneous pneumothorax or patients with pneumothorax that does not resolve within 1 week.

Pharmacologic Highlights

No routine pharmacologic measures will treat pneumothorax, but the patient may need antibiotics, local anesthesia agents for procedures, and analgesics, depending on the extent and nature of the injury. Analgesia is administered for pain once the patient's pulmonary status has stabilized.

746 Polycystic Kidney Disease Independent

Place the patient in a semi-Fowler position to improve lung expansion. Change the patient's position every 2 hours to prevent infection and allow for lung drainage. For patients with traumatic closed pneumothorax, turn the patient onto the unaffected side to improve the ventilation-to-perfusion ratio. Encourage coughing and deep breathing to remove secretions.

For patients with traumatic open pneumothorax, prepare a sterile occlusive dressing and cover the wound. Monitor carefully for a tension pneumothorax (absent breath sounds, tracheal deviation) because the occlusive dressing prevents air from escaping the lungs. Teach alternative pain relief techniques. Explain all procedures in advance to decrease the patient's anxiety.

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