Standardized Care Plan for patients with spontaneous pneumothorax PDF

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Summary

Pneumothorax (NT) consists of the presence of air in the pleural space, which is one of the most frequent forms of thoracic disease. The entry of air into the pleural cavity causes a loss of intrapleural pressure, normally negative with respect to atmospheric pressure, thus causing a lung collapse...

Description

Standardized Care Plan for patients with spontaneous pneumothorax Pneumothorax (NT) consists of the presence of air in the pleural space, which is one of the most frequent forms of thoracic disease. The entry of air into the pleural cavity causes a loss of intrapleural pressure, normally negative with respect to atmospheric pressure, thus causing a lung collapse. (1–5) TN is a vital emergency since the presence of air in the pleural cavity decreases the vital capacity, which is the maximum amount of air that is expelled from the lungs after a complete inspiration. On the other hand, the inspired volume per minute and venous return are also decreased. The degree of functional impact will depend on the size of the collapse, as well as the patient's previous functional reserve and will require early action. (3) Although it can occur as a consequence of trauma, whether accidental or iatrogenic, sometimes it may not have a predisposing factor, in which case we would be talking about a spontaneous pneumothorax, which we can classify as: primary, secondary or catamenial. In addition, the Society for Pulmonology and Thoracic Surgery (SEPAR) classifies pneumothorax as total, complete, or partial. (Annex I) (3,6,7,8) Depending on the type of pneumothorax that the patient presents, as well as its characteristics, the appropriate treatment for this will vary from rest to a more invasive treatment, such as surgery. (Annex II) (8) The characteristic patient of this type of pneumothorax is a young, tall man with a thin complexion and between 16 and 25 years of age, however, this type of pneumothorax has an inaccurate incidence, ranging around 18-28 / 100.1

cases per year in men and 6-9.8 / 100,000 in women, representing

2.7 to 7.1% of all lung diseases and are the most frequent cause of urgent admissions in thoracic surgery services, as well as 96% of all lung diseases. Most authors agree that 80% of the pneumothoraces that occur to us in everyday life constitute spontaneous pneumothorax. (9-11)

1

The etiology of NE is generally unknown, however, they are usually associated with smoking, family history and medical history in the case of NE. However, other risk factors are known, such as sudden changes in atmospheric pressure, exposure to high intensity sounds or noises, Marfan syndrome or the presence of systemic endometriosis. (12-16) The clinical picture that it presents is usually variable, however, symptoms such as dyspnea, cough, polypnea and pleuritic pain with no apparent cause are frequent, characterized by being intense, sudden and stabbing, which can radiate to the rest of the chest and which it tends to increase with coughing and respiratory movements. The severity of the symptoms tends to correlate with the size and speed with which the pneumothorax sets in, so that on some occasions the symptoms may be subtle and insufficient for the correct diagnosis of EN (Annex III) (4,6,10 , 14,17) Although they are more common on the right side, bilateral pneumothorax occurs in less than 10% of patients, and 25% of patients recur in the first two years. Recurrence of primary spontaneous pneumothorax represents a complication that occurs most frequently during the first year. After the second pneumothorax, the possibility of having a third episode increases to more than 50%, as well as the appearance of possible complications. (Annex IV) (8,10) It is proven that meticulous care is important in all thoracic procedures, among which respiratory physiotherapy, pain control and monitoring of the thoracic drainage system are of vital importance, among others. These activities are carried out by nurses, and the proper performance of this care is essential for the recovery and autonomy of the patient. For this reason, it has been considered appropriate to carry out a standardized care plan based on evidence, thus avoiding inappropriate variability in clinical practice.

OBJECTIVES General purpose: 

Carry out a standard nursing care plan on the most frequent problems in patients with spontaneous pneumothorax.

Specific objectives: 

Identify

the

main

problems

that

patients

with

spontaneous

pneumothorax can develop. 

Identify the nursing care that should be applied to patients with spontaneous

pneumothorax

according

to

the

latest

scientific

evidence. 

Develop a tool that helps nursing professionals apply quality nursing care and avoid inappropriate variability in clinical practice.

METHODOLOGY The work consists of the elaboration of a standardized care plan, for which an

exhaustive

bibliographic

search

has

been

carried

out

and

the

competencies established in the Study Plan have been applied. The bibliographic search took place in a period between 12/27/19 and 03/15/20 and the work was carried out between January and May 2020. In conducting the bibliographic search on spontaneous pneumothorax and its care, articles published in English and Spanish from 2012 have been used, which were relevant to the work and which were available in full text in databases such as Pubmed , Cochrane, ScienceDirect, Scielo and Cuiden. The following keywords were used in the definition of the bibliographic search: pneumothorax and spontaneous, combining them with the operator

Boolean "AND". In addition, the following inclusion and exclusion criteria were applied (Table 1): Table 1: Bibliographic search criteria INCLUSION CRITERIA 

Articles

free

to

EXCLUSION CRITERIA 

type of pneumothorax other

text full. 

Articles

than spontaneous. published

in



the last 5 years *. 

Specific articles on another

Articles

what

talk

exclusively surgery.

Articles in Spanish and English.



Articles

what try

on

bilateral pneumothorax.

Source: self made * Some articles are older than 2015, however, their inclusion in the work has been considered timely due to their clinical relevance and timelessness.

Table 2: Bibliographic search BASES OF

KEYWORDS AND

ARTICLES

BOOLEAN OPERATOR

FOUND

ARTICLES EMPLOYEES

DATA Cochrane SciELO PubMed

Spontaneous AND

3

1

7

0

13

4

1

1

132

4

2

1

pneumothor ax Fisterra ScienceDire ct CARE Plus

AND / OR pneumothorax spontaneous Pneumothorax

Source: self made Information was also consulted in other information sources such as clinical practice guidelines of the Hospital Universitario de Albacete, websites of

organizations such as the Society for Pulmonology and Thoracic Surgery (SEPAR) or MSD Manuals, as well as medical journals reflected in the bibliography, for which the search period was extended due to lack of more current information. To prepare a Standardized Care Plan (PCE) for the patient suffering from spontaneous pneumothorax, an assessment of basic needs was carried out following the Virginia Henderson model (Annex V). The PCE has been developed by elaborating the most relevant nursing diagnoses and collaboration problems that can occur in patients suffering from spontaneous pneumothorax, using the NANDA-NOC-NIC taxonomies. (18.19) For the implantation of this PCE for a patient with pneumothorax, an expert group in pneumothorax would be formed, in addition to presenting it and implementing a pilot experience in a thoracic surgery plant. After the evaluation and evaluation of the PCE by the staff, possible errors would be corrected and its effectiveness would be re-evaluated.

DEVELOPMENT After analyzing the data obtained in the previous bibliographic review, it is observed that the needs that are altered more frequently in the target population to whom the work is directed, patients who suffer a spontaneous pneumothorax, are: -

Need 1: Breathe normally. The alteration of this need is related to the pneumothorax, as well as the pain that the chest drainage will produce and the anxiety that the pathology itself will produce.

-

Need 4: Move and maintain proper postures. The patient will feel discomfort at the movement, in addition to uncertainty about what movements he can or cannot perform or in which position he should be placed.

-

Need 14: Learn, discover or satisfy the curiosity that leads to normal development and to use available resources. This need is altered by the lack of knowledge about the disease and its correct development.

Taking into account the needs that are affected, the following nursing diagnoses and the following collaboration problems have been identified (Table 3): Table 3: Nursing diagnoses and collaboration problems NURSING DIAGNOSTICS Anxiety Knowledge

POTENTIAL COMPLICATIONS Ineffective breathing pattern

deficient:

disease Knowledge

COLLABORATION PROBLEMS /

Tension pneumothorax secondary to pneumothorax.

deficient:

treatment Ineffective coping

Subcutaneous emphysema secondary to pneumothorax. Pneumomediastinum secondary to pneumothorax.

Degradation of physic movility

Hemopneumothorax secondary to lung collapse. Empyema

secondary to

pneumothorax. Pain

acute

secondary

to lung collapse. Risk of infection secondary to surgical wound Risk of bleeding secondary to surgical wound. Pleural effusion secondary to pneumothorax. Source: self made

INDEPENDENCE DIAGNOSTICS (00146) Anxiety r / c stressors, hospitalization and your state of health (Fp) m / p insecurity or restlessness, worry or nervousness.

Definition: Vague feeling of discomfort or threat accompanied by an autonomic response (whose origin is often unknown to the individual); feeling of apprehension caused by anticipation of danger. It is a warning sign that warns of a danger. General purpose: the patient will verbalize the reduction of anxiety to tolerable or manageable levels. Specific objectives: the patient: -

You will name the events that generate the anxious response.

-

You will identify effective strategies to cope with anxiety and that will help reduce it.

-

You will acquire competence in the execution of relaxation techniques. ANXIETY

NOC / INDICATORS

1402

Self-

monitoring

the

ACTIVITIES

N I C 5820 Decrease

all

procedures,

including

the

possible sensations to be experienced

from anxiety

during the procedure.

anxiety Personal

actions

eliminate

or

to

reduce

feelings apprehension, or

 Explain

unease

of tension, from

an

unidentified source.

 Create an trust.

Minimize apprehension,

fear,

omens, or concern related

to

unidentified of

an source

environment that facilitates

 Encourage the expression of feelings, perceptions and fears.  Identify changes in anxiety level.

anticipated

danger. INDICATORS SCALE: Shown: Never (1); Rarely (2); Sometimes (3); Frequently (4); Always (5)

7310 Caring for

 Introduce himself.

nursing at

 Have adequate privacy for the patient, family or loved ones.

entry

 Carry out the physical assessment of admission.

 140207 Use relaxation

Facilitate

techniques.

admission

 140214 Refers to sleep adequately.

the of

the

patient in a health center.

 Carry out the psychosocial assessment of admission.  Provide relevant information in writing.

 140215 Absence of physical manifestations of anxiety.

(00126) Poor knowledge: disease and treatment r / c lack of exposure (C) m / p inaccurate following of instructions and verbalization of the problem by the patient.

Definition: lack or deficiency of cognitive information related to a specific topic. General purpose: the patient will acquire the knowledge and skills necessary to manage their illness. Specific objectives: the patient: -

It will specify your learning needs.

-

It will express the usefulness of the knowledge or skills acquired in managing your health care.

-

Verbalize the increase in your ability to perform the required techniques or skills.

POOR KNOWLEDGE: DISEASE AND TREATMENT NOC / INDICATORS

 Assess

1803 Knowledge:

of

about

the

process of a specific disease and

current

level

of

the disease process.

understanding

transmitted

the

knowledge of the patient related to

disease process Degree

ACTIVITIES

N I C

prevention

of

complications.

5602

 Explain the pathophysiology of the

Teaching:

disease

disease

anatomy and physiology.

process

 Describe

and

the

its

relationship

common

signs

with

and

symptoms of the disease. Help the patient

INDICATOR S

understand

SCALE: Knowledge: None (1); Scarce

 Provide

(2); Moderate (3); Substantial (4); Extensive (5)

Process

the information of

the disease.  180304 Risk factors.  180309 Complications of the disease.

information

about

the

disease.

related to a  180302

 Identify possible etiologies.

process

 Discuss treatment options.  Avoid empty promises.  Instruct the patient about the signs

of disease.

and symptoms to report.

POOR KNOWLEDGE: DISEASE AND TREATMENT NOC / INDICATORS

ACTIVITIES

N I C

 Explain to the patient what his pathology, So

1803 Knowledge: process of

what he patient of

understanding

transmitted

about

the

process of a specific disease and

their possible

 Begin instruction only after

disease Degree

as

complications.

prevention

of

INDICATOR S

ready to learn.

Facilitate The

SCALE: Knowledge: None (1); Scarce

the ability

(2); Moderate (3); Substantial (4);

to process

 Set realistic and objective goals with the patient.  Provide an environment that encourages learning.  Encourage the active participation of

Promote

Extensive (5)

to be

5520

learning

complications.

prove

the patient.  Give adequate time to master the

and understand information .

 180302

Process

of

content.

the disease.

 Simplify instructions whenever

 180304 Risk factors.

possible.

 180309 Complications of the disease.

 Answer the questions in a way clear.

1814 Knowledge:

 Explain the procedure to the patient

procedures

through sensory preparation.

therapeutic Degree

 Take note of the characteristics of

of

transmitted

knowledge about

a

3440 Care incision site

therapeutic regimen.

 Clean the area around the incision with Cleaning,

Extensive (5)

and

 Clean the area around the drain or the end of the drain tube.

promotion of the healing

 181401

an appropriate antiseptic solution.

monitoring

SCALE: Knowledge: None (1); Scarce (2); Moderate (3); Substantial (4);

 Monitor the healing process at the incision site.

procedure within a

INDICATOR S

any drainage.

 Instruct the patient (or caregiver) on

of

how to care for the incision during

a

bathing or showering.

Therapeutic

wound

procedure  181402 Purpose

 Teach the patient to care for the closed

through

of the procedure 

181410 Possible

sutures, clips or

undesirable effects

staples.

incision including observing signs and symptoms of infection.

(00085) Impairment of physical mobility r / c discomfort and reluctance to start movement (Ff) m / p limitation of the capacity for motor skills.

Definition: limitation of the independent, intentional movement suffered by the person in the whole of his body or of one or more limbs General purpose: the / the patient will acquire their maximum mobilization capacity during their hospital stay. Specific objectives: the patient: -

It will cooperate in mobilization according to its capabilities.

-

He will state that he knows and will carry out the prescribed exercises.

DEGRADATION OF PHYSIC MOVILITY NOC / INDICATORS

ACTIVITIES

N I C

 Instruct the patient about the techniques

0208 Level of

safe transport and ambulation.

mobility

0221 Therapy

Ability to move with

exercises:

resolution

wandering

 Assist the patient in ambulation initial.  Dress the patient in comfortable clothing.

INDICATORS SCALE: Dependency: Dependent (1); You need help and devices (2); Need help (3); Independent with help (4); Freestanding (5)

 020802

Stimulation

and

 020803 Muscle movement.  020805 Carrying out the transfer.

tolerated.

assistance

in

ambulation

to

 Teach the patient to get into the

maintain or restore

correct position during the transfer

autonomous

process.

bodily

functions

 Foment

a

wandering

independent within safe limits.

Maintenance of body position.

 Help the patient to sit up in bed, as

and

volunteers

during

treatment

and recovery from...