REPUBLIC OF THE PHILIPPINES

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
LUCINDA CAMPUS, BRGY. UNGOT, TARLAC CITY

______________________________________________________________

A Clinical Case Study

Presented to the
Faculty of the Department of Nursing
College of Science
Tarlac State University

TENSION PNEUMOTHORAX
Submitted by:

Jia Laurice P. Barandino

Angel Marie Bergonio
Nicole Ann L. Inocencion
Marizh Ann Jade D. Magno
Aleckza Jade S. Melendez
Hazel Joyce Q. Reyes
Alfred Dominic S. Santos
Rosemarie B. Sebastian
Catherine C. Taberna
Judy Ann B. Valdez

BSN 4-2 (Group 4)

Submitted To:

Anne Myrtle M. Lorenzo RN, MAN

Clinical Instructor
CASE SCENARIO

A 47-year-old man with a history of hypertension and coronary artery disease was
involved in a multiple car motor vehicle accident. He was the restrained driver in a head-
on collision going approximately 55 mph. He was noted to have a GCS of 12 (eyes 3,
verbal 4, motor 5) at the scene and was transported to the emergency department for
further evaluation. Upon examination in the emergency department his first set of vitals
were T 37C, HR 110, BP 110/85, RR 22, SpO2 90%, GCS 11 (eyes 3, verbal 3, motor
5). He was noted to have paradoxical chest rise, diminished breath sounds on the left,
tracheal deviation to the right, multiple ecchymosis to his anterior chest wall bilaterally,
and subcutaneous emphysema to his left anterior chest wall. The remainder of his exam
was unremarkable.

After a tube thoracostomy was placed, 100 mL of blood was evacuated from the chest.
The chest tube was placed to suction through a pleur-evac system. A post procedure
chest x-ray was obtained which showed the chest tube in proper posterior-apical
position with the last drainage hole within the chest cavity. The patient was stabilized,
and a chest CT was performed which revealed multiple rib fractures, consistent with a
flail chest segment, multiple areas of lung contusion, and bilateral basilar pleural
effusions.

The patient’s inspiratory effort became poor, and he had multiple episodes of
desaturation. An arterial blood gas showed a pH 7.27, CO2 55, O2 65, HCO3 25. The
patient was subsequently intubated and placed on volume control mechanical
ventilation, tidal volume 400 mL, respiratory rate 18, pressure support 10, PEEP 8, FIO2
100%. Fluid balance was carefully monitored during his intubated status and protective
lung ventilation was maintained. The patient required IV pain control with placement of
an epidural catheter for pain associated with his multiple rib fractures and flail segment.
Over the next few days, the pain was well controlled, hypoxia associated with lung
contusions improved, daily spontaneous breathing and awakening trials were performed
and the patient was successfully extubated. Chest tubes were removed after complete
resolution of his pneumothorax and hemothorax and the patient was subsequently
discharged to a rehabilitation center
 I. INTRODUCTION

A. Brief discussion of the disease condition

Tension pneumothorax is a life-threatening condition caused by the continuous
entrance and entrapment of air into the pleural space, thereby compressing the lungs,
heart, blood vessels, and other structures in the chest. The pleura is a double-layered
membrane that lines the inner part of the chest wall and the surface of the lungs,
allowing them to move and slide together during respiration. The two layers of the
pleura fold onto each other, forming the pleural space. Under normal conditions, the
pleural space contains a thin layer of fluid that prevents the two layers of the pleura from
rubbing against each other. (Tintanalli’s Emergency medicine A comprehensive
study guide book 8th edition) - follow proper format of citation – Last name, year of
publication

B. Current trends and statistics about the disease condition

(global statistics?)
In the national database, among more than 68 million hospitalizations, 60 094 were
associated with a main diagnosis of pneumothorax over the period January 2012–
December 2014. After excluding 436 hospitalizations related to patients aged less than
14 years and 21 with inadequate coding data, 59 637 hospitalizations were analyzed.

According to Lung Center of the Philippines a total rate of 15,300 reported

nationwide from 2009 to 2015. - this should be placed at the beginning of the
paragraph.

C. Reason for choosing the presentation.

We, the student nurses from the Tarlac State University College of Science -
Department of Nursing BSN 4-2 (Group 4) worked under the supervision of our clinical
instructor, chose this case because we want to explore on how Tension Pneumothorax
progressed and develop as a disorder. Also, we would like to impart the knowledge in
this case study to our readers about the disorder, its etiology and risk factors, the
treatments and rehabilitative approach in the management of the said disease.

D. Objectives
 General Objectives
 - To develop understanding and investigate every information given by the
client. To connect this data to create proper nursing diagnosis and implement
evidenced based nursing and medical practices. In addition, to fulfill and
achieve the patient’s optimal well-being requirement.

 Specific Objectives
- At the end of this case study, the student should be able to; 
o To assess client's state diagnosed with Tension pneumothorax during
the rotation. 
o To know what are the diagnostic and laboratory procedures to be
done 
o To formulate correct nursing diagnosis base on the identified clinical
signs and manifestations from the patient. 
o To plan the appropriate nursing intervention based on the client's state
during the rotation.   
o To implement the interventions that will result of the improvement of
the patient. 
o To evaluate the client's condition after the application of appropriate
nursing care and managements 
o To evaluate of medical progression from the client's diagnosis of
Tension pneumothorax
o To be able to create a proper documentation.
II. NURSING PROCESS
A. Assessment

1. PERSONAL DATA
a) Demographic data
Name: Patient X
Age: 47 years old
Height: 5’6
Weight: 70 kgs
Address: Tarlac City
Gender: Male
Date of Birth: March 6, 1979
Birthplace: Tarlac City
Civil Status: Married
Occupation: Retired Driver
Nationality: Filipino
Chief Complaint:
Final Diagnosis: Tension Pneumothorax
b) Environmental Status

- Patient A is currently living in Tarlac City, together with his family. Their house
is made of mixed steel and cement. They use water tank pump as a source of
their water for bathing and use it in the house. Their house is commonly
surrounded by other houses and is living near the highway, where there are
commonly exposed to pollution.

c) Lifestyle (Habits, Recreational, Hobbies)

- Patient A stated that she normally eats chicken or meat in his meals, he eats 3
times a day. He does not have any physical activities aside from walking, his
hobbies were to watch television and staying at home. He drinks alcohol but not
smokes.
2. FAMILY HISTORY OF HEALTH AND ILLNESS (GENOGRAM)
3. PRESENT ILLNESS
At 10:30 p.m., December 2, 2021, a 47-year-old male who had been involved in a
multiple-vehicle collision was brought to the hospital. He was sent to the hospital for
additional assessment after being the restrained motorist in a 55 mph head-on accident.
Due to the abnormalities in his breathing, he was found to have paradoxical chest
rise, a decreased breath sound on the left, a tracheal deviation to the right and
bilateral numerous ecchymosis on his anterior chest wall. The rest of his test was
normal.

4. PAST ILLNESS:
MEDICAL HISTORY: Patient has history of hypertension and coronary artery disease.
SURGICAL HISTORY: No past surgical history.
MEDICATION: No medication mentioned.
ALLERGIES: No known food and drug allergies.
5. 13 AREAS OF ASSESSMENT

I. SOCIAL STATUS
Patient X is 47-year-old man, currently residing in Capas, Tarlac together with his
wife and his children. According to Patient X, he dedicated his time on working for the
sake of his family. Even though his job takes most of his time because he is a driver,
he said that he has a lot of friends in their neighborhood and tend to volunteer on any
community works in his free time.. Patient X has a good personality and a humble
attitude. He also stated that sometimes, he attends church with his family but only on
special occasions.
Norms: The ability to interact successfully with people and within environment of which
each person is a part to develop and maintain intimacy with significant others and to
develop respect and tolerance for those with different opinions and beliefs which are
necessary determinants for a person’s social state. (Kozier, 2015)
Analysis: Patient X’s social status is normal. According to Erik Erikson theory, During
middle adulthood (40 to 65 years old), the conflict that they may encounter is
generativity vs. Stagnation wherein the important key point in here is the work and
parenthood. In this phase, they continue to build their lives, focusing on their career and
family. Those who are successful during this phase will feel that they are contributing to
the world by being active in their home and community. (Cherry, 2021

II. MENTAL STATUS

During our assessment, Patient X has GCS score of 12 wherein he his eyes open to
sounds (3), confused (4), and withdraws from pain (5). But later, his GCS declined into
a score of 11 wherein his verbal response declined in to a score of 3 because he started
emitting words but not coherent.
Norms: The clients must be alert and awake with eyes open and looking at the
examiner and able to responds appropriately. (Weber, 1988)
Analysis: The mental status of the patient is not normal. According to the Glasgow
Coma Scale, a score of 9-12 indicates a moderate head injury. (Iverson, 2021)

III. EMOTIONAL STATUS

While assessing Patient X, he is firmly grasping his hand on one of the student nurses
as if he doesn’t want to be left behind. He expressed a need of help and anxiety for his
current condition even though his words are not coherent. The patient began to tear up
while guarding his chest.
Norms: Normally, the patient should have the ability to manage stress and to express
emotion appropriately. It also involves the ability to recognize, accept and express
feelings and to accept one’s limitations. (Fundamentals of Nursing: Concepts,
Process, and Practice, 10th Edition, 2018)
Analysis: Patient X manages to answer our questions as he express his anxiety
regarding his condition and began to cry. Therefore, his emotional status is not normal.
According to the study of Dohun Kim et.al (2017), Pneumothorax patient may be at high
risk for severe stress. Morover, post-traumatic stress was higher in elderly patient.

IV. SENSORY PERCEPTION

Patient X has a good eyesight. His hearing ability is normal using whisper test with
distance of two feet. Her sense of smell is normal, and he can distinguish foul and fresh
odor. His lips are light brown in color. isr tongue is slightly pink, and he can taste
whatever foods she eats. However, he expressed shortness of breath and observed a
guarding on his chest. Multiple ecchymosis was noted on anterior chest wall bilaterally
and a subcutaneous emphysema on left anterior chest wall.
Norms: Each of the five senses becomes less efficient in older adult hood. Changes
result in loss of visual acuity, less power of adaptation to darkness and dim light,
decreased in accommodation to near and far objects. The loss of hearing is the ability
related to aging effects people over age 65. Gradual loss of hearing is more common
among man than women, perhaps because men are more frequently in noisy work
environment. Older people have a poorer sense of taste and smell and are less
stimulated by food than young. Loss of skin receptors takes place gradually, producing
in increased threshold for sensations of pain, touch, and temperature. (Fundamentals
of Nursing 7th edition Barbara Kozier)
Analysis: Patient X has a good vision. The sense of smell, taste and hearing can
perceive stimuli accordingly. However, for the sense of touch, pain was detected due to
the multiple ecchymosis and emphysema. The main symptom of ecchymosis is an area
of skin discoloration larger than 1 centimeter. The area may also be sensitive and
painful to touch.(Osborn, 2018)

V. MOTOR STATUS
Patient X’s motor response was scored 5 all throughtout his physical examination. He
experienced limited movement. He was only confined to his bed. There is a multiple
ecchymosis noted on anterior chestwall bilaterally and a subcutaneous emphysema on
left anterior chestwall.
Norms: Normal motor stability includes the ability to perform different activities without
causing pain and discomfort. It should be firm and have coordinated movements.
(Estes, 2011)
Analysis: Patient x’s Motor status is not normal due to his limited movement because of
pain caused by the bruises and emphysema on his chest. According to the Glasgow
Coma Scale, a score of 5 in the motor response corresponds to purposeful movement
to painful stimulus. (Iverson 2021)

VI. BODY TEMPERATURE

Date Assessed Time Temperature Analysis

December. 2, 2021 1:00 PM 37.0 °C The patient has no
fever.
4:00 PM 37.2°C

Norms: Normal axillary temperature is within 34.4°C to 37.4°C. (Health assessment

and physical examination 3rd edition by Mary Ellen Zator Estes)

Analysis: Patient X has a normal range of body temperature therefore, it is noted to be

normal. The presentation of a pneumothorax varies between minimal pleuritic chest
discomfort and breathlessness to a life‐threatening medical emergency with
cardiorespiratory collapse requiring immediate intervention and subsequent prevention.
Fever may occur but only occasionally. (Currie et.al, 2007)

VII. RESPIRATORY STATUS

Date & Time Respiratory Rate Analysis
December 02,021
22 bpm Abnormal
11 AM
Norms: A normal respiratory rate for adult ranges from 12-20 cycles per minute.
Average is 18 cycles per minute. Breathing patterns must be regular and even in
rhythm. The normal breath sound is bronchial which is high in pitch, loud in intensity and
blowing or hollow in quantity, Broncho vesicular is moderate in pitch, moderate intensity
and combination of bronchial and vesicular, and vesicular is low in pitch, soft intensity
and gentle rustling or breezy in quality (Berman et al., 2018).
Analysis: Patient X noted to have increased respiratory rate because of his current
condition. In tension pneumothorax, air flows into the pleural cavity during inhalation but
is retained in the pleural cavity during exhalation and thus cannot exit, leading to
a gradual increase in intra-pleural cavity pressure.(Weiser, G. 2020).

VIII. CIRCULATORY STATUS

The circulatory status of the patient as well as blood pressure noted below:
Date & Time Pulse Rate Analysis
December 02, 2021 110 bpm Abnormal
11 AM

Date & Time Blood Pressure Analysis

December 02, 2021 110/85 mmHg Normal
11 AM

Date & Time Oxygen Saturation Analysis

December 02,021
90% Abnormal
11 AM

Norms: Normal cardiac rate for an adult is 60-100 beats per minute while the normal
blood pressure is 120/80 mmHg. Blanch Test was performed, and the capillary refill is
less than 2 seconds and is normal after it returned within normal state in 1-2 seconds.
The pulse must have a regular beat and not bounding nor weak. Blood pressure is not
measured on the client’s limb if its injured or ill, has an intravenous infusion or blood
transfusion. (Kozier & Erbs, Fundamentals of Nursing, Tenth Edition)
Analysis: Upon assessment the patient has a normal blood pressure. However, pulse
rate noted to be decreased because of his current condition. In tension pneumothorax,
air continues to enter the pleural space as the person breathes and pressure
rises inside the chest.However, the patient also noted to have decreased in O2. Tension
pneumothorax occurs when air accumulates between the chest wall and the lung and
increases pressure in the chest, reducing the amount of blood returned to the
heart.Symptoms include chest pain, shortness of breath, rapid breathing, and a racing
heart, followed by shock. (Weiser, G. 2020).

IX. NUTRITIONAL STATUS

Patient F.L. usually eats 3 times a day but sometimes, he skipped his meals
since he is too workaholic. He drinks 8-12 glasses of water a day approximately 2-3
liters and drinks 3-4 cups of coffee during night shift. He usually eats 2 cups of rice with
vegetable or sometimes canned goods.There is no culture or religious dietary restriction
reported by the patient. At some point of the examination, the patient was weighing 70
kg and standing 5’6” tall, with a BMI of 24.82.

PARAMETER COMPUTATION NORMS ANALYSIS

Height: 5’6” kg <16=Malnourished The patient falls
BMI = 2
height ( m ) 16-19=Underweight to the NORMAL
Weight: 70 kgs 20-25=Normal 24.82
70 kg 31-40=Moderate to state.
BMI =
(2.82 )2
severe obesity
>40=Morbidly obese
BMI: 24.82
(Berman et.al., 2018)

Norms: Criteria in knowing a person’s healthy weight is by using the Body Mass Index
(BMI) which is calculated as follow: Lifestyle behaviors are also a great influence on
people’s health. A person’s physiologic age reflects his or her health status and may or
may not reflect the person’s chronological age. The following factors greatly affect a
person’s health and his or her physiologic age: sleeping regularly, eating well and
balanced meals including breakfast, engaging in physical activities regularly, not
smoking nor using alcohol or drinking in moderation, and maintaining a healthy body
weight. Over the years, the effects of these lifestyle choices accumulate and will
manifest in a person’s life span. (Fundamentals of Nursing: Concepts, Process and
Practice, 7th Edition, 2004).
Analysis: Patient has healthy lifestyle and Diet and his BMI is 24.82 which is
considered normal. The National Institute of Health (NIH) now uses BMI to define a
person as underweight, normal weight, overweight or obese instead of traditional height
vs. weight charts. (CB Weir, 2021).

X. ELIMINATION STATUS
Patient X has a normal bladder elimination. He mentioned that he does not
experienced any pain or discomfort in urinating. He stated that he voided 4-5 times with
the amount of 2 liters per day. His urine is yellow in color. Bowel pattern is normal with a
with a brown color stool, with an average amount and soft formed consistency. Patient
did not report any difficulty or problems in defecating and voiding.
Norms: Normal bowel movement of a person must be 1-2 times a day and voiding 3 to
4 times with an output of 1200 to 1500 ml per day. A normal stool is brown in color and
well-formed while a urine is clear to yellowish in color. (Kozier, Fundamentals of
Nursing, 7th Edition, 2009)
Analysis:
Upon assessment, the patient’s elimination status is normal.The patient has a normal
elimination pattern. Nurses may assess bladder function by measuring the amount of
residual urine. On average, adults urinate 30 mL each hour. (Sharma, et al. 2020).

XI. REPRODUCTIVE STATUS

Patient X was being circumcised when he was 10 years old and stated that he is
sexually active when his wife is still alive he claimed of satisfaction. As per him, he
has no history of sexually transmitted disease.

Norms: Male circumcision reduces the risk of HIV infection among heterosexual men in
sub-Saharan Africa. Consequently, the World Health Organization (WHO) recommends
consideration of circumcision as part of a comprehensive HIV prevention program in
areas with high rates of HIV. The effectiveness of using circumcision to prevent HIV in
the developed world is unclear; however, there is some evidence that circumcision
reduces HIV infection risk for men who have sex with men. Circumcision is also
associated with reduced rates of cancer-causing forms of human papillomavirus (HPV),
and UTIs.
Analysis: According to the above statement, patient’s reproductive status is normal.
Normal male reproductive anatomy, normal nutrition, and the general absence of other
interviewing chronic illnesses. (Lacroix, et al. 2021)

XII. SLEEP AND REST PATTERN

Patient X stated that he usually sleeps 7 to 8 hours a day. He usually sleeps at 8 or 9
pm and wakes at 5:00 am. He doesn’t have any difficulty in sleeping.
Norms: Sleep refers to altered consciousness with general slowing of physiologic
process while rest refers to relaxation and calmness, both mental and physical. A typical
sleeper will pass through 7-9 hours of sleep and take a rest using some relaxation
activities such as reading, telling stories and others. (Nursing Fundamentals by Rick
Daniels)

Analysis:

Patient X sleep pattern is normal. Normal sleep pattern allows your body and mind to
recharge, leaving you refreshed and alert when you wake up. Healthy sleep also helps
the body remain healthy and stave off diseases.(Schwab, R. 2020, June).

XIII. SKIN AND APPENDAGES

Prior to assessment patient X has no history of skin allergy, fingernails and toenails
were short, clean and pinkish in color no signs of clubbing.Hair is equally distributed
with fine and black color. Scalp was smooth and a little bit oily. Scalp appeared clean
and no lesions or lump. He was noted to have multiple ecchymosis to his anterior chest
wall bilaterally, and subcutaneous emphysema to his left anterior chest wall.
Norms: Skin color varies from light to deep brown, pink to light pink and free from skin
diseases. Hair is resilient and evenly distributed. The nail plate is normally colorless and
has a convex curve. The angle between the fingernail and the nailbed is normally 160
degrees. Kozier&Erb’s (2015)
Analysis:
Based from the above information, the patient has a multiple ecchymosis.Skin is warm
to touch, fingernail and toenails were also normal. All of the skin appendages and
nerves play important roles in the physical, chemical and biological function of normal
skin. (Weng, et al. 2020)
6. LABORATORY TEST AND DIAGNOSTIC PROCEDURES

Diagnostic/ Date Indication/ Normal Result and Nursing

Laboratory ordered/D Purpose values interpretat responsibility
Procedure ate done ion
Date A chest X-ray is Chest Proper Before the
ordered: an imaging test Xray posterior procedure
that uses X-rays shows apical  Remov
to look at the normal position e all
Chest X-ray structures and size and with the metallic
organs in your shape last objects.
Dec 3, chest. It can of the
2021 drainage
help your chest  Assess
hole within the
healthcare wall and
provider see the the chest patient’
how well your main cavity s ability
lungs and heart structur to hold
are working. es in his or
Certain heart the her
problems can chest. breath.
cause changes White
in your lungs. shadow  Provide
Certain s on the appropr
diseases can chest iate
cause changes Xray clothing
in the structure signify
of the heart or solid  Instruct
lungs. structur patient
Diagnosis of rib es and to
fractures is fluids cooper
based on such as, ate
clinical bone of during
assessment; rib the rib the
views are rarely cage, proced
helpful and vertebra ure
many rib e, heart,
fractures are not aorta, AFTER THE
visible and PROCEDURE:
bones
 Provide
of the
comfort
shoulde
.
rs.

Diagnostic/ Date Indication/ Normal Result Nursing

Laboratory ordered/ Purpose values and responsibility
Procedure Date interpreta
done tion
Date CT scan is a The lungs Multiple BEFORE THE
ordered: type of imaging and Rib PROCEDURE
test. It uses X- airways Fractures,
ray and are normal. consistent  Obtain
Dec 3, computer No pleural with a flail an
Chest Computed 2021 informe
technology to effusion or segment,
tomography (CT) d
make detailed thickening. multiple
pictures of the Heart size areas of consent
organs and is normal. lung properl
structures No contusion, y
inside your pericardial and signed.
chest. CT is effusion. bilateral  Assess
the gold The pleural for any
standard mediastinu effusion. history
investigation m of
for diagnosis of structures allergie
pulmonary have s to
embolus and normal iodinate
after major configurati d dye
trauma, CT of on. Chest or
the head, neck, wall is shellfis
and body is unremarka h if
now ble.  contrast
mandatory. It media
can help detect is to be
small or used.
anterior  Check
pneumothorac for
es and NPO
evaluate status.
loculated  Instruct
pleural the
effusions that patient
can aid to wear
interventional comfort
strategies. able,
loose-
fitting
clothing
during
the
exam.
 Provide
informa
tion
about
the
contrast
 medium
.
 Tell the
patient
that a
mild
transien
t pain
from
the
needle
punctur
e and a
flushed
sensati
on from
an I.V.
contrast
medium
will be
experie
nced.
DURING THE
PROCEDURE
 Tell the
patient
to
remain
still and
to
immedi
ately
report
sympto
ms of
itching,
difficult
y
breathi
ng or
swallow
ing,
nausea,
vomitin
g,
dizzine
ss, and
headac
he.
 Inform
about
 the
duratio
n of the
proced
ure.
AFTER THE
PROCEDURE
 Instruct
the
patient
to
resume
the
usual
diet and
activitie
s
unless
otherwi
se
ordered
.
 Encour
age the
patient
to
increas
e fluid
intake
(if a
contrast
is
given).
This is
so to
promot
e
excretio
n of the
dye

Diagnostic/ Date Indication/ Normal Result Analysi Nursing

 Laboratory ordere Purpose values s and Respon
Procedure d/Date interpre sibility
done tation
of
results
Arterial Blood Date It is used to  pH:  pH Low Before
Gas ordered: monitor the 7.3 - number
Dec 3, acid-base 5- 7.2 of pH -Check
2021 balance of 7.4 7 may for orders
patients. 5 indicate Explain
They may  Part acidosis the
help make a ial arterial
diagnosis, pre blood gas
indicate the ssur High analysis
severity of a e of numbers evaluates
 CO of carbon
condition oxy how well
2- dioxide
and help to gen the lungs
55 may
assess (Pa are
treatment. O2) indicate delivering
ABGs : 75 acidosis the
provide the to oxygen to
following 100 the blood
information mm and
Decreas eliminatin
oxygenation, Hg ed levels g carbon
Adequacy of  Part
 Ox of dioxide.
ventilation, ial
yg oxygen
and Acid- pre
en indicates -Tell the
base levels ssur
Sat inadequa patient
e of te supply
ura that the
car of
tio test
bon oxygenat
n: requires a
diox ion
65 blood
ide
(Pa sample.
Normal
CO
-Explain
2):
to the
35-
patient,
45
who will
mm  HC
perform
Hg O3
the
 Bic -25
arterial
arb
puncture,
ona
when it
te
will occur,
(HC
and
O3)
where the
:
puncture
22-
site will
26
be; radial,
mE
 q/L brachial,
 Oxy or
gen femoral
satu
rati After
on -Applying
(O2 pressure
to the
Sat)
puncture
: site for 3
94- to 5
100 minutes
% and when
bleeding
has
stopped,
tape a
gauze pad
firmly over
it.

-Monitor
for
complicati
ons of
ABGs
Monitor
vital signs
and
observe
for signs
of
circulator
y
impairme
nt.
7. ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

The lungs are fairly large organs, each lung is divided into lobes by fissures; the left lung has
two lobes and the right lung has three lobes. The surface of lungs is covered with its own
visceral serosa called visceral pleura and the walls of the thoracic cavity are lined by the parietal
pleura these pleural membranes produce pleural fluid which allows the lungs to glide easily over
the thorax wall during breathing. After the main bronchi enters the lungs, it subdivides into
smaller and smaller branches (secondary and tertiary bronchi), ending in the smallest
passageways the bronchioles. (Marieb and Keller, 2018)

Pleura is a vital part of the respiratory tract whose role it is to cushion the lungs and reduce any
friction which may develop between the lungs, rib cage, and chest cavity. The pleura consists of
a two-layered membrane that covers each lung. The layers are separated by a small amount of
viscous lubricant known as pleural fluid.
There are two pleurae, one for each lung, and each pleura is a single membrane that folds back
on itself to form two layers. The space between the membranes (called the pleural cavity) is
filled with a thin, lubricating liquid (called pleural fluid).
The pleura is comprised of two distinct layers:

 The visceral pleura is the thin, slippery membrane that covers the surface of the lungs
and dips into the areas separating the different lobes of the lungs (called the hilum).
 The parietal pleura is the outer membrane that lines the inner chest wall and diaphragm
(the muscle

 separating the chest and abdominal

cavities).
The visceral and parietal pleura join at the hilum, which also serves as the point of entry for the
bronchus, blood vessels, and nerves.
The pleural cavity, also known as the intrapleural space, contains pleural fluid secreted by the
mesothelial cells. The fluid allows the layers to glide over each other as the lungs inflate and
deflate during respiration. The structure of the pleura is essential to respiration, providing the
lungs with the lubrication and cushioning needed to inhale and exhale. The intrapleural space
contains roughly 4 cubic centimeters (ccs) to 5 ccs of pleural fluid which reduces friction
whenever the lungs expand or contract.
The pleura fluid itself has a slightly adhesive quality that helps draw the lungs outward during
inhalation rather than slipping round in the chest cavity. In addition, pleural fluid creates surface
tension that helps maintain the position of the lungs against the chest wall.
The pleurae also serve as a division between other organs in the body, preventing them from
interfering with lung function and vice versa.
8. PATHOPHYSIOLOGY OF TENSION PNEUMOTHORAX (BOOK-BASED)
. PATHOPHYSIOLOGY OF TENSION PNEUMOTHORAX PATIENT-BASED
 B. PLANNING

NURSING CARE PLAN #1

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective Ineffective breathing After 15-30 minutes Independent After 15-30 minutes of
The patient brought to the pattern related to of nursing 1. Assist patient vital signs and 1.To assist in creating nursing intervention,
emergency department with decreased lung intervention, the characteristics of respirations at an accurate diagnosis the patient was able to
diminished breath sounds expansion (air/fluid patient will establish least every 4 hours. Auscultate and monitor establish a normal/
accumulation) a normal/ effective breath sounds effectiveness of medical effective respiratory
Objective: respiratory pattern treatment. Breath pattern with ABGs
ABGs with ABGs within 2. Re-inflating the lung by sounds may be absent within patient’s normal
- O2 Sat of 90% patient’s normal evacuating the pleural air. or diminished in the range
-HCO3=25 range portion of lungs that has
-Pco2 collapsed
-Ph=7.27
-CO2=55
-Use accessory muscles 2.patients with a primary
spontaneous
3. Check the respiratory function, pneumothorax that is
Vital signs as follow:
noting rapid or shallow small with minimal
T: 37C
respirations, dyspnea, symptoms may have
HR: 110bpm
development of cyanosis, spontaneous sealing
BP: 110/85
changes in vital signs. and lung re-expansion
RR: 22
4. Observe for synchronous
respiratory pattern when using a
mechanical ventilator. Note
changes in airway pressure.
3.Respiratory distress
5. Auscultate breath sounds and changes in vital
signs may occur as a
result of physiological
stress and pain or may
6. Assist patient with splinting indicate the
painful area when coughing,
 deep breathing. development of shock
due to hypoxia or
7. Observe water seal chamber haemorrhage.
bubbling

8. Know the location of air leak

(patient or system centered) by 4.Difficulty breathing
clamping thoracic catheter just with ventilator and
distal to exit from the chest. increasing airway
pressure suggests
Dependent worsening of condition
or development of
9. Administer oxygen therapy as complications.
prescribed

5. Breath sounds may

be diminished or absent
in a lobe, lung segment,
or entire lung field
10. Maintain fluid restriction if
(unilateral)
ordered
6.Supporting chest and
Collaborative
abdominal muscles
11. Administer antibiotics as
make coughing more
ordered
effective and less
traumatic.

7.Bubbling during
expiration reflects
venting of
pneumothorax.

8.if bubbling stops when

the catheter is clamped
 at the insertion site, leak
is patient-centered (at
insertion site or within
the patient).

9.The patient with

possible tension
pneumothorax should
immediately be given a
high concentration of
supplemental oxygen to
treat the hypoxemia.

10. To correctly balance

fluid

11 Antibiotics will treat

the bacterial infection.

NURSING CARE PLAN #2

 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective Impaired gas After 4 hours of Independent After 4 hours of

He appears to be in obvious exchange related to nursing intervention, nursing intervention,
respiratory distress, with fluid accumulation the patient will 1. Assess the patient’s vital signs, 1. To assist in the patient was
increased breathing effort. in the alveolar sacs maintain optimal gas especially the oxygen saturation creating an maintain optimal gas
as evidenced by exchange and characteristics of accurate exchange – check
Objective: difficulty of respirations at least every 4 diagnosis and grammar
ABGs breathing. hours. Also, monitor the results monitor
- O2 Sat of 90% of ABG analysis effectiveness of
-HCO3=25 medical
-Pco2 treatment. ABG
-Ph=7.27 Analysis: To
-CO2=55 2. . Administer supplemental oxygen check if there is
carefully, as prescribed. Discontinue an increase in
V/S taken as follows: if SpO2 level is above the target PaCO2 and a
range, or as ordered by the
decrease in
physician.
T: 37C PaO2, which are
HR: 110 bpm the signs of
3. Elevate the head of the bed.
BP: 110/85 hypoxemia and
Assist the patient to assume
RR: 22 respiratory
semi-Fowler’s position.
acidosis.

2. To increase the
oxygen level and
4. Monitor respirations: quality, achieve an
rate, pattern, depth and SpO2 value
breathing effort. within the target
range.
 3. Head elevation
and semi-
5. Auscultate lung sounds. Also Fowler’s position
assess for the presence of help improve the
jugular vein distention (JVD) or expansion of the
tracheal deviation. lungs, enabling
the patient to
breathe more
effectively.
6. Observe for signs of hypoxemia

4. . Rapid, shallow
breathing and
hypoventilation
7. Monitor for changes in affect gas
orientation and behavior exchange by
affecting CO2
levels. Flaring of
the nostrils,
dyspnea, use of
8. Monitor ABGs accessory
muscles,
tachypnea
and/or apnea are
all signs of
severe distress
that require
immediate
intervention.

5. Absence of lung
sounds, JVD and
/ or tracheal
deviation could
signify a
pneumothorax or
 hemothorax

6. . Tachycardia,
restlessness,
diaphoresis,
head ache,
lethargy and
confusion are all
signs of
hypoxemia

7. Restlessness is
an early sign of
hypoxia.
Mentation gets
worse as
hypoxia
increases due to
lack of blood
supply to the
brain

8. Increasing
Paco2 and
decreasing
PaO2 are signs
of respiratory
failure.
 NURSING CARE PLAN #3

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective: Ineffective tissue After 8 hours of Independent After 8 hours of

perfusion related to nursing intervention, 1. Monitor and record vital signs 1. To have a baseline nursing intervention,
He complains having increased the patient will date the patient was
difficulty of breathing. He intrathoracic engages in 2. Maintain on bed rest engaged in behaviors
was asked about his name pressure as behaviors or actions or actions to improve
and he started 1-2 words evidenced by to improve tissue 2. Restricted activity tissue perfusion
with shallow breaths hypoxia perfusion reduces oxygen
demands in the
3. Asses ptient general condtion heart and other
Objective: organ
ABGs 4. Assess for signs of decreased
- O2 Sat of 90% tissue perfusion 3. To have a baseline
-HCO3=25 data and note any
-Pco2 abnormal findings
-Ph=7.27
-CO2=55 4. Particular clusters
of signs and
-Use accessory muscles symptoms occur
-hypoxia with differing
5. Assess for probable contributing causes. Evaluation
Vital signs as follow : factors related to temporarily of ineffective tissue
T: 37C impaired arterial blood flow. perfusion defining
BP: 110/85 characteristics
HR: 110bpm provides a baseline
RR: 22 6. check respirations and absence for future
of work of breathing comparison

5. Early detection of
7. Check rapid changes or the source
continued shifts in mental status facilitates quick,
effective
management.
8. Record BP readings for
orthostatic changes (drop of
20mm Hg systolic BP or 10 mm
Hg diastolic BP with position
changes). 6. cardiac pump
malfunction and/or
9. Use pulse oximetry to monitor ischemic pain may
oxygen saturation and pulse result in respiratory
rate. distress.

7. Electrolyte/ acid
base variations,
hypoxia, and
systemic emboli
influence cerebral
perfusion.

8. . Stable BP is
needed to keep
sufficient tissue
perfusion.

9. Pulse oximetry is a
useful tool to detect
changes in
oxygenation
 NURSING CARE PLAN #4

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective Acute pain related After 8 hours of 1. Assess the pain characteristics: A good assessmnent of After 8 hours of nursing
He was experiencing chest to positive pressure nursing intervention qualitity (sharp, burning) severity pain will help in the intervention patient will
pain because of the chest in the pleural space Short term: (0-10 scale) location onset treatment and ongoing able report pain as 3
tube placed to suction Patient will report (gradual, sudden) duration (how management of pain or less on 0-10 scale,
through a pleur-evac pain less than 3 on long) precipitating or relieving intermittent and sharp
system 0-10 scale factors in incision area
 Patients vital signs
Objective: will be within normal 2. Monitor vital signs
ABGs units
- O2 Sat of 90%
-HCO3=25 Long term: 3. Assess for non verbal signs of
-Pco2 Patient will be free pain
-Ph=7.27 on pain
Tachycardia, elevated
-CO2=55
blood pressure,
tachypnea, and fever may Vital signs within
V/S taken as follows: normal limit
accompany pain
T: 37C
4. Give analgesics as ordered and
HR: 110 bpm
evaluate the effectiveness Some patients may
BP: 110/85 No non-verbal signs of
verbally deny pain when it
RR: 22 pain noted
is still present.
Restlessness, inability to
Pain scale: 7/10
focus, frowning,
5. Assess the patients expectation grimacing, and guarding
of pain relief of the area may be non-
verbal signs of acute pain
Analgesics given as
Narcostics and indicated ordered. Patients
6. Assess for compliations for
for acute pain. Pain reports satisfactory
analgesics especially respiratory
medication are absorbed pain relief after
depression
and metabolized administration
differently in each patient,
so their effectiveness
must be assessed after
administration
Patient’s state ‘I want
7. Anticipate the need for pain relief Some patients are some relief. Know
and respond immediately to content in reduction of some pain will still exist
complaints of pain pain, others may expect a
complete elimination. This
affects the patient
perception of the No complications of
8. Eliminate additional stressors effectiveness of treatment analgesia noted
when possible. Provide rest
periods, sleep and relaxation
Excessive sedation and
respiratory depression are
severe side effects that
need reported
immediately and may
require discontinuation of
medication. Urinary
retention, Patients reports pain as
nausea/vomiting and soon as it starts
constipation can also
occur with narcotic use
and need reported and
treated

The most effective way to

deal with pain is to
prevent it. Early
intervention can decrease Patients appear
the total amount of relaxed, is sleeping
analgesic required. Quick throughout the night
response decreases the
patient’s anxiety
regarding having their
needs met and
demonstrate caring

Outside resources of
stress, anxiety and lack of
sleep all may exaggerate
the patient’s perception
of pain
C. IMPLEMENTATION

1. DRUG STUDY #1

NAME OF DOSAGE MECHANISM OF NURSING

INDICATION CONTRAINDICATION SIDE EFFECTS
DRUG AND ROUTE ACTION RESPONSIBIL
DOSAGE: Binds with opiate  Morphine is Hypersensitivity to  CNS: >Observe 14
Generic 10mg receptor in the CNS, indicated for morphine; respiratory dizziness, of medication
Name: altering perception of the relief of insufficiency or euphoria, light- >Reassess
Morphine ROUTE: and emotional severe acute a depression; severe headedness, patient’s level
Sulfate I.V response to pain. nd CNS depression; nightmares, pain.
severe chronic attack of bronchial sedation, >Keep opioid
Brand FREQUEN pain. asthma; heart failure somnolence, antagonist
name: CY:
Kadian
 Analgesic secondary to chronic seizures, (naloxone) an
Q 15 adjunct during lung disease; cardiac depression, resuscitation
minutes anesthesia arrhythmias; hallucinations, equipment
Classificatio
n: Opioid increased intracranial nervousness, available.
TIMING: Intraspinal use
agonist  or cerebrospinal physical >Monitor
PRN for with micro
analgesic pressure; head dependence. circulatory,
pain infusion injuries; brain tumor;  CV: respiratory, bl
devices for the acute alcoholism; bradycardia, and bowel fun
relief of delirium tremens; cardiac arrest, carefully.
intractable convulsive disorders; shock, >Dilute and
pain. after biliary tract hypertension, administer slo
surgery; suspected tachycardia IV to minimize
surgical abdomen;  GI: likelihood of
surgical anastomosis; constipation, adverse effec
concomitantly with nausea and
MAO inhibitors or vomiting, >Morphine is
within 14 days of such anorexia, of choice in
treatment. biliary tract relieving MI pa
spasm, dry may cause
mouth, ileus transient decr
 GU: urine in blood press
retention,
 HEMATOLOGI
C:
thrombocytope
nia
 RESPIRATOR
Y: apnea,
respiratory
arrest,
respiratory
depression

 SKIN:
diaphoresis,
edema, pruritus
and skin
flushing
 DRUG STUDY #2

NAME OF DOSAGE MECHANISM OF NURSING

INDICATION CONTRAINDICATION SIDE EFFECTS
DRUG AND ROUTE ACTION RESPONSIBIL
DOSAGE: First-generation Cefazolin injection Hypersensitivity To  Anorexia >Observe 14
Generic 500 mg semisynthetic is used to treat Cefazolin Or The  Diarrhea of medication.
Name: cephalosporin that certain infections Cephalosporin Class  Eosinophilia >Assess patie
Cefazolin ROUTE: binds to 1 or more caused by Of Antibacterial  Fever infection (vital
I.V penicillin-binding bacteria including Drugs, Penicillins, Or signs; appear
Brand  Increased
proteins, thereby skin, bone, joint, Other Beta-lactams transaminas of surgical site
name: FREQUEN arresting bacterial genital, blood, urine, WBC) a
Kefzol CY: es
cell-wall synthesis heart valve, Cefazolin for injection  Leukopenia beginning and
Q 6-8 hrs. and inhibiting respiratory tract during therapy
Classificatio is contraindicated in  Nausea and
bacterial replication; (including patients who have a >Obtain speci
n: vomiting
has poor capacity to pneumonia), history of immediate for culture and
Cephalospor  Neutropenia
cross blood-brain biliary tract, and hypersensitivity sensitivity bef
in, 1st  Oral
barrier; primarily urinary tract reactions initiating the
Generation candidiasis
active against skin infections. (e.g., anaphylaxis, therapy.
flora, including S Cefazolin injection  Pain at >Administer
serious skin reactions)
aureus also may be used injection site directly into ve
to cefazolin or the
before, during,  Phlebitis and infuse ove
cephalosporin class
and sometimes for of antibacterial drugs,  Pseudomem minutes or slo
a brief period after penicillins, or other branous into tubing of
surgery in order to beta-lactams colitis compatible IV
prevent the patient  Seizure infusion soluti
from getting an  Stevens-
infection. Johnson >Observe pat
syndrome for sign and
Cefazolin injection  Thrombocyt symptoms of
is in a class of openia anaphylaxis
medications called  Thrombocyt
osis >Solution is u
cephalosporin light-yellow to
antibiotics. It  Transient
 works by killing elevation of yellow.
bacteria. hepatic
enzymes >Discard if
 Vaginitis precipitate is
present

2. MEDICAL MANAGEMENT N/A

 Medical Date performed/ General Indication Client reaction to
management/treatment changed/ description purpose treatment
discontinued
A mechanical ventilator The main purpose of a The patient was able to
is a machine that helps a mechanical ventilator is maintain adequate
patient breathe to allow the patient ventilation. thus,
(ventilate) when they are time to heal. Usually, as increasing his
having surgery or cannot soon as a patient can respiratory rate and has
DATE ORDERED:
breathe on their own due breathe effectively on improved breathing
October 29, 2021
to a critical illness. The their own, they are pattern.
MECHANICAL
patient is connected to taken off the
VENTILATION DATE PERFORMED:
the ventilator with a mechanical ventilator. The patient's oxygen
October 29, 2021
hollow tube (artificial saturation before was
Tidal volume: 400 mL
airway) that goes in their 90% and now his spO2
DATE DISCONTINUED:
mouth and down into is currently at 95%,
November 6, 2021
their main airway or indicating that his
trachea. They remain on oxygenation has
the ventilator until they improved.
improve enough to
breathe on their own.

Medical Date performed/ General Indication purpose Client reaction to

 management/treatment changed/ description treatment
discontinued
MORPHINE SULFATE DATE ORDERED: A drug used to treat  Morphine is
December 3, 2021 moderate to severe pain. indicated for the
10mg q 15 minutes I.V It binds to opioid relief of The patient was
DATE PERFORMED: receptors in the central severe acute and experiencing severe
PRN for Pain December 3, 2021 nervous system and some severe chronic pain. pain, this opioid helps
other tissues. Morphine  Analgesic adjunct maintain the patient’s
sulfate is made from during anesthesia
comfort throughout
opium. It is a type of
 Intraspinal use with the illness.
opiate and a type of
analgesic agent. micro infusion
devices for the relief
of intractable pain.
 Medical Date performed/ General Indication purpose Client reaction to
management/treatment changed/ description treatment
discontinued
0.9% Normal Saline DATE ORDERED: Normal Saline is the 0.9% Normal Saline is The client’s body
December 3, 2021 chemical name for salt. one of the most response to the
is a crystalloid isotonic common IV fluids, It is medication given was
DATE PERFORMED: IV fluid that contains administered for most for electrolyte
December 3, 2021 water, sodium. It is hydration needs: replenishment. Fluid
called normal saline vomiting and diarrhea, balance was carefully
DATE solution because the electrolyte monitored during his
DISCONTINUED: percentage of sodium replenishment intubated status
December 6, 2021 chloride dissolved in the
solution is similar to the
usual concentration of
sodium and chloride in
the intravascular space.
 Medical Date performed/ General Indication purpose Client reaction to
management/treatment changed/ description treatment
discontinued
CEFAZOLIN DATE ORDERED: Antibiotic that is used to  Cefazolin  Administered
December 3, 2021 treat bacterial injection also for no longer
500mg q 6-8 hrs IV infections, including may be used than 24 hours
DATE PERFORMED: severe or life- before, during, after tube
December 3, 2021 and sometimes thoracostomy.
threatening forms.
for a brief
Cefazolin is also used to period after  This antibiotic
help prevent infection in surgery in order helps the client
people having certain to prevent the to combat
types of surgery. patient from infection from
getting an contamination.
infection.
 Cefazolin  There were no
injection is in a signs and
class of symptoms of
medications anaphylaxis
called
cephalosporin
antibiotics. It
works by
killing bacteria.
3. SURGICAL MANAGEMENT

Name of procedure Date Brief description Indication/purpose Client’s Nursing

performed response responsibilities prior
to to, during, and
operation surgical
procedure(actual)
Tube Thoracostomy Procedure December A tube thoracostomy, The objectives of The Pre-op
3, 2021 also known as open treatment are to drain patient’s
chest drainage, is a the pleural cavity and condition is  Secure consent
surgical procedure to to achieve complete favorable,  Explain procedure
drain the collection of expansion of the lung. and his to the patient
pleural fluid, air, The fluid is drained, recovery is  Monitor vital signs
blood, or pus from and appropriate progressing to patient safety
your antibiotics, in large well prior to operation
pleural cavity through doses, are prescribed  Instruct patient for
a tube inserted in on the basis of the Remove if patient
your chest. causative organism. having a nail
Drainage of the polish for easy
pleural fluid depends access for
on the stage of the monitoring
disease and is cyanosis
accomplished by one
of the following Intra op
methods:  Ensure sterility
• Needle aspiration  Perform surgery
(thoracentesis) if safety checklist
volume is small and
 Provide care
fluid is not too thick.
specific to method
• Tube thoracostomy
of drainage of
with fibrinolytic agents
pleural fluid.
instilled through chest
 Help patient cope
tube when indicated.
with condition;
instruct in lung
 • Open chest expansion
drainage via breathing
thoracotomy to exercises to
remove thickened restore normal
pleura, pus, and respiratory
debris and to remove function.
the underlying Post-op
diseased pulmonary
tissue.  Teach patient and
family signs and
• Decortication, symptoms of
surgical removal, if infection and how
inflammation has and when to
been long standing. contact the health
care provider.
 Instruct patient
and family about
care of drainage
system and drain
site and
measurement and
observation of
drainage

 Respiratory status
is assessed by
monitoring rate,
depth, and pattern
of respiration.
 Patient’s airway
is maintained
 Pharmacological
agents may be
prescribed
 TYPE OF DIET Date Indication/s Nursing Responsibility

December 2021
High calorie diet
A high-calorie, high- - Encourage clients and
protein diet gives the families to practice the
body more energy and following dietary habits:
4. DIET
extra nutrition to help the
body heal. This diet is
appropriate to those who -Eat slowly and
have certain health concentrate on the
conditions that increase smell, taste, and texture
the body's need for of food.
protein and calories.
However, intake of -Eat a variety of foods
reduced-fat dairy that are high in nutrients
products can help and check the Nutrition
keep calorie counts Facts Labels on
down., packaged foods.
-Eat less fat and fewer
high-fat foods.
-Eat more fruits and
vegetables that do not
have added fat or sugar.
- Eat pasta, rice, breads,
and cereals without
added fats and sugars
used in preparation or at
the table.
-Eat fewer sugars and
sweets (e.g., candy
cookies, cake, soda).
-Avoid drinking alcohol.

High protein diet December Instruct the patient to:

2021 Protein is important for
the body's ability to -Encourage the
generate new cells. patient to plan healthy,
Complex carbohydrates balanced meals and
help the digestion snacks that include
system function better. the right number of
That will allow the body foods from 5 food
5. ACTIVITY/EXERCISE

TYPE OF GENERAL INDICATION/ NURSING

EXERCISE DESCRIPTION PURPOSE RESPONSIBILITY
BREATHING This can strengthen It's important to  Provide
breathing muscles, get practice deep adequate pain
EXERCISES
more oxygen, and breathing and relief 
breathe with less coughing so that  Maintain the
effort. This allows the patient can be able to patients head in
body to fully exchange do the exercises a neutral
position with the
incoming oxygen with easily after surgery.
bed elevated 30
outgoing carbon These exercises
to 40 degrees
dioxide. will help patient’s  Educate the
breathing, clear the patient to take a
lungs, and lower the deep breath and
risk of pneumonia. hold it for
approximately 3
seconds,
encourage them
to do this at
least 10 times
every hour
 Include the
significant other
in the education
and encourage
them to prompt
the patient each
 hour
 Provide a rolled
up towel or
pillow to
patients who
have undergone
a sternotomy or
other surgery to
the thorax or
abdomen and
encourage them
to hug the towel
to their chest or
wound site
when coughing
to minimize
discomfort.

WALKING Walking is a type of This exercise can help  Identify the

cardiovascular stop the development
prescribed
physical activity in of stroke-causing
which increases the blood clots, prevent activity level.
heart rate and muscle atrophy,  Continue to
improves blood flow improves blood flow
that can help in which aids in quicker assess strength
lowering the blood wound healing. The and joint
pressure. It helps to gastrointestinal,
mobility.
boost energy levels by genitourinary,
releasing certain pulmonary and urinary  Advise the
hormones like tract functions are all importance of
endorphins and improved by walking.
delivering oxygen warm up,
throughout the body. ensuring that
muscles are
 well supplied
with oxygen
 Precautions
such as: walking
on a flat surface
to reduce the
strain on legs
and feet,
another way to
ensure patient
safety is to walk
with assistance
if patient will feel
unsteady.
6. NURSING MANAGEMENT

SOAPIE CHARTING – asan ang SOAPIE charting? Check Fundamentals of Nursing for your SOAPIE charting
format
D. EVALUATION

DISCHARGE PLANNING
- For patient with Tension Pneumothorax to fully recover after treatment, one of the
important duty of nurses is to ensure continuity of health and quality care as the patient
leaves the hospital premises including teaching plan for the patient about his condition
proper exercise, diet, medication, self-care strategies, and importance of follow-up and
check-up.

MEDICATION
- The patient was instructed to take medicine as prescribed by the physician to take
medications or the length of time. Thus, to provide adequate relief for the patient
HEALTH TEACHING

HEALTH TEACHING
- Instruct the patient to avoid smoking.
- Teach the patient to do relaxation technique it is important to take 4 slow, deep
breaths every 1 to 2 hours while awake. Do this even though your chest may hurt
when you breathe. It sends extra oxygen and blood to the lung. This is important
to help keep the lung expanded. If an incentive spirometer (breathing exercise
device) was given, use it as directed.
- Encourage to avoid or limit activities with drastic changes in air pressure (scuba
diving and flying).
- Follow your provider’s recommendations if you do these activities.
- See your provider regularly to monitor any lung conditions.

FOLLOW UP
- Follow-up 2 weeks after discharge for the doctor to know for signs of infection
III. CONCLUSION
After 6 days of nursing intervention and medical management the patient was discharged from
the hospital due to Tension Pneumothorax. The patient was instructed to do the following
discharge planning intervention and follow up check-up care. This study was able to provide
comprehensive and thorough information regarding Tension Pneumothorax including its overall
disease process, common clinical manifestation, diagnostic test result, different medical and
nursing care which contributes on the personal development of each nursing student in terms of
their competency in practicing efficient and evidenced based skills in dealing client with Tension
Pneumothorax in an actual clinical area.

IV. RECOMMENDATION

In view of the following conclusions determined from the study, the following
recommendations should be undertaken:

For the student nurses, this case study is recommended for student nurses to serve
as their guide and reference for their study related to patients with Tension Pneumothorax, this
study will inform them about the problems that they may encounter during their clinical practice
on the said case and will help them become equipped in rendering good and effective nursing
intervention and care.

For the patients, this study will help them to have knowledge on what are the
things they need to do when they experience this situation. Also, for them to be able to
reach the state of being completely healthy physically, emotionally and psychologically.

For the future researchers, this study will serve as a guide on how they are
going to conduct future research. This will help them dig deeper regarding to this topic
and bridge the gap between this research and the results and findings.
V. REVIEW OF RELATED LITERATURE

TENSION PNEUMOTHORAX
Jolata, R., & Sayad, E. (2020) “Tension Pneumothorax.” https://www.ncbi.nlm.nih.gov/books/NBK559090/

Traumatic and tension pneumothoraces are more common than spontaneous

pneumothoraces. Transthoracic needle aspiration and central venous catheters are
usually the most common causes of iatrogenic pneumothorax. The rate of iatrogenic
pneumothoraces is increasing in US hospitals as intensive care modalities have
increasingly dependant on positive pressure ventilation and central venous catheters.
Central venous catheterization increases the risk of pneumothoraces when placed in
the internal jugular or subclavian. The incidence is about 1 to 13% but increases to 40%
if multiple attempts are made. These numbers are lower if procedures are done under
ultrasound. Iatrogenic pneumothorax usually causes substantial morbidity but rarely
death. The incidence is 5 to 7 per 10,000 hospital admissions.
Tension pneumothoraces can develop in 1 to 2% of cases initially presenting with
idiopathic spontaneous pneumothoraces. It is difficult to determine the actual incidence
of tension pneumothorax as by the time trauma patients are transported to trauma
centers, they have already received decompressive needle thoracotomies. Patients with
trauma tend to have an associated pneumothorax or tension pneumothorax 20% of the
time. In cases of severe chest trauma, there is an associated pneumothorax 50% of the
time. The incidence of traumatic pneumothorax depends on the size and mechanism of
the injury. A review of military deaths from thoracic trauma suggests that up to 5% of
combat casualties with thoracic trauma have tension pneumothorax at the time of death.
VI. BIBLIOGRAPHY

Book-based

Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. O. (2016). Brunner & Suddarth's
textbook of medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams &
Wilkins.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse's pocket guide:
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