Page 1578 - Saunders Comprehensive Review For NCLEX-RN

d. An open pneumothorax occurs when
an opening through the chest wall
allows the entrance of positive
atmospheric air pressure into the
pleural space.
e. A tension pneumothorax occurs from a
blunt chest injury or from mechanical
ventilation with PEEP when a buildup
of positive pressure occurs in the
pleural space.
2. Assessment (Box 50-3)

3. Interventions

a. Diagnosis of pneumothorax is made by
chest x-ray.
b. Apply a nonporous dressing over an
open chest wound.
c. Administer oxygen as prescribed.
d. Place the client in a Fowler’s position.
e. Prepare for chest tube placement, which
will remain in place until the lung has
expanded fully.
f. Monitor the chest tube drainage system.
g. Monitor for subcutaneous emphysema.
h. See Chapter 69 for information on
caring for a client with chest tubes.

Clients with a respiratory disorder should

be positioned with the head of the bed elevated.
V. Acute Respiratory Failure
A. Description
1. Occurs when insufficient oxygen is transported to the
blood or inadequate carbon dioxide is removed from
the lungs and the client’s compensatory mechanisms
fail
2. Causes include a mechanical abnormality of the lungs
or chest wall, a defect in the respiratory control center
in the brain, or an impairment in the function of the
respiratory muscles.

3. In oxygenation failure, or hypoxemic

respiratory failure, oxygen may reach the alveoli but
cannot be absorbed or used properly, resulting in a
PaO lower than 60 mm Hg, arterial oxygen
2
saturation (SaO ) lower than 90%, or partial pressure
2

1578