Pneumothorax NCLEX Case Study: Chest Tube Care and 6 Next Gen Questions

Sudden sharp chest pain that is worse with a deep breath is pleuritic pain, and chest pain and shortness of breath are common symptoms of pneumothorax. The client also speaks in short sentences, the left chest moves less than the right, there are no breath sounds over the left lung and the percussion note is hyperresonant. The one-sided loss of breath sounds with a hyperresonant note is the finding that points to a pneumothorax, and together these findings show that air in the pleural space is affecting breathing. Smoking and a tall build are linked to pneumothorax but are not findings that need action now. The skin is warm and dry with pink lips, and the neck veins are flat, so neither needs immediate action. Takeaway: sudden pleuritic chest pain and shortness of breath, with absent breath sounds on one side and a hyperresonant note, point to pneumothorax and need immediate follow-up.

Sources: Open RN Nursing Advanced Skills, 4.2 Basic Concepts (central lines); Open RN Nursing Advanced Skills, 6.2 Basic Concepts (chest tubes); NHLBI: Pleural Disorders, Diagnosis; NHLBI: Pleural Disorders, Causes and Risk Factors; Open RN Nursing Advanced Skills, 6.4 Troubleshooting Problems and Complications; Open RN Nursing Skills, 11.2 Basic Concepts of Oxygenation

The 0910 findings are compared with two conditions that can cause chest pain and shortness of breath. Sharp chest pain that is worse with a deep breath and a pulse oximetry reading of 91% on room air occur with a pneumothorax and with pneumonia, and smoking raises the risk of both, so these findings do not separate them. The finding that separates them is the percussion note over the quiet left lung. Tapping over air in the pleural space gives more echo than usual, a hyperresonant note, while the dense lung of pneumonia gives a dull note and crackles. Men who are taller than average are more likely to have a spontaneous pneumothorax, and this client is a 22-year-old man who is 188 cm tall. Takeaway: chest pain, a low oxygen reading and smoking fit both pneumothorax and pneumonia; absent breath sounds with a hyperresonant note point to a pneumothorax.

Sources: NHLBI: Pleural Disorders, Causes and Risk Factors; NHLBI: Pleural Disorders, Symptoms; NHLBI: Pleural Disorders, Diagnosis; NHLBI: Pneumonia, Causes and Risk Factors; NHLBI: Pneumonia, Symptoms; Open RN Nursing Skills, 10.3 Respiratory Assessment; Open RN Nursing Advanced Skills, 4.2 Basic Concepts (central lines); Open RN Nursing Advanced Skills, 6.4 Troubleshooting Problems and Complications

The deciding cues are the absent breath sounds over the left lung with a hyperresonant note, together with a pulse of 112/min, respirations of 26/min and a pulse oximetry reading of 91% on room air. These show a pneumothorax that is already affecting breathing. Left untreated, a pneumothorax can progress to a tension pneumothorax: a very large pneumothorax that interferes with blood flow through the chest and can lead to failure of the heart and lungs. A pulmonary embolism can also cause pleuritic pain, fast breathing and a low oxygen reading, but one-sided absent breath sounds with a hyperresonant note point to air in the pleural space and not to a clot. Hypovolemic shock follows blood loss, and the notes record no bleeding. Takeaway: in a pneumothorax, the complication to watch for is a tension pneumothorax; worsening distress, a falling pulse oximetry reading and a rising pulse can come before the blood pressure falls.

Sources: NHLBI: Pleurisy, Pleural Effusion, and Pneumothorax; NHLBI: Pleural Disorders, Diagnosis; NHLBI: Pulmonary Embolism; Open RN Nursing Advanced Skills, 6.4 Troubleshooting Problems and Complications; Open RN Nursing Skills, 11.2 Basic Concepts of Oxygenation; Prehospital management of chest injuries: systematic review and guideline update (CC BY 4.0)

The repeat film after needle aspiration shows the air space unchanged, and a chest tube is ordered. The order is for water-seal drainage and for oxygen titrated to a printed range, so the nurse gives oxygen as ordered and does not connect the unit to wall suction, which is not ordered. Care for a client with a chest tube keeps the client sitting upright, which supports deep breathing. Sterile petroleum gauze and tape stay at the bedside for an emergency such as a tube that comes out of the chest. Coughing and deep breathing are encouraged, so the client is not taught to avoid coughing. Takeaway: with a chest tube, give care as ordered, keep the client upright, encourage coughing and deep breathing and keep dressing supplies at the bedside.

Sources: NHLBI: Pleural Disorders, Treatment; Open RN Nursing Advanced Skills, 6.3 Nursing Responsibilities for Clients With Chest Tube Drainage Systems; Open RN Nursing Advanced Skills, 6.4 Troubleshooting Problems and Complications; Open RN Nursing Skills, 11.6 Checklist for Oxygen Therapy

The deciding cue is the drainage unit that was knocked over: it lies on its side and the water level in the water-seal chamber is below the 2 cm mark. The tube is still attached, and the client is breathing without distress. For a unit that has been knocked over, the nurse sets it upright, checks the water-seal level and refills it. The nurse also assesses the client's breathing and pulse oximetry reading, because the unit is part of the treatment for a pneumothorax. A tube is not clamped routinely, because of the risk of a tension pneumothorax. The unit is kept below the level of the chest, not lifted to it. Removing the tube is not a nursing response to a tipped unit, and waiting for the next scheduled check leaves the problem unfixed. Takeaway: when the drainage unit is knocked over, set it upright, check the water-seal level and refill it, and assess the client.

Sources: Open RN Nursing Advanced Skills, 6.3 Nursing Responsibilities for Clients With Chest Tube Drainage Systems; Open RN Nursing Advanced Skills, 6.4 Troubleshooting Problems and Complications; Open RN Nursing Advanced Skills, 6.2 Basic Concepts

Each Day 2 finding is compared with the earlier chart. Improved: the respiratory rate is 16/min, down from 26/min on admission and within the adult range of 12–20/min; the pulse is 82/min, down from 112/min and within the adult range of 60–100/min; and the pulse oximetry reading is 98% on room air, up from 91% and inside the ordered range of 94–98%. Not changed: the temperature is normal at each check, and the water level still rises and falls with breathing, which shows that the tube is patent. Worsened: the drainage was pale yellow and clear and is now cloudy. Cloudy drainage can be a sign of infection, so the nurse notifies the primary health care provider (PHCP). Takeaway: a client can improve in oxygenation and breathing while a new finding, such as cloudy chest tube drainage, still needs prompt follow-up.

Sources: Open RN Nursing Advanced Skills, 6.3 Nursing Responsibilities for Clients With Chest Tube Drainage Systems; Open RN Nursing Skills 2e, 1.3 Vital Signs; Open RN Nursing Skills, 10.3 Respiratory Assessment