Risk for Trauma/Suffocation | Nursing Care Plan for Pneumothorax

Nursing diagnosis: risk for trauma/suffocation

Risk factors may include

Concurrent disease or injury process

Dependence on external device—chest drainage system

Lack of safety education and precautions

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Risk Control

Recognize need for and seek assistance to prevent complications.

Caregiver Will

Correct and avoid environmental and physical hazards.

Nursing intervention with rationale:

1. Review with client purpose and function of CDU, taking note of safety features.

Rationale: Information on how system works provides reassurance, reducing client anxiety.

2. Instruct client to refrain from lying or pulling on tubing.

Rationale: Reduces risk of obstructing drainage or inadvertently disconnecting tubing.

3. Identify changes and situations that should be reported to caregivers, such as change in sound of bubbling, sudden “air hunger” and chest pain, and disconnection of equipment.

Rationale: Timely intervention may prevent serious complications.

4. Anchor thoracic catheter to chest wall and provide extra length of tubing before turning or moving client.

Rationale: Prevents thoracic catheter dislodgment or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing.

5. Provide safe transportation if client is sent off unit for diagnostic purposes. Before transporting, check water-seal chamber for correct fluid level; presence or absence of bubbling;

and presence, degree, and timing of tidaling. Ascertain whether chest tube can be clamped or disconnected from suction source.

Rationale: Promotes continuation of optimal evacuation of fluid or air during transport. If client is draining large amounts of chest fluid or air, tube should not be clamped or suction interrupted

because of risk of accumulating fluid or air, compromising respiratory status.

6. Monitor thoracic insertion site, noting condition of skin and presence and characteristics of drainage from around the catheter. Change and reapply sterile occlusive dressing as needed.

Rationale: Provides for early recognition and treatment of developing skin or tissue erosion or infection.

7. Observe for signs of respiratory distress if thoracic catheter is disconnected or dislodged.

Rationale: Pneumothorax may recur or worsen, compromising respiratory function and requiring emergency intervention.