A nurse is caring for a patient with a penetrating chest wound. What is the nurse's immediate priority action?
A 28-year-old male patient arrives at the emergency department after being stabbed in the left chest during an altercation. The knife has been removed by bystanders before arrival. Assessment reveals: respiratory rate 32/min, heart rate 128 bpm, blood pressure 90/60 mmHg, oxygen saturation 88% on room air. The patient is sitting upright, leaning forward, and appears anxious. Breath sounds are diminished on the left side, and there is visible chest wall movement asymmetry during respiration.
1Apply a three-sided occlusive dressing to the wound site
2Administer high-flow oxygen via non-rebreather mask✓ 정답
3Prepare for immediate chest tube insertion
4Position the patient in high Fowler's position
해설
Administering high-flow oxygen via a non-rebreather mask is the immediate priority. The patient has a SpO2 of 88%, indicating severe, life-threatening hypoxemia that must be corrected first under the ABCDE (Airway, Breathing, Circulation) framework. Applying a three-sided occlusive dressing (Choice 1) is important to prevent further air entry but does not rapidly correct existing hypoxemia. Chest tube insertion (Choice 3) is the definitive treatment but requires provider preparation and is not the nurse's immediate independent action. High Fowler's positioning (Choice 4) does not correct critical hypoxemia, and the patient has already self-adopted an optimal upright, forward-leaning posture; forcibly repositioning may worsen anxiety and oxygen demand.
Understanding the Clinical Scenario
The patient presents with classic signs of a tension pneumothorax following a penetrating chest wound. The assessment findings—tachycardia (HR 128 bpm), hypotension (BP 90/60 mmHg), tachypnea (RR 32/min), hypoxemia (SpO2 88%), diminished left-sided breath sounds, and asymmetric chest wall movement—indicate a progressive accumulation of air in the pleural space under pressure. The patient's posture (sitting upright, leaning forward) is a compensatory mechanism to facilitate respiratory muscle function. The immediate priority is to address the life-threatening hypoxemia and hemodynamic compromise.
Analysis of the Priority Action
The correct answer is to administer high-flow oxygen via a non-rebreather mask. In the management of trauma, the primary survey follows the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach. While all listed interventions are necessary for a tension pneumothorax, the sequence is critical. The patient's oxygen saturation of 88% on room air signifies severe hypoxemia, which directly threatens tissue oxygenation and cardiac function. The Guidelines for Essential Trauma Care emphasize that strengthening the organization of trauma care, including immediate resuscitation priorities, can lower mortality [1]. Oxygenation is a foundational step in the "Breathing" assessment and management phase, taking precedence over dressing application, which addresses the wound but not the immediate systemic hypoxia.
Why Other Options Are Not the Immediate Priority
- Applying a three-sided occlusive dressing is a critical intervention for an open pneumothorax to prevent air from entering the pleural space during inspiration while allowing trapped air to escape during expiration. However, the patient is already exhibiting signs of a developing tension pneumothorax, meaning air is accumulating and not exiting. While this dressing prevents further air entry, it does not rapidly correct the existing, life-threatening hypoxemia and hemodynamic instability. Oxygenation must be optimized first.
- Preparing for immediate chest tube insertion is the definitive treatment for a tension pneumothorax, as it evacuates the trapped air and allows the lung to re-expand. However, this is a provider-level procedure that requires preparation and time. The nurse's immediate, independent action is to support the patient's failing physiology with high-flow oxygen while the team prepares for the procedure. The circulatory collapse seen in tension pneumothorax involves obstructed venous return, and maximizing oxygen content in the remaining circulating blood is a vital temporizing measure.
- Positioning the patient in high Fowler's position can facilitate chest expansion and ease breathing for patients with respiratory distress. However, the patient has already self-positioned into an upright, forward-leaning posture, which is optimal for him. Forcibly repositioning him may increase anxiety and oxygen consumption without providing a benefit greater than correcting the critical hypoxemia. The patient's current position is acceptable while the priority of oxygenation is addressed.
Pathophysiological Rationale and Clinical Integration
In a tension pneumothorax, injury to the lung or chest wall creates a one-way valve effect. Air enters the pleural space during inspiration but cannot exit during expiration. As pressure builds, the mediastinum shifts toward the unaffected side, compressing the contralateral lung and, crucially, kinking the great vessels (superior and inferior vena cava). This kinking drastically reduces venous return to the heart, leading to decreased cardiac output and the observed hypotension (obstructive shock). The Guidelines for Essential Trauma Care highlight that injury is a major cause of death and that organized trauma care improves outcomes [1]. The immediate provision of high-flow oxygen increases the partial pressure of oxygen in the alveoli, maximizing the oxygen saturation of the hemoglobin that is still circulating. This is the fastest way to mitigate tissue hypoxia while preparing for definitive decompression. This approach aligns with the principle that in trauma resuscitation, physiological stabilization begins simultaneously with assessment, and the most immediately life-threatening physiological derangement—in this case, severe hypoxemia—is addressed first.
References (research sources)
[1]
Guidelines for Essential Trauma Care: Second Edition (2026).GuidelineMock C, Hardcastle TC, Gaarder C, Gupta A, Gyedu A, Joshipura M, Steyn E, Essential Trauma Care revision author group. (2026) · DOI: 10.1002/wjs.70321
Tension Pneumothorax: Immediate Nursing PriorityApplying the ABCDE Framework to a Penetrating Chest Wound
The first action for a patient with a suspected tension pneumothorax and severe hypoxemia (SpO2 88%) is to administer high-flow oxygen via a non-rebreather mask. This directly addresses the 'Breathing' component of the primary survey and corrects life-threatening tissue hypoxia before proceeding to other interventions.
Classic assessment findings include tracheal deviation (late sign), diminished breath sounds on the affected side, asymmetric chest wall movement, tachycardia, and hypotension. The patient's upright, leaning-forward posture is a compensatory mechanism to aid respiratory muscle function.
Caution
Do not place a patient with a suspected tension pneumothorax in High Fowler's position as a first action; this can increase intrathoracic pressure and worsen respiratory distress. Needle decompression and chest tube insertion are definitive treatments but are performed by a provider after initial stabilization.
Tension Pneumothorax — A life-threatening condition where air enters the pleural space and cannot escape, causing lung collapse, mediastinal shift, and hemodynamic compromise.
ABCDE Primary Survey — A systematic approach to trauma care prioritizing Airway, Breathing, Circulation, Disability, and Exposure to identify and manage immediate life threats.
Non-rebreather Mask — A device delivering high concentrations of oxygen (60-90%) with a reservoir bag and one-way valves, used for patients with severe hypoxemia who are breathing spontaneously.