Concept Mapping for Pneumothorax

Assessment:Baseline cardiopulmonary status including vs (145/86, RR: 22, O2 sat: 90% HR: 101) SOB, cyanosis, anxiety, absent of breath sound on affected side, crackles noted adjacent to affected areas, sudden sharp focal chest pain , muffled heart sound ,vein neck distention and bruises, open chest wound, asymmetric chest movement

Monitoring/Care/intervention After insertion, monitor vital signs Q15 X2, Q30min X2.

Q1hr X4. Monitor amount/type of drainage by marking drainage

level on outside of the collection chamber Q1hr. Report drainage greater than 100ml/hr or changes in characteristics of drainage

Assess patient drainage for air leaks Maintain drainage free of loops Assess insertion and surrounding site for inflammation

and infection. Monitor pain and intervene as necessary

5. Activity intoleranceInterventions: Determine cause of intolerance. When appropriate increase activity allowing the client to assist with

positioning and transfers. Perform ROM exercise and decrease the amount of time

spent in bed. Allow patient time to relief self

from sitting. Assess for constipation. Provide

emotional support and encouragement. Use a

gait walking belt when ambulating.

Ineffective Breathing PatternData Support: O2 sat low 90s, RR 22 sternotomy incision and painInterventions: Monitor respiratory rate, depth and ease of respiration. Note pattern. Note use of accessory muscles, nasal flaring,

irritability or confusion. Observe color of tongue, skin. Monitor Oxygen saturation.

Determine severity of dyspnea. Support client in using pursed-lip and controlled

breathing techniques. Position client in upright or semi fowlers position. Administer oxygen as needed. Increase client’s activity

to three times a day or as tolerated. Encourage deep breathing and coughing.

Chief Medical Diagnosis: Pneumothorax SOB, PainPriority Assessments: VS (RR 22, O2: 90%),

Patient Teaching Explain the procedure, the indication

for the chest tube insertion and how the closed chest drainage system works

Keep patient in semi fowlers’ position

Instruct patient to turn Q2hr, to promote drainage

Instruct patient to engage in coughing and deep breathing exercise and splinting the affected side to reduce complication.

Encourage passive or active ROM of the arm in the affected side

Instruct patient and family about activity prescribed while maintain the drainage system below the level of chest

Knowledge Deficit- Importance of Deep breath cough and use of incentive spirometer- The signs of infection-To assess pain -Teach about Medication (administration and side-effects,)- -Practice ROM exercises to build strength and increase ambulation

Expected Outcomes

Removal of air, fluid or blood from the chest cavity Fluctuation or tidaling noted in water chamber seal

until lungs is expanded Relief of respiratory distress Re-expansion of collapsed lungs, validated by chest

radiography Effective respiratory rate, rhythm and depth of

respiration

2. Acute Pain r/t traumatic surgeryData Support: Patient rates pain as 5/10 on pain scale, grimaces.Interventions: Assess pain level. Ask to describe pain and triggers. Ask client to identify a comfort function goal on a self

report pain tool. Assess facial expressions and behaviors. Prevent pain during

procedures. Administer opioids orally or intravenously. Review client’s flow sheet

and MAR. Teach and implement non-pharmacological interventions