PRIORITIZED NURSING PROBLEM FOR PNEUMOTHORAX
Nursing Diagnosis Nursing Intervention
Ineffective breathing Independent
pattern related to 1. Elevate head of bed as
airway obstruction permitted and position on
secondary to sides, as indicated.
Pneumothorax.
2. Encourage deep breathing if
client is conscious
3. Monitor rate, rhythm, and
depth of respiration. Note
breathing irregularities, for
example, apneustic, ataxic, or
cluster breathing.
4. Note competence of gag and
swallow reflexes and client’s
ability to protect own airway.
5. Auscultate breath sounds,
noting areas of
hypoventilation and presence
Rationale
Facilitates lung expansion and
ventilation, and reduces risk of
airway obstruction by tongue.
Upright position allows increased
diaphragmatic excursion secondary
to downward shift of internal
organs from gravity.
Inhaling through nose allows air to
be filtered, warmed and humidified.
Changes may indicate onset of
pulmonary complications.
Deviations may also suggest
respiratory problems if neglected
could worsen patient’s state of
health.
Ability to mobilize or clear
secretions is important to airway
maintenance. Loss of swallow or
cough reflex may indicate need for
artificial airway or intubation.
Identifies pulmonary problems
such as atelectasis, congestion, and
airway obstruction, which may
 of adventitious sounds.
6. Instruct the patient to avoid
over-eating and gas forming
foods.
7. Maintain calm attitude while
dealing with the patient.
Dependent
8. Administer pain killer
/sedative/ antipyretic as
prescribed by the doctor
Collaborative
jeopardize cerebral oxygenation.
Breath sounds may be diminished
or absent in a lobe, lung segment,
or entire lung field (unilateral).
Atelectatic area will have no breath
sounds, and partially collapsed
areas have decreased sounds.
Consuming gas forming foods can
cause bloating and discomfort by
pushing on the diaphragm, making
it difficult and uncomfortable to
breathe.
To promote good environment
necessary to improve patient’s
health. Assists patient to deal with
the physiological effects of
hypoxia, which may be manifested
as anxiety and/or fear.
To follow patient’s therapeutic
regimen to stabilize her wellness of
health.
CTT maintains prescribed
intrapleural negativity, which

9. Assist in reclogging of the
Chest tube thoracostomy
10. Review serial chest x-rays.
11. Administer supplemental
oxygen via
cannula/mask/mechanical
ventilation as indicated.
promotes optimum lung expansions
and fluid drainage.
Monitors progress of resolving
pneumothorax and re-expansion of
lung. Can identify malposition of
endotracheal tube (ET) affecting
lung re-expansion.
Aids in reducing work of breathing;
promotes relief of respiratory
distress and cyanosis associated
with hypoxemia.
References:
 https://nurseslabs.com/pneu
mothorax/
 https://nurseslabs.com/3-
hemothoraxpneumothorax-
nursing-care-plans/
 https://www.coursehero.co
m/file/39940631/nursing-
care-plan-
pneumothoraxpdf/