Medical-surgical Nursing Demystified

(Michael S) #1

CHAPTER 2 Respiratory System^119



  • Mediastinal shift and tracheal deviation toward the unaffected side with ten-
    sion pneumothorax


INTERPRETING TEST RESULTS



  • Shadows on chest x-ray, indicating a collapsed lung.

  • Increased carbon dioxide shown in arterial blood gas.

  • Low oxygen saturation on pulse oximetry.


TREATMENT


Once identified, a pneumothorax can be treated and completely resolved. A ten-
sion pneumothorax can become a life-threatening condition. Careful monitoring
and early intervention is critical for these patients. A small area may resolve with-
out intervention, but the patient will still be monitored until resolution.



  • Bedrest.

  • Supplemental oxygen if needed.

  • Chest tube connected to suction to re-expand lung if needed.

  • Administer analgesic if needed:

    • morphine




NURSING DIAGNOSES



  • Acute pain

  • Ineffective breathing

  • Impaired gas exchange


NURSING INTERVENTION



  • Place patient in high Fowler’s or semi-Fowler’s position to ease respiratory
    effort.

  • Monitor drainage of the chest tube for amount and characteristics of output.
    Note changes.

  • Monitor vital signs for changes.

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