Primary spontaneous pneumothorax

Primary spontaneous pneumothorax

Marlene Roman

A pneumothorax is defined as air in the pleural space (air between the lung and chest wall). The most complete figures on the incidence of primary spontaneous pneumothorax come from a study done by Melton, Hepper, and Offord (1979) of the residents of Olmsted County, Minnesota. Based on this study, it is estimated that approximately 20,000 new cases of spontaneous pneumothorax will occur annually in the United States (Baumann & Strange, 1997). Males are 4 to 10 times more likely to experience spontaneous pneumothorax than females. One study by Goebbel, Rhea, Nelson, and David (1963) reported that 52% of a group of 119 patients had an ipsilateral recurrence within 6 years of a primary spontaneous pneumothorax. The incidence of subsequent pneumothoraces increases to 62% and 83% for patients with second and third pneumothoraces who are not treated with thoracotomy.

A spontaneous pneumothorax is a relatively common clinical problem in the United States. The majority of patients who require hospitalization due to a primary spontaneous pneumothorax will be admitted to a medical-surgical unit. The recommended medical treatment and the nursing care required for a patient with a spontaneous pneumothorax will be discussed.

Case Study

M.A. is an 18-year-old male who presented to the emergency room with complaints of mild to moderate shortness of breath and right-sided pleuritic chest pain. His history shows previous recurrent bilateral spontaneous pneumothoraces treated by tube thoracostomy and chemical pleurodesis. Current radiographic films confirm a right pneumothorax. A chest tube is placed and the patient is admitted to a general surgical floor. M.A. had previously been treated with chest tube placement, left upper lobe apical bleb resection, and mechanical pleurodesis. Surgical intervention is warranted at this time because of M.A.’s history and likelihood of further recurrence. During this hospital stay, M.A. undergoes thoracoscopy with mechanical pleurodesis and resection of a bleb.

Anatomy and Physiology Of the Pleura

The pleura is a serous membrane that covers the lung parenchyma, the mediastinum, the diaphragm, and the rib cage. The pleura is subdivided into the parietal pleura which covers the inner surface of the thoracic cage, mediastinum, and diaphragm; and the visceral pleura which covers the entire surface of the lungs except at the hili, where the bronchi and major blood vessels enter the lungs (see Figure 1). The parietal pleura is further divided into four parts: costal, cervical, diaphragmatic, and mediastinal. The costal pleura lines the ribs, cartilages, and vertebral bodies, and is the thickest portion of the parietal pleura. The visceral pleura covers the lungs so firmly that it is not possible to strip it from the lung tissue under normal circumstances (Wolfe, 1991). Since the surfaces of the visceral and parietal pleurae normally touch each other, the space between them (the pleural space) is actually only a potential space. This space contains a thin layer of serous fluid that coats the opposing surfaces. Although the lungs are elastic and have an inherent tendency to recoil and collapse, the negative pressure in the pleural space helps to maintain the lungs in full expansion. When air or a larger amount of fluid accumulates in the pleural space, the visceral and parietal pleural surfaces are separated. Negative pressure is lost and the lung collapses.


Etiology of Pneumothorax

Spontaneous pneumothorax can occur without antecedent trauma or otherwise obvious cause, whereas traumatic pneumothorax occurs as a result of direct or indirect trauma to the chest. Primary spontaneous pneumothorax occurs in otherwise healthy individuals, and secondary spontaneous pneumothorax occurs as a complication of underlying disease, most commonly chronic obstructive pulmonary disease.

A primary spontaneous pneumothorax is a common occurrence in young, otherwise healthy adults (Light, 1983). While it may occur at any age, it predominantly occurs in young, healthy people in their late teens and early 20s. It is much more common in males who are tall and thin, and have a long and narrow chest.

Pathogenesis of Primary Spontaneous Pneumothorax

Primary spontaneous pneumothorax is believed to result from rupture of a subpleural apical bleb (blister-like formation). The pathogenesis of a subpleural bleb is unclear, although there is a strong association between smoking and the development of a primary spontaneous pneumothorax. It is probable that disease of the small airways related to smoking contributes to the development of a subpleural bleb.

A less commonly occurring primary spontaneous pneumothorax, a catamenial pneumothorax, is a syndrome of recurrent pneumothorax occurring within 48 to 72 hours of onset of menses (Carter & Ettonsohn, 1990). This syndrome was described for the first time in 1958 by Maurer and associates, and it was named catamenial pneumothorax by Lillington, Mitchell, and Wood in 1972. The initial pneumothorax usually does not occur until the woman is at least 30 years of age, and it typically occurs on the right side. A catamenial pneumothorax tends to be recurrent unless there is a definitive therapeutic intervention. On the average, patients have about five pneumothoraces before the diagnosis is recognized (Lillington et al., 1972).

Although numerous hypotheses have been studied, the underlying pathogenesis of catamenial pneumothorax remains poorly understood. It is thought to be associated with endometriosis. Carter and Ettonsohn (1990) found that if menstrual history was neglected, diagnosis may be delayed or even prevented. This may lead to an underestimation of the true incidence of the disorder and to a delay in initiating appropriate therapy.

Catamenial pneumothorax has been managed with a wide range of interventions, ranging from thoracotomy with mechanical pleurodesis to the present treatment with oral contraceptives, progesterone, or gonadotropin-releasing hormone analogs (Blanco et al., 1998).

Clinical Manifestations

A thorough clinical history and physical examination are essential in establishing the diagnosis. Chest pain and dyspnea are the two main symptoms associated with the development of primary spontaneous pneumothorax. In one study of 39 patients with primary spontaneous pneumothorax, all patients had chest pain or dyspnea and symptoms were present in 25 out of the 39 patients (64%) (Vail, Always, & England, 1960). In another study (Seremetis, 1970), chest pain was reported in 140 of 155 patients (90%).

Most patients present with an acute onset of chest pain and dyspnea. The chest pain is usually sharp, localized to the side of the pneumothorax, and worsens with respiratory effort. The initial sharp chest pain may subside after a few hours and may be followed by a dull ache. The severity of the dyspnea and its progression may vary depending on the size of the pneumothorax and the patient’s respiratory reserve. A patient with a small pneumothorax may not experience any signs or symptoms.

On physical exam, chest movement and breath sounds may be decreased or absent on the affected side. Percussion reveals hyperresonance over the pneumothorax, and absence of transmitted vocal vibration will be noted upon palpation. Cyanosis, tachycardia, and tachypnea may also be present.


A chest x-ray may reveal a lowered diaphragm, air in the pleural cavity, and partial or total lung collapse on the affected side (see Figure 2). Treatment of a tension pneumothorax may be based on clinical history and physical exam only. Emphasis should be placed on the patient’s clinical status, not on the radiographic size of the pneumothorax, when making therapeutic choices (Baumann & Strange, 1997). There should be a high index of suspicion when the patient reports a history of previous pneumothorax. A second chest x-ray will be taken 24 hours after the first to rule out a larger collapse.



The treatment goals for pneumothorax are to alleviate the symptoms, eliminate the air from the pleural space, decrease the likelihood of recurrence, and decrease the likelihood of progression to tension pneumothorax. Treatment decisions are based on the severity and duration of symptoms, the presence of underlying pulmonary disease, and the history of previous pneumothoraces (DeMeester & LaFontaine, 1983). Depending on the percentage of the pleural cavity filled with air, a spontaneous pneumothorax may be described as small (60%). In most cases, symptoms are experienced by patients with a moderate or large pneumothorax.

A small, stable pneumothorax in which the patient is symptom-free may be treated by observation only. An uncomplicated, untreated pneumothorax will resolve slowly at approximately 1.25% per day. The rate of reabsorption can be increased by using supplemental oxygen, which increases the nitrogen gradient from the lung to the pleura (Leavell, 1996). Oxygen delivery varies from nasal cannula oxygen at 3L/minute to high-flow masks, including partial rebreathing masks (Baumann & Strange, 1997). Young adults usually become symptom-free after 24 hours because of their respiratory reserve, although they may experience a decreased exercise tolerance. A patient with a previous history of spontaneous pneumothorax will usually recognize the symptoms and will seek medical attention.

Tension Pneumothorax

With moderate to severe pneumothorax, profound respiratory distress may develop with signs of tension pneumothorax. A tension pneumothorax (see Figure 3) occurs when air enters the pleural cavity and cannot escape. With each inspiration more air becomes trapped resulting in increasing intrathoracic pressure. Mediastinal structures may shift to the unaffected side and compress the opposite lung, leading to acute respiratory distress.


The mediastinal shift compresses the great vessels, reducing venous return, and decreasing cardiac output and blood pressure. Clinical signs and symptoms of a tension pneumothorax include a weak and rapid pulse, decreased blood pressure, pallor, neck vein distension, anxiety, and tracheal deviation away from the affected side. Physical findings of hyperresonance, absent breath sounds, and mediastinal shift away from the involved side are diagnostic (Scott, 1991). Untreated tension pneumothorax can result in severe hypoxia, respiratory acidosis, and death.

Thoracostomy Tube

In the presence of a larger pneumothorax, a thoracostomy tube is inserted to remove the air from the pleural space. The tube is usually connected to a chest drainage system, although it may be connected to a Heimlich valve (see Figure 4). Water seal drainage is usually adequate for most patients. If a persistent air leak exists, 15 to 20 cm of water suction is indicated. Suction hastens expansion by actively removing air from the pleural cavity and promoting apposition of the pleural surfaces. Failure to respond to initial treatment and/or the existence of other factors may indicate a need for further treatment. Recurrence rate after the first spontaneous pneumothorax treated with tube thoracostomy is between 23% and 52% (Milanez et al., 1994). After placement of the chest tube, a followup chest x-ray should be ordered.

Figure 4.

Heimlich Valve

A Heimlich valve is a small, plastic one-way valve used for chest

drainage. Dr. Henry Heimlich, better known for the abdominal thrust

(the Heimlich maneuver), introduced the valve in the 1960s. The device

was used extensively in the Vietnam War and is now used by emergency

trauma teams for safe transport of patients with chest trauma. The

portable Heimlich valve is also used for a small, nondraining or

slowly resolving pneumothorax.

The Heimlich valve consists of a plaster tube with a flutter valve (see

Figure 7). The flutter valve, a length of rubber tubing that is

flattened on one end (similar to a Penrose[TM] drain), allows air or

fluid to pass in one direction only (away from the patient). The

Heimlich flutter valve allows air and/or fluid to drain from the

pleural cavity during expiration without allowing additional air

to enter during inspiration.


Sterile technique is used to connect the proximal end of the valve

to the end of the chest tube. It is taped securely to prevent it from

dislodging. The distal end may be left open to air if there is no

fluid draining. If fluid is draining, the distal end may be covered

with a gauze pad or with a glove. The glove must be vented to allow

air to escape. If the glove is not vented, the patient would be at

risk for developing a tension pneumothorax because the air has no

outlet for escape and it would remain in the pleural cavity.

If the patient is discharged home with the Heimlich valve, education is

of utmost importance. The patient must be instructed on the reason for

the valve, what to do if it becomes disconnected or if it starts

draining, and when to call the physician.

Chemical Pleurodesis

A persistent air leak may be managed by chemical pleurodesis. Chemical pleurodesis involves instillation of a variety of agents, such as talc, doxycycline, and bleomycin. Talc is effective in preventing recurrences and it has minimal long-term effects, as well as being inexpensive. Nursing and medical care should be coordinated prior to the procedure and an analgesic should be given to the patient, because pleurodesis can cause intense pleuritic pain (Samuel, 1997).

After instilling the sclerosing agent, the physician either clamps or loops the chest tube. The decision to rotate the patient from side to side and back to front depends on the physician’s preference and on the patient’s ability to tolerate turning. Instilling these agents into the pleural cavity via the thoracostomy tube causes adhesions to form between the parietal and visceral pleural surfaces. The adhesions serve to seal off the air leak and result in the fusion of the pleural surfaces, theoretically eliminating the pleural space.

Surgical Intervention

Surgical intervention may be indicated for recurrent pneumothorax, bilateral pneumothorax, prolonged air leak (longer than 5 to 7 days), or inability to fully expand the lung (Leavell, 1996). Surgical intervention not only solves the present pneumothorax, but also diminishes the likelihood of recurrence. Various methods proposed for scarification of the pleura range from mechanical pleurodesis to visceral and parietal pleurectomy. Because pleural abrasion with a dry gauze is less traumatic than pleurectomy and does not affect a later thoracotomy, it is the procedure of choice.

Mechanical Pleurodesis

Mechanical pleurodesis may either be completed through a posterolateral thoracotomy incision or via video-assisted thoracic surgery (VATS). The VATS approach is a less-invasive means of complete visualization of the lung and pleura. VATS is a valid alternative to open thoracotomy for treating spontaneous pneumothorax, with less than a 5% recurrence rate, decreased patient discomfort, and a shortened postoperative hospitalization (Rao et al., 1999).

The parietal and visceral pleurae, and the peripheral surface of the lung, are assessed. Subpleural blebs are identified, most often found at the apex of the upper lobe but occasionally in the apex of the superior segment or along the edge of a fissure. Dry sponges are used to vigorously abrade the parietal pleural surface until the surface is inflamed and bleeds (see Figure 5). Once the abrasion is completed, the blebs are isolated from the underlying lung with staples or ligature. The isolated portion of lung with the blebs may be excised or may be left unresected.


In a study done by Nezu, Kushibe, Tojo, Takahama, and Kitamura (199T), 34 patients had a thoracoscopic wedge resection of blebs performed using a stapling device and done under local anesthesia with sedation. An indication for this surgery includes knowledge of the precise bleb location prior to the procedure. Prior to surgery, 0.5% lidocaine was administered into the pleural space. Medication to reduce anxiety and pain, such as diazepam and butorphanol tartrate, was administered during the procedure. Minor postoperative complications (air leakage and transient atelectasis) were seen in only three patients. One patient had a recurrence of his spontaneous pneumothorax 3 months after the procedure. The hospital stay was shorter for patients who received local anesthesia as compared to a group of 38 patients who had the procedure performed under general anesthesia.


Parietal pleurectomy creates an inflammatory surface that promotes fixation of the lung to the endothoracic fascia. Pleurectomy is the most secure procedure to obtain permanent pleurodesis. Because the disease is nearly always limited to the lung apex, an apical pleurectomy combined with bleb excision is enough for definitive control of recurrences (Shields, 1989).

Nursing Management

The goals of nursing care for a patient with a spontaneous pneumothorax include preventing complications, resolving the pneumothorax, pain management, and education of the patient and family (Blank-Reid & Reid, 1999; DeMeester & Lafontaine, 1983).

Preventing Complications/Resolution Of the Pneumothorax

The patient is admitted into the hospital if the pneumothorax is moderate to large and/or the patient is symptomatic and requires a thoracostomy tube. No matter which drainage system is used (see Figure 6), the principles of caring for the patient with a thoracostomy tube remain the same. A closed, sterile system must be maintained to prevent the introduction of air and pathogens into the chest cavity. The chest tube removes air and/or fluid in the pleural cavity and also prevents air and/or fluid from returning. Of primary importance is an understanding of the characteristics of the system both by the responsible physician and the nursing staff (Scott, 1991).


Chest Drainage System

Today’s chest drainage systems combine the three-bottle system into one. The three basic components of the chest drainage system include the collection chamber, the water seal chamber, and the suction control chamber. The nurse must monitor the chest drainage system to make sure it is functioning correctly.

Collection chamber. The collection chamber collects drainage and allows for monitoring the amount, color, and consistency. With a pneumothorax, a lack of chest tube output is an expected finding because air, not fluid, is being evacuated from the patient.

Water seal chamber. The water seal chamber allows air to drain from a patient’s chest but not return. The chamber contains 2 cm of sterile water, enough to submerge the bottom of the water seal tube, and creates a one-way valve. A small amount of bubbling will normally occur when (a) the patient is first connected to the chest drainage system and the suction is initially applied, (b) fluid drainage displaces air in the collection chamber, or (c) the patient has an air leak in the pleural space. This is noted especially when the patient exhales or coughs.

The nurse should observe for a large amount of bubbling that is not in concert with the patient’s breathing pattern. Excessive, continuous bubbling may indicate a large air leak in the system. The nurse should check all connections for a possible disconnection, check the drainage unit for any cracks, and replace if needed. Bubbling in the water seal chamber will slowly disappear as the lung re-expands, air stops leaking, and the lung fills the pleural space.

The chest drainage system should be assessed for fluctuation of the water level (tidaling), which should occur in the long tube in the water seal chamber. The water level rises approximately 5 cm to 10 cm when the patient inhales and falls when the patient exhales. As negative pressure in the pleural space increases during inspiration, the water level increases. During expiration, as negative pressure in the pleural space decreases, the water level also decreases. Fluctuation will diminish as the lung re-expands and fills the pleural space. No fluctuation can mean obstruction of the tubing or re-expansion of the lung.

Negative pressure reflects the vacuum level that is present in the intrathoracic cavity and is indicated by the water level in the long tube of the water seal chamber. When water in the tube rises and remains above the water level in the chamber itself (above the 2 cm mark), negative pressure is present in the patient’s pleural space. An excess of negative pressure can potentially cause damage to the pleural tissues. Most chest drainage systems now provide a valve (either automatic or manual) to relieve this excess negative-pressure buildup.

Suction control chamber. Chest drainage systems use suction to increase the drainage rate and help re-expand the lung. If the system is placed to water suction, the amount of suction should be specified by the physician. If no amount of suction is specified, the usual amount is 15 cm to 20 cm water suction depending on the type of chest drainage system used. The suction control chamber regulates the suction source to levels acceptable for thoracic drainage. The fluid level in the suction control chamber, not the amount of suction delivered from the outside suction source, governs the suction’s intensity. This chamber should be monitored for the water level and for gentle bubbling. The water level must be kept at the amount ordered. Aggressive bubbling will cause the water to evaporate at a faster rate. The suction water level should be checked periodically to ensure that it is at the ordered level. Excessive levels of suction may damage tissue, whereas an inadequate level of suction may delay lung re-expansion.

Other Helpful Tips

The tubing on the chest drainage system should be routinely checked to ensure there are no kinks or dependent loops. An occluded drainage system may predispose the patient to a tension pneumothorax. The tubing should be draped next to the patient in the bed so dependent loops do not hang down the side of the bed. The tubing between the patient and the drainage system should be long enough to allow the patient to move and turn.

If the chest tube falls out, the patient may develop an open pneumothorax. A dry, sterile gauze should be placed promptly over the site, and the physician should be notified. An occlusive dressing should not be used to cover the site because the patient may be put at risk for developing a tension pneumothorax. The patient may require a new chest tube to be inserted.

If the chest tube disconnects from the drainage unit, a temporary water seal can be established by immersing the open end of the chest tube in a bottle of sterile water. The end of the patient connector on the drain system may be cleansed with alcohol and reconnected if it has not been contaminated. If the patient connector on the drain system is contaminated, a new chest drainage system must be set up. To prevent disconnection, secure the ends of the chest tube to the drainage tubing by placing tape from the chest tube across the connector to the drainage tubing. Taping should be done according to the institution’s policy. To prevent tension from being placed on the chest tube insertion site, flag the chest tube to the chest wall below the dressing.

A sample of drainage fluid may be obtained from the resealable connecting tube. Drainage should not be taken from the collection chamber because that will not reflect the current condition of the pleural fluid. If drainage is minimal, a dependent loop in the tubing will allow fluid to collect for sampling. When sufficient fluid has collected, the nurse should wipe the tubing with an antiseptic gauze. The fluid sample can be aspirated with a 20-gauge or smaller needle.

Patient Assessment

The patient’s vital signs, respiratory status, skin color, and pain level should be assessed. Pain management is essential if the patient is to be able to deep breathe and cough. Occasionally, the patient may complain of severe burning pain. The burning sensation is caused by the chest tube irritating the diaphragm. Changing the patient’s position will move the chest tube away from the diaphragm and relieve the burning sensation.

Splinting and decreased breath sounds indicate poor lung expansion and a need for more pain medication. Effective deep breathing and coughing are difficult, if not impossible, to achieve if the patient is suffering from pain. The patient should be monitored for respiratory distress, dyspnea, subcutaneous emphysema, and chest pain. Signs of tension pneumothorax and mediastinal shift, including respiratory distress, tracheal deviation, and dyspnea, should also be noted and the physician notified if any of them are present.

Subcutaneous emphysema is present in a small number of patients with spontaneous pneumothorax. As the air escapes from the pleural space, it settles into the subcutaneous tissues. The area around the patient’s neck or at the chest tube insertion site should be palpated for crepitus, which has the feel of “Rice Krispies.” The patient should be taught and encouraged to deep breathe and cough at least hourly to prevent atelectasis and to assist in removing air and/or fluid from the pleural space. The best way to assist the patient with lung expansion is to get the patient out of bed as soon as possible. Sitting up in a chair and ambulating are the best methods to prevent atelectasis. Placing a pillow under the patient’s arm will help the patient splint the incision and allow him/her to deep breathe and cough while helping to decrease the pain.

The patient is often reluctant to move the arm on the side of the pneumothorax because of the pain from the chest tube. The patient should be encouraged to do shoulder lifts when out of bed. Full range of motion in the shoulder on the affected side will prevent the patient from developing a frozen shoulder (Gallon, 1998).

The chest tube dressing should be dry and intact. The nurse should check it periodically for drainage. The dressing should either be reinforced or changed according to the institution’s policy.


Documentation should include the following:

* Date and time that the chest drainage was initiated.

* Amount of suction applied.

* Amount and type of drainage.

* Patient’s respiratory status, including breath sounds and ability to deep breathe and cough.

* Presence or absence of tidaling and bubbling in the waterseal chamber.

* Presence or absence of complications.

* Patient education.

Additional documentation includes changing or reinforcing a dressing, assessing the patient’s skin condition, and obtaining a sample of drainage for analysis.

Removal of the Chest Tube

Removal of the chest tube is done when the chest x-ray reveals full-lung expansion, 24 to 48 hours have passed without any air leak, and less than 150 ml of fluid have drained in a 24-hour period (Blank-Reid & Reid, 1999). The length of time for a chest tube to remain is usually 3 days but varies with the individual patient. The physician may order the tube to be clamped for a brief period before removal to determine the patient’s tolerance. While the tube is clamped, the nurse should watch for signs of tension pneumothorax; if these appear, the tubing should be unclamped, suction re-established, and the physician notified immediately. When the tube is ready to be removed, the physician will cut the sutures and the tube will be removed while the patient performs the Valsalva maneuver, exhaling against a closed glottis to prevent air from re-entering the chest. The exit site will be redressed with petroleum-soaked gauze. A small amount of serous drainage is normal. The petroleum gauze can be removed after 48 to 72 hours and replaced with a Band-Aid[TM] if the drainage is minimal. The patient may take a shower and/or bath 72 hours after the chest tube has been removed. A chest x-ray is usually ordered 12 to 24 hours following chest tube removal to check for residual air.

Educating the Patient/Family

The patient with a spontaneous pneumothorax has a 10% to 60% chance of experiencing a recurrence on the same or opposite side after the initial occurrence and up to 80% after a second occurrence (Baumann & Strange, 1997; Gallon, 1998; Light, 1983). A pneumothorax may recur a few days after the initial pneumothorax, or up to 20 years later. The average recurrence takes place within 2 to 3 years after the initial episode.

The patient should be prepared for a recurrence by explaining the risk and answering any questions the patient and/or family may have. The importance of detecting signs and symptoms and of seeking medical attention immediately must be emphasized. The patient should be instructed to watch for signs of recurrence, such as chest or shoulder pain especially on inspiration, shortness of breath or vague chest discomfort, anxiety or restlessness, increased pulse or respiratory rate, and a dry cough.

Discharge instructions should include limiting vigorous activities for 1 week to a month, no lifting of heavy objects, and calling for a follow-up appointment with the physician. Once the patient has experienced a spontaneous pneumothorax, the chance of recurrence increases greatly. Educating the patient and/or family is of primary importance to ensure that the patient who begins to experience symptoms will contact his/her physician and go to the nearest emergency room.


A spontaneous pneumothorax may be difficult to detect and can be easily overlooked. By knowing how to assess the patient and intervene appropriately, the nurse can help prevent potentially fatal complications. The nurse can also help the patient and family understand the importance of knowing the symptoms of a spontaneous pneumothorax and the actions to take to obtain immediate medical help.

Note: This manuscript is dedicated to Stephanie. She was a mentor to many nurses who worked on the thoracic surgical unit at Massachusetts General Hospital. She taught them well. She was not only a mentor, but also a friend, and she is greatly missed.


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Marlene Roman, MSN, RN, ARNP, is a Medical-Surgical Clinical Nurse Specialist, North Broward Medical Center, Pompano Beach, FL.

Alyse Weinstein, SN, is a Patient Care Technician, St. Luke’s Hospital, Chesterfield, MO. She is currently a Generic Nursing Student at Jewish Hospital College of Nursing and Allied Health.

Stephanie Macaluso, MSN, RN, ARNP, CS, was a Medical-Surgical Nurse, Massachusetts General Hospital, Boston, MA, at the time this article was written.

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