NUR 111 (Nursing Care of Clients with Life –

Threatening Conditions, Acutely Ill/Multi-organ

Problems, High Acuity and Emergency
STUDENT ACTIVITY SHEET Situation)
BS NURSING / FOURTH YEAR
Session # 5

Materials: MS notebook, paper, pen, index card,

LESSON TITLE: Pneumothorax and bond paper (short & long size)
LEARNING TARGETS: References:
At the end of the lesson, the student nurses will be to: Smeltzer S.C., & Bare B.G. (2010) Brunner and
1. Define what is Pneumothorax; Suddarth’s Textbook of Medical- Surgical Nursing.
2. Differentiate the classifications of Pneumothorax; Lippincott William & Wilkins
3. Explain the pathophysiology of the disease condition;
4. Identify the causes of the disease conditions and its Sommer S., Johnson J. (2013) RN Adult Medical
clinical manifestations; and, Surgical Nursing. Assessment Technology
5. Discuss the nursing and surgical management of Institute, LLC.
patients with pneumothorax. https://www.nurseslab.com

LESSON PREVIEW/REVIEW (10 minutes)

Instruction: Enumerate and define the two types of pulmonary arterial hypertension.
1. __________ - ___________________________________________________________________________
2. __________ - ___________________________________________________________________________

MAIN LESSON (60 minutes)

Pneumothorax
 Pneumothorax is one of the disorders of the chest and lower respiratory tract.
 Pneumothorax, or a collapsed lung, is the collection of air in the spaces around the lungs. The air buildup puts
pressure on the lung(s), so it cannot expand as much as it normally.
 Pneumothorax occurs when the parietal or visceral pleura is breached and the pleural space is exposed to
positive atmospheric pressure.
 The pressure in the pleural space is normally negative.
 A spontaneous pneumothorax occurs with the rupture of a bleb.
 An open pneumothorax occurs when an opening through the chest wall allows the entrance of positive
atmospheric pressure into the pleural space.
Diagnosis of pneumothorax is made by chest x-ray film.

Classification
Types of pneumothorax include simple, traumatic, and tension pneumothorax
Simple pneumothorax.
 A simple or spontaneous pneumothorax occurs when air enters the pleural space through a breach of either the
parietal or visceral pleura.
 Traumatic pneumothorax. A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself
and enters the pleural space or from a wound in the chest wall.
 Tension pneumothorax. A tension pneumothorax occurs when air is drawn into the pleural space from a lacerated
lung or through a small opening or wound in the chest wall.

Pathophysiology
The pathophysiology of pneumothorax includes:
 Negative pressure. The negative pressure is required to maintain lung inflation.
 Breach. When either pleura is breached, air enters the pleural space.
 Collapse. When positive pressure has entered the pleural space, the lung or a portion of it collapses.

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  Causes

The cause leads to the identification of the type of pneumothorax:

1. Rupture of a bleb. A spontaneous pneumothorax may occur in an apparently healthy person in the absence of
trauma due to rupture of an air-filled bleb.
2. Blunt trauma. Blunt trauma like rib fractures could cause traumatic pneumothorax.
3. Invasive procedures. Traumatic pneumothorax may occur during invasive thoracic procedures in which the
pleura is inadvertently punctured.
4. Penetrating chest or abdominal trauma. Trauma such as stab wounds or gunshot wounds could cause
traumatic pneumothorax.

Clinical Manifestations
The signs and symptoms associated with pneumothorax depend on its size and cause.
 Pain. Pain is usually sudden and may be pleuritic.
 Minimal respiratory distress. The patient may have only minimal respiratory distress with slight chest discomfort
and tachypnea.
 Dyspnea. Due to pain, the patient has difficulty in breathing.
 Central cyanosis. The patient may develop central cyanosis from severe hypoxemia.
 Chest expansion. In simple and tension pneumothorax, chest expansion is decreased.
 Breath sounds. Breath sounds are diminished or absent in both simple and tension pneumothorax.
 Tracheal alignment. In simple pneumothorax, the trachea is midline while in tension pneumothorax, the trachea
is shifted away from the affected side

Assessment and Diagnosis

Pneumothorax is assessed and diagnosed with the following:
1. Thoracic CT: Studies show that CT is more sensitive than x-ray in detecting thoracic injuries, lung
contusion, hemothorax, and pneumothorax. Early CT may influence therapeutic management.
2. Chest x-ray: Reveals air and/or fluid accumulation in the pleural space; may show shift of mediastinal structures
(heart).
3. ABGs: Variable depending on the degree of compromised lung function, altered breathing mechanics, and the
ability to compensate. Paco2 occasionally elevated. Pao2 may be normal or decreased; oxygen saturation usually
decreased.
4. Thoracentesis: Presence of blood/serosanguineous fluid indicates hemothorax.
5. Hb: May be decreased, indicating blood loss.
6. Medical Management

Medical management of pneumothorax depends on its cause and severity

 Chest tube. A small chest tube is inserted near the second intercostal space to drain the fluid and air. For
patients with jeopardized gas exchange, chest tube insertion may be necessary to achieve lung re-
expansion. The priority is to maintain airway, breathing, and circulation. The most important interventions focus on
reinflation 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 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. These could indicate an air leak, but do not clamp a chest
tube without a physician’s order because clamping may lead to tension pneumothorax.
 Autotransfusion. Autotransfusion involves taking the patient’s own blood that has been drained from the chest,
filtering it, and then transfusing it back into the vascular system.
 Antibiotics. Antibiotics are usually prescribed to combat infection from contamination.
 Oxygen therapy. The patient with possible tension pneumothorax should immediately be given a high
concentration of supplemental oxygen to treat the hypoxemia.

Surgical Management
 If more than 1500 ml of blood is aspirated initially by thoracentesis, the rule is to open the chest wall surgically.
 Thoracotomy. The chest wall is opened surgically to remove the blood or air trapped in the pleural space.

Nursing Management
Nursing management of a patient with pneumothorax include the following steps.

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Education (Department of Nursing) 2 of 7
Nursing Assessment: The nurse should assess the following:
 Tracheal alignment.
 Expansion of the chest.
 Breath sounds.
 Percussion of the chest.

Nursing Diagnosis: Based on the assessment data, the major nursing diagnoses for the patient are:
 Acute pain related to the positive pressure in the pleural space.
 Ineffective breathing pattern related to respiratory distress.
 Ineffective peripheral tissue perfusion related to severe hypoxemia.
 Anxiety related to difficulty in breathing.

Nursing Care Planning and Goals: The goals for the patient include:
 Relief of pain.
 Adherence to prescribed pharmacological regimen.
 Establishment of a normal, effective respiratory pattern as evidenced by absence of cyanosis.
 Demonstration of increase in perfusion.
 Be relaxed and report anxiety is reduced to a manageable level.

Nursing Interventions:
 Reexpansion. The patient is instructed to inhale and strain against a closed glottis to reexpand the lung and eject
the air from the thorax.
 Sterile covering. The opening is plugged by sealing it with gauze impregnated with petrolatum.
 Oxygen saturation. Pulse oximetry is used to monitor oxygen saturation.

Evaluation
 Expected patient outcomes include:
 Pain is relieved.
 Adhered to prescribed pharmacological regimen.
 Established a normal, effective respiratory pattern as evidenced by absence of cyanosis.
 Demonstrated increase in perfusion.
 Patient is relaxed and reported anxiety is reduced to a manageable level.

CHECK FOR UNDERSTANDING (25 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1. An initial characteristic symptom of a simple pneumothorax is:

A. ARDS
B. Severe onset of chest pain
C. Severe respiratory distress
D. Tachypnea and chest discomfort.
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

2. Clinical manifestations related to pneumothorax include the following except for:

A. Pleuritic pain
B. Respiratory distress
C. Acrocyanosis
D. Tachypnea
ANSWER: ________

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 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

3. Which of the following the nurse assesses in patient with pneumothorax?

A. Tracheal alignment
B. Expansion of the chest
C. Breath sounds
D. All of the above
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

4. The pressure required in the pleural space to keep the lungs inflated is:
A. Positive
B. Negative
C. Atmospheric
D. All of the above
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

5. The following are types of pneumothorax except:

A. Trauma
B. Simple
C. Tension
D. Direct
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

6. The healthcare provider is assisting during the insertion of a pulmonary artery catheter. Which of these, if assessed in
the patient, would indicate the patient is experiencing a complication from the catheter insertion?
A. Inspiration phase is greater than expiration
B. Diaphragmatic excursion of 3 cm
C. Tracheal deviation from normal
D. Vesicular breath sounds noted on auscultation
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

7. During the assessment of a 60-year-old female patient, you note the following signs: dyspnea, hypotension, reduced
chest expansion on the left side, hyper resonant percussion note and tactile fremitus on the left side, absent breath
sounds on the left side, and a tracheal shift to the right. These findings suggest which of the following?
A. A pleural effusion on the left side
B. A pneumothorax on the left side
C. Atelectasis on the left side
D. Consolidation on the left side
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

8. A 50-year-old male patient is intubated with a size 8 endotracheal tube and is receiving volume-controlled A/C
ventilation. Upon assessment, you note that the patient’s cuff pressure is measured at 38 cm H2O. Which of the
following would you recommend?

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Education (Department of Nursing) 4 of 7
 A. Withdraw the tube 1-2 cm and reassess the patient’s breath sounds
B. Recommend reintubation with a smaller endotracheal tube
C. Lower the cuff pressure to < 30 cm H2O
D. Recommend ventilation via a tracheostomy instead
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

9. An adult patient who is receiving mechanical ventilation suddenly started showing signs of tachypnea. Upon
assessment, you note tracheal deviation to the right and decreased breath sounds and hyperresonance on the left.
Which of the following would you recommend?
A. The patient needs suctioning
B. The patient needs a bronchoscopy
C. The insertion of a chest tube
D. The patient needs a thoracentesis
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

10. During the assessment of a 52-year-old female patient that is receiving oxygen via nasal cannula at 4 L/min, you hear
the bubble humidifier making a whistling noise. Which of the following is the most likely cause of this finding?
A. There is an obstruction in the delivery tube
B. The patient’s ventilation has increased
C. There is a clogged system diffuser
D. The flowmeter pressure is set too high
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
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4. ANSWER: ________
RATIO:_______________________________________________________________________________________
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5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________

RATIO:_______________________________________________________________________________________
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LESSON WRAP-UP (25 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Activity: CAT: 3-2-1

Instructions:

1. As an exit ticket at the end of the class period

2. Record three things you learned from the lesson.
3. Next, two things that you found interesting and that you’d like to learn more about.
4. Then, record one question you still have about the lesson.

Three things you learned:

1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________

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Education (Department of Nursing) 6 of 7
Two things that you’d like to learn more about:
1. __________________________________________________________________________________
2. __________________________________________________________________________________

One question you still have:

1. __________________________________________________________________________________

(For Related Learning Experience, please refer to your clinical instructor.)

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