About
Partial or full collapse of the lung due to a collection of blood in the pleural cavity compressing the lungs due to trauma or injury.
Assess
Breath sounds absent, trauma, wounds, bleeding, dyspnea, pain with inspiration, unequal chest expansion.
Complications
Respiratory distress, hemorrhage.
Diagnosis
- Impaired gas exchange related to decreased surface for air exchange at the alveoli-capillary membrane.
- Ineffective breathing pattern related to injury to chest wall.
- Goals
- The client will maintain a pulse-oximetry at or above 94%.
- The client will state a decrease in pain less than 4 on a 0-10 scale.
- The client will identify strategies to promote lung re-expansion.
Interventions
- Assess vital signs, pulse oximetry, lung sounds, and pain levels frequently.
- Maintain chest tube drainage system.
- Monitor drainage from chest tube drainage systems.
- Assess for equal bilateral chest expansion.
- Administer pain medicine as ordered by a physician.
- Teach client measures to prevent infection or complication from injuries.
- Teach client to reposition frequently and to perform coughing and deep breathing exercises.
- Teach client signs and symptoms of infection or complications to report immediately to health care provider.
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