Page 88 - Critical Care Nursing Demystified

Chapter 2 CARE OF THE PATIENT WITH CRITICAL RESPIRATORY NEEDS 73

Interpreting Test Results

Chest x-ray (color will be blacker than black), computed tomography (CT), or
ultrasound will indicate presence of fluid buildup causing a pneumothorax.

ABGs will indicate a respiratory alkalosis if the patient is in the early stages
and a respiratory acidosis if the patient develops hypercarbia (later).

Treatment
Administer supplemental oxygen with a watchful eye on the SaO (pulse
2
oximetry).
Control the patient’s pain.
Decompress the pneumothorax with a chest tube or temporary one-way
valve or thoracentesis.
Determine the cause of the pneumothorax.

Nursing Diagnoses Expected Outcomes
Gas exchange impaired The patientʼs ABGs will return to baseline with
specific watch over the pO 2 Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
Decreased cardiac output The patientʼs BP, HR, and pulmonary artery
pressures will remain within normal limits after
institution of PEEP therapy
Pain, acute The patient will report a +2 level of pain after
administering morphine

Nursing Interventions
Assess the patient’s vital signs and SaO frequently to see if the patient is pro-
2
gressing or developing complications.
Assess chest wall movement and breath sounds as movement decreases on the
affected side and breath sounds become diminished or absent.
Assess the level of pain using a visual analogue or quantitative scale to see if
therapy is effective.
Assist with thoracentesis or insertion of chest drainage tube to remove air/
fluid and reestablish negative pressure in the lungs.
Administer pain medications with an eye to the respiratory rate. Most pain
medications that the patient needs, like morphine sulfate, also decrease the
respiratory effort.