What should be the focus of your assessment of this patient? What specific abnormal findings might you notice?

  1. How do the patient’s vital signs reflect his current situation?  Do any of them concern you and if so, why?

For a healthy adult the normal vital signs includes RR 12-16 breaths per minute, BP 120/80, HR 60-100 beats per minute, and SpO2 95%-100%.  The vital signs presented by the patients include HR 102, BP 142/88, RR 32, and SpO2 97% on room air, chest pain (8/10). His HR, RR, and BP are higher than the normal range as well as increased chest pain. These vital signs demonstrate that the patient has tachycardia because the heart beats faster than the normal rate while at rest resulting in these symptoms.

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The focus of assessment of this patient is pneumothorax and head laceration. Pneumothorax is a life-threatening condition and assessment of its cause is crucial in fostering appropriate treatment to the right type of pneumothorax. Pain in the head laceration areas, which may raise concerns of damage to the structure below the skin, bleeding, or infection (Huang, Ahmed, D'Souza & Awad, 2018).

The abnormal findings noticed include the elevated blood pressure.  Patients with pneumothorax usually have low blood pressure, which is contrary in John’s case. Although uncommon, some patients with pneumothorax present high blood pressure level. Tension pneumothorax is commonly found among individuals with high blood pressure, which is an indication that John has tension pneumothorax. A tension pneumothorax can lead to a collapse of the nearby lung completely and push the major blood vessels and the heart to one of the chest thus leading to elevated blood pressure in a patient (Huang, Ahmed, D'Souza & Awad, 2018).

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  1.     What is the priority nursing diagnosis for this patient?

 The nursing assessment will include collecting data on:

  •         Pain/anxiety
  •         Chest expansion
  •         Breath pattern

The nursing diagnosis based on the assessment data include:

  •         Acute pain related to chest pain when taking deep breaths and coughing
  •         Anxiety associated with difficulty in breathing
  •         Ineffective breathing pattern associated with respiratory problems

The nursing care planning and goals for the patient include:

  •         Ensuring the patient is relaxed to minimize anxiety to manageable level
  •         Relief pain
  •         Create a normal and effective respiratory pattern for the patient evidenced by normalized respiratory rate and ease in breathing.

Nursing Interventions

  •         Supporting the patient’s abdominal muscles and chest to make breathing and coughing less traumatic and more effective.
  •         Assist the patient to minimize anxiety or fear through helping them to take deeper and slower respirations.
  •         Inserting the chest tube to facilitate optimum fluid drainage and lung expansion.
  •         Monitoring the progress of re-expansion of lung and addressing pneumothorax (Lewis, Dirksen, Heitkemper & Bucher, 2014).

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