A nurse is caring for a postoperative patient who develops severe respiratory distress with decreased oxygen saturation, increased peak inspiratory pressures, and absent breath sounds on the right side while on mechanical ventilation. What is the most appropriate immediate nursing action?

심화 해설

임상 시나리오

핵심 개념

• Tension Pneumothorax — Tension pneumothorax. A condition where air enters the pleural cavity but cannot escape due to a 'one-way valve' mechanism, causing pressure to continuously increase. It compresses the lung and shifts the mediastinum toward the unaffected side, obstructing venous blood return to the heart, and is a life-threatening emergency.
• Needle Decompression — Needle decompression. An emergency treatment for tension pneumothorax, where a large-bore needle (usually 14G or 16G) is inserted into the second intercostal space at the midclavicular line on the affected side to release excessive air pressure from the pleural cavity to the outside.
• Mechanical Ventilation — Mechanical ventilation. A treatment that assists or replaces a patient's breathing using a ventilator. Positive pressure ventilation can be a risk factor for pneumothorax, such as tension pneumothorax.
• Peak Inspiratory Pressure — Peak inspiratory pressure. The maximum pressure applied to the airway during mechanical ventilation. In tension pneumothorax, increased pleural cavity pressure makes lung expansion difficult, so the PIP required to deliver the same volume of air rises sharply.
• Chest Tube Thoracostomy — Chest tube insertion. This is a definitive treatment following needle decompression, where a chest tube is inserted into the pleural cavity through the intercostal space to continuously drain air or fluid and promote lung re-expansion.