About
Air leak from the lungs into the pleural space causing partial or complete collapse of the lung.
Assess
Assess for recent trauma, open or closed pneumothorax, anxiousness, dyspnea; pain, location and intensity, lung sounds reduced on effected side; possible deviation of trachea; assess chest tube drainage system if one is inserted.
Complications
Respiratory distress- requires intubation.
Impaired gas exchange- requires increasing O2 therapy and/ or intubation.
Diagnosis
- Pain related to trauma and dyspnea
- Impaired gas exchange related to trauma of the lung tissues
- Ineffective breathing pattern related to decreased functional lung tissue
Goals
The client will have a re-expansion of lung tissue.
The client will maintain adequate oxygenation.
Interventions
- Assess lung sounds.
- Monitor vital signs and pulse oximetry.
- Monitor for respiratory distress.
- Monitor closed chest tube drainage system, be sure suction is set appropriately and the chambers are full with necessary water.
- Administer oxygen, as indicated.
- Administer antibiotics and analgesics or opiates, as ordered.
- Monitor for signs/ symptoms of complications.
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