Help with nursing diagnoses for spontaneous pneumothorax

Students LPN/LVN Students


Hi, I need some help. I have to come up with 3 diagnoses and 3 interventions with rationales for a patient with spontaneous pneumothorax.

I have one complete diagnosis with interventions for Impaired Gas Exchange.

I have another diagnosis for Impaired Tissue Perfusion, but I cannot think of two more interventions other than "apply TEDS and ALPS" to promote venous return.

I've already looked at the careplans post #109, and I'm still lost. Any help would be greatly appreciated!

Daytonite, BSN, RN

1 Article; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

i haven't the faintest idea which thread post #109 is on because there are a number of careplan threads that have over 100 posts.

when care planning you need to follow the nursing process. you need to first work with the patient's assessment data in order to diagnose their nursing problems because all diagnoses are based upon the abnormal assessment data the patient has. the process of diagnosis is no different from the way a doctor diagnoses a medical disease. the doc does a physical exam and orders tests. from the information obtained (data) the doc is most interested in what is abnormal. every medical diagnosis has very specific signs and symptoms and when the data comes back and the specific signs and symptoms of a disease or condition (such as a spontaneous pneumothorax) are present then the doctor diagnoses it.

we do a similar process in nursing except instead of medical diagnoses and conditions we are diagnosing nursing problems with labels on them that we call nursing diagnoses. every nursing diagnosis has a definition and a broad list of signs and symptoms that are called defining characteristics. the patient must have at least one or more of these defining characteristics in order for you to apply that nursing diagnosis to them. it is also helpful to read the definition of the nursing diagnosis because it often explains what the label doesn't clearly state. interventions are nursing orders given to treat the symptoms that the patient is having in much the same way that a doctor orders treatment for the symptoms of the medical disease/condition the patient has.

nursing problem (nursing diagnoses)--> proven by existence of signs and symptoms (abnormal assessment data)--> treatment you order (nursing interventions) is based upon signs and symptoms present --> rationales are explanations of
the nursing intervention is appropriate

assessment consists of:

  • a health history (review of systems) - no information provided

  • performing a physical exam - no information provided
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - no information provided
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you need to look up information about this condition. you need to know its pathophysiology in order to develop the related factors for some of your nursing diagnostic statements. a patient who has a spontaneous pneumothorax will have sudden sharp pleuritic pain in the side of the chest on which the pneumothorax has occurred, dyspnea, possible cyanosis, chest distention due to the build up of leaking air, or body fluids (depending on the reason for the pneumothorax), tympanic resonance, and no breath sounds upon auscultation over the area of the pneumothorax, subcutaneous emphysema, asymmetrical chest wall movement with respirations.
    • - pneumothorax - "primary spontaneous pneumothorax occurs in patients without underlying pulmonary disease, classically in tall, thin young men in their teens and 20s. it is thought to be due to spontaneous rupture of subpleural apical blebs or bullae that result from smoking or that are inherited. it generally occurs at rest, although some cases occur with activities involving reaching or stretching. primary spontaneous pneumothorax also occurs during diving and high-altitude flying because of unequally transmitted pressure changes in the lung."

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - no information provided - treatment for pneumothorax is usually the insertion of a chest tube and administration of supplemental oxygen. these patients are at risk for the development of pneumonia because of the pain so they tend to not breathe deeply creating an ideal situation for bacteria to flourish.

what are the patient's symptoms to support diagnosing impaired gas exchange and impaired tissue perfusion (specify organ)? those symptoms need to be known because your nursing interventions will be aimed at them. you cannot just pull diagnoses out of the thin air without a reason for choosing them. the patient must be having signs and symptoms of impaired gas exchange (ex: dyspnea cyanosis) and impaired tissue perfusion, cardiopulmonary (ex: rapid respirations, chest pain, using accessory muscles to breath) [impaired tissue perfusion, cardiopulmonary is usually used for patient's with pulmonary embolism and the lung tissue is in jeopardy of infarction and dying. impaired tissue perfusion, peripheral is used for patients with a dvt, deep vein thrombosis. applying ted hose and alps are not going to help the patient's pneumothorax but will be appropriate for someone with pvt, peripheral vascular disease, dvt or thrombophlebitis.]

see - help with care plans

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