A trauma patient who sustained blunt chest injury becomes acutely diaphoretic and hypotensive. The right hemithorax is hyperresonant to percussion, breath sounds are absent on the right, and the trachea is deviated to the left. SpO2 has fallen from 96 to 80 percent on 4 L nasal cannula. Which nursing actions are appropriate before the provider arrives at the bedside? Select all that apply.
Select All That Apply
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Explanation
Tension pneumothorax is a clinical diagnosis — the combination of absent breath sounds, hyperresonance, contralateral tracheal deviation, and obstructive shock physiology mandates immediate decompression rather than imaging. Definitive management is needle decompression (2nd ICS midclavicular line, or 4th–5th ICS anterior axillary line in adults) followed by chest tube. Transporting to CT is contraindicated because it delays life-saving intervention.
Tension PTX kills by compressing the great vessels and obstructing venous return — every minute of imaging is a minute closer to PEA arrest. The nurse provides 100 percent O2, alerts the provider STAT, sets up needle decompression and chest-tube trays, ensures monitoring and IV access, and never sends the patient to CT to confirm a clinical emergency.
Blunt chest trauma patient abruptly becomes diaphoretic and hypotensive. The right hemithorax is hyperresonant, breath sounds are absent on the right, and the trachea is deviated to the left. SpO2 falls from 96 to 80 percent on 4 L nasal cannula. The clinical picture is tension pneumothorax.
Tension pneumothorax — One-way valve air leak into the pleural space producing ipsilateral hyperresonance, contralateral tracheal deviation, and obstructive shock.
Needle decompression — Insertion of a 14-gauge angiocatheter at the 2nd ICS midclavicular line (or 4th–5th ICS anterior axillary line in adults) to convert tension to simple pneumothorax.
Tracheal deviation — Trachea shifted away from the affected side under tension pneumothorax physiology; a late and ominous sign.