Spontaneous Pneumothorax

Objectives
After completing this case study, the student should be able to:

• Identify signs and symptoms of a pneumothorax
• Describe the rationale behind the use of a chest tube
• Identify warning signs related to chest tube management
• Provide education to the patient with a pneumothorax/chest tube
• Use the Tanner’s Clinical Judgment Mode by noticing, interpreting, responding and reflecting during the scenario

Case Presentation

A 26-year-old professional male presents to the emergency department for sudden onset of shortness of breath and chest pain following a collision with another player during a soccer game. The patient is accompanied by a friend and fellow team member. The patient reports that during the collision, the other player’s shoulder was forced into the patient’s chest. He reports sharp right-sided chest pain that started shortly after the collision and worsens with inhalation or movement. The patient denies recent injury to his head or abdomen. 

Medical History

The patient’s past medical history is unremarkable. Past surgical history includes a tonsillectomy at age 10. The patient does not take any medications. The patient reports drinking 3 to 5 beers per week, and denies tobacco and illicit drug use. The patient is  not married and does not have any children. The patient is a professional soccer player and lives in a house with two other teammates. Family medical history is remarkable for coronary artery disease and hypercholesterolemia in the patient’s father.

Physical Assessment Findings

Vital signs include the following: 
Heart rate: 110 bpm
Respiratory rate: 30 
Blood pressure: 110/82 mmHg
O2 sats: 92% in room air
Temp: 98.6 F
Pain level: 8 of 10

On physical assessment, the patient appears mildly anxious and has difficulty speaking in full sentences. Respirations are shallow and rapid. No pallor or cyanosis are present. There are diminished breath sounds on the right with hyperresonance on percussion. The breath sounds on the left are clear. The trachea is midline. The electrocardiogram (EKG) reveals sinus tachycardia. Peripheral pulses are 2+. No murmur is auscultated. The patient is alert and oriented x 4. The patient is ambulatory, although ambulation increases the shortness of breath. The abdomen is soft, flat, and non-distended with active bowel sounds. No obvious injury is present to the head or abdomen. Moist mucous membranes are present. Skin turgor is normal. No signs of bruising or erythema.

Laboratory and Diagnostic Testing and Results

The chest x-ray showed a large amount of air in the pleural space of the right lung. 

The arterial blood gas values were as follows:

pH: 7.30 (normal range: 7.35-7.45)
PaCO2: 60 mmHg (normal range: 35-45 mmHg)
PaO2: 55 mmHg (normal range: 80-100 mmHg)
HCO3-: 26 mEq/L (normal range: 22-28 mEq/L)
SaO2: 85% (normal range: >95%)

The complete blood count and metabolic panel (chemistry) were within normal limits. 

Next steps: Implementing Clinical Nursing Judgment

After reviewing the clinical presentation and physical assessment, the nurse understands the patient is at risk for respiratory decompensation and failure. After a discussion with the provider, the nurse prepares the patient and the healthcare team for chest tube placement. 

Noticing

1. Describe the clinical presentation of the patient. What is your initial impression?
2. How does the patient appear clinically to you? Provide specific examples.
3. How does the patient appear socially to you? Provide specific examples.
4. How does the patient appear psychologically to you? Provide specific examples. 
5. Based on these assessments, what are your greatest clinical concerns?

Interpreting

1. How do the clinical and diagnostic findings suggest a diagnosis of a pneumothorax?
2. How do blood gas results reflect the impaired ventilation and oxygenation associated with a pneumothorax?
3. What signs and symptoms would indicate that the pneumothorax is increasing?
4. Discuss why the placement of a chest tube would be the preferred method of treatment.
5. How do you expect the patient’s clinical presentation to improve after chest tube placement?
6. Describe any clinical, social, psychological factors that may impact the situation.
7. Identify the patient's educational needs, readiness to learn, learning preferences, barriers to treatment, and expectations. 

 Responding

1. What are your most important nursing interventions in caring for this patient?
2. What is the role of the nurse before, during, and after chest tube placement?
3. Are there any interventions you can delegate?
4. What steps can you take to prepare the patient for the procedure?
5. What steps can you take after the procedure to ensure patient safety and minimize adverse effects of chest tube placement?
6. Discuss the warning signs related to chest tube malfunction or dislodgement.
7. Identify any safety concerns you have while caring for a patient with a chest tube.

Reflection

Reflection in-practice: 
What was your initial concern when you discovered the patient was experiencing respiratory distress and had a pneumothorax?

Reflection on-practice

1. What might you do in your future practice to prepare for this situation?
2. What are your biggest concerns surrounding chest tube management?
3. Identify stresses you believe nurses experience as they manage chest tubes in patients.
4. Reflect on how nurses can best prepare to care for patients with chest tubes.
5. Describe the importance of the nursing role in this scenario.
6. List three ways you increase your knowledge, skills, or attitudes while caring for a patient with a pneumothorax.
7. Write a paragraph with no more than 200 words discussing what it is like to be the nurse and the patient in this type of scenario. Include a discussion of how to maximize your role as a patient advocate after the patient undergoes a painful procedure.

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