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81 Cards in this Set
- Front
- Back
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Examples of blunt trauma |
- MVA - pedestrian accidents - falls - crush injuries - explosion |
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Examples of penetrating trauma |
- Gunshot wound - stab wounds |
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Cardiac tamponade |
pleural sacs fill with fluid. occurs very rapidly with penetrating wounds. Results in decreased cardiac output. and beck's triade |
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Beck's triade |
- sustended neck veins - hypotensive - muffled heart sounds |
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What happens when CO is decreased? |
if not treated immediately, very high mortality rate |
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pathophysiology of pneumothorax |
Intrapleural pressure is normally negative (less than atmospheric pressure) because of inward lung and outward chest wall recoil. In pneumothorax, air enters the pleural space from outside the chest (as seen with open wound) or from the lung itself (with open or closed) via mediastinal tissue planes or direct pleural perforation. |
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What is pneumothorax? |
pneumothorax is air in the pleural space causing partial or complete lung collapse. |
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types of pneumothorax |
- open -closed -tension |
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Closed pneumothorax: |
- most common is spontaneous pneumothorax caused by the rupture of a bleb - can also be caused by subclavian catheter insertion, broken ribs, perforated esophagus |
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Who do spontaneous pneuthoraxes happen to most frequently? |
young healthy men between 20-40 yo by rupture of bleb - these men are often tall, thin, and smokers |
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blebs |
blisters on lungs - can be 1-10 cm in size - cause unknown |
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open pneumothorax generally caused by: |
penetrating chest wound - impaled by object |
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Cardinal signs of open pneumothorax |
- sucking or hissing sound on inspiration - medial stinal flutter |
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s/s of open pneumothorax/penetrating chest wound |
- sucking or hissing sound on inspiration - difficulty breathing - hyperventialtion |
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medial stinal flutter |
thorax, lungs, trach, esophagus, heart etc all sway from left to right while breathing |
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emergency treatment of open pneumothorax: |
- tape 4x4 (or whatever size) against wound on 3 sides. This won't allow outside air into the body but will allow air to get out |
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other than trauma/impalment, what else can cause an open pneumothorax |
surgical thoractomy |
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Tension penuemothorax |
- injured chest or lung acts as one-way valve. Air can get in, but a flap of chest or lung tissue blocks it from getting out. - air becomes trapped between the lung and chest wall causing lung to collpase - can happen in open or closed pneumothorax |
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What happens in a tension pneumothorax |
- heart, trachea, esophagus, and vessels are pushed to the other side causing blood vessels to kink. THIS IS CALLED MEDIAL STINAL SHIFT |
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2 main signs of a tension pneumothorax: |
JVD and tracheal deviation (both late signs) |
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how is tension pneumothorax treated emergently? |
14g needle insrterd into 2nd intercostal space, midclavicular to let air out (aka NEEDLE DECOMPRESSION) Once at ER, chest tube will be placed |
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hemothorax |
-Blood accumulation in chest cavity -May occur slowly or rapidlydepending on size of disrupted blood vessel -May occur due to penetrating orblunt trauma |
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Hemothorax is often seen with these types of trauma: |
- MVAs - open pneumothorax |
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In massive hemothorax, blood lossis complicated by: |
low oxygen levels in blood (hypoxia) |
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Tx for hemothorax |
insert needle into 5th or 6th intercostal space |
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other less common causes of hemothorax: |
- tumor -PE -anticoag therapy - adhesions to pleural tissue |
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With what kind of hemothorax do you typically see s/s: |
a large hemothorax. A small bleed may not produce s/s |
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ClinicalManifestationsPneumothorax |
§Pain §Dyspnea §Restlessness §Tachypnea §Tachycardia §Absence of chest movement§Diminished/absent breath sounds §Cough with or without hemoptysis§Asymmetric chest movement§Hyperresonance on percussion(very loud)-latefinding |
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What is hemoptysis |
spitting up blood |
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ClinicalManifestationsTension Pneumothorax |
- SevereRespiratory Distress - Hypotension - Extremerestlessness, agitation - Mediastinalshift-trachea deviated - Diminishedheart sounds - Distendedneck veins - Subcutaneousemphysema - Hemodynamicinstability |
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Subcutaneousemphysema |
- air trapped into subq tissue- skin crackles and pops like rice kripsies when you touch it. Swelling |
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Dx of pneumothorax/chest injuries: |
- Chest x-ray: Ultrasound: aka FAST- focused assessment with sonography and trauma. To rule out cardiac tamponade. More sensitive and specific in dx pneumothorax and hemothorax. -Chest CT : (once stabilized) chest deformities damage to aorta |
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FAST |
an ultrasound focused assessment with sonography and trauma. To rule out cardiac tamponade. More sensitive and specific in dx pneumothorax and hemothorax. |
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Labs with pneumothorax/chest injuries |
-ABG -Serum lactate: buildi upoflactic acid -CBC and complete metabprofile -Coagstudies |
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TX for a pneumothorax: |
chest tube |
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Nursing responsibilities re: chest tube: |
- ensure dressing around tube is tight and intact - assess for difficulty breathing - assess effectiveness by pulse ox - listen to breath sounds of each lung check insertion site skin for infection - check alignment of trachea - palpate for subq emphysema - deep breath, coung, incentive spiro encouragment - reposition pt who complains of burining chest pain ensure you can't see eyelets of chest tube |
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Where are chest tubes placed and what is the purpose of each one? |
- an air drainage tube is placed in the 2nd/3rd intercostal space - a blood drainage tube in placed in the 5th/6th intercostal space |
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Where should the collection device be placed |
below the incision site to allow gravity to drain |
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how many chambers are typically found on stationary chest tube drainage systems and what is the purpose of each |
- the first chamber is for drainage collection - the second chamber is the water seal that pevents air from moving back up the tubing system into the chest - the 3rd chamber is for suction |
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How often is fluid drainage measured? |
- it is measured hourly for the first 24 hrs and then at least once every 8 hours after that |
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Why must chamber one never be allowed to completely fill? |
the tube from the patient goes into chamber one shallowly. If the chamber fills up completely with blood/drainage, it will touch the tube and drainage will stop possibly leading to a tension pneumothorax |
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How much water is typically put into chamber 2 |
at least 2 cm (almost an inch) |
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What does bubbling in the second chamber indicate |
an air leak of some kind. It is ok to see some bubbling with pt coughing or expiration, as air is supposed to be leaving the body during those things. But if it's constantly bubbling, air is leaking somehwere-- either between the tubing and the body or somewhere in the pt's body/lungs |
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What amount of drainage should be reported to doc? |
drainage >100 mL/hr |
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Tidaling |
- the water in the narrow chamber of the water seal chamber normally rises 2-4 inches during inhalation and falls during exhalation. |
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What does an absence of tidaling indicate |
either - the lung has fully re-expanded or - there is an obstruction in the chest tube (kinked, pt is laying on it, etc) |
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What are some precautions should take to ensure she can quickly address many chest tube problems |
- tape junctions in the tubing to prevent accidental disconnections - keep an occlusive dressing at insertion site - keep sterile gauze at bedside to cover insertion site immediately in case chest tube becomes dislodged - keep padded clamps at bedside for use if drainage system is interrupted - position the drainage tube in such a manner so as to prevent kinks and large loops of tubing |
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What level is the 3rd chamber typically set to |
typically -20 cm water - this # must be ordered by doc |
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What do you do if there is a blood clot in the tubing |
gently milk the clot hand over hand, stopping between each hand hold, to move the clot and prevent obstruction |
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Why do we not strip or vigorously milk the tubing |
it can create up to -400 cm of water negative pressure, damaging lung tissue |
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When is the drainage in chamber one emptied? |
Never, an entirely new set is set up and the first set is discarded if the 1st chamber becomes so fully that it needs to be changed. |
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What does the nurse assess on the drainage system? |
FOCUS Fluctuating.tidaling Output Color Air S connection to suction (and how many cm H20) |
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When do you clamp the chest tube? |
- only for brief periods of time to change the drainage system or to check for air leaks (clamping to check for air leaks must be prescribed by doc, i believe) |
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What does the nurse document regarding the drainage system |
- amount - color - characteristics of fluid in drainage system as often as needed/prescribed by md or policy |
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When should nurse notify doc or Rapid response team for a pt with a chest tube: |
1. tracheal deviation 2. sudden onset or increased intensity of dyspnea 3. O2 sat < 90 4. drainage > 70 mL/hr (or 100 per Hennie) 5. visible eyelets on chest tube 6. chest tube falls out of pt's chest 7. chest tube falls out of drainage system 8. drainage in tube stops (in first 24 hours) ((and no occlusion in tubing found) |
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What do you do if chest tube falls out of pt's chest |
First cover area with dry, sterile gauze notify MD (or RRT if pt in immediate resp distress) |
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What do you do if chest tube disconnects from drainage tube |
- put end of tube in container of sterile water and keep below level of pt's chest - then notify doc (or RRT if warranted by pt condition) |
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Flail chest |
- three of more ribs fractured in two or more places or fractured sternum - most severe chest injury |
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s/s of flail chest |
- SEVERE pain at site - rapid, shallow breathing - paradoxical respirations - pneumothorax may be present - possilbe underlying contusion to lung could lead to hypoxia |
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pneumotitis |
inflammation of lung itself |
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atelactasis |
a complete or partial collapse of a lung or lobe of a lung — develops when the tiny air sacs (alveoli) within the lung become deflated. |
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paradoxical respirations |
chestwall will suck in on inspiration and will bulge out on expiration on effectedside |
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s/s you would expect to see with flail chest: |
- SEVERE pain at site - rapid, shallow breathing - pneumonitis could develop - pulmonary edema - paradoxical respirations - pt can't/won't cough to get rid of secretions - pt will initially hyperventilate, then because of retained CO2, will go into resp acidosis and will have shallow, rapid respirations - absence of breath sounds - restlessness LOW BP |
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signs of pulmonary edema: |
- SOB - dyspnea - wheezing/gasping - anxiety/restlessness - rapid, irregular heart beat |
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Tx for flail chest: |
- pt's will often go to ICU and get on ventilator while healing occurs - monitoring of ABGs - slow rate (~75mL/hr or less) on IV to prevent causing pulmonary edema |
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pulmonary contusion |
a contusion (bruise) of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels (hypoxia). - hemorrhage occurs in and between alveoli |
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pulmonary contusion causes: |
rapid deceletation (as in during MVa) |
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s/s of pulmonary contusion |
- hypoxemia - dyspnea - bronchial mucoas is irritated and increased secretions -hemoptysis - decreased breathing sounds - crackles, wheezes |
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TX of pulmonary contusion |
- airway management - pain management - DIURETICS to stop/rprevent pulmonary edema - ABX to prevent infection |
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ThoracicSurgeries: |
-Pneumonectomy - Lobectomy - SegmentalResection - WedgeResection -Video-AssistedThoracic Surgery (VATS) |
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Pneumonectomy: |
removal of entire lung with severing of the bronchus - often done for cancer (of entier or nearly entire lung) - will NOT have chest tube placed (as there is no lung there post-op, so it can't drain) |
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lobectomy |
forcancer, for cyst, bleb, adhesions, abcess- removing one of the lobes of thelung. PT will have a chest tube. Sometimes 2, one for air and one fordrainage. When you remove lobe, remaining lobes will grow to take up sameamount of space |
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Segmentalresection: |
removing a section of lung. Pt will have chest tube |
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Wedgeresection- |
dx or to remove nodules; depending on approach will have chest tube |
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Video-assisted Thoracic surgery (VATS) |
three holes made in chest, equipment and scopes placed thru these holes, removal of part will be thru one (or more?) of these holes, 2 of these holes will be used to place chest drain tube for post-op |
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general post-op care: |
- hemodynamic monitoring - imporve gas exchange and breathing - improve airway clearance - promote mobility and shoulder exercises - relieve pain and discomfort - mtn fluid volume and nutrition |
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how often are VS done post-op |
Vsq15 min for first 2 hrs on unit (including O2 sat) |
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other post-op interventions |
O2sat Incentivespirohourly Keephob elevated -Cough to prevent pneumonia-Hourly coughing in first 24 hrs atleast |
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turning post-pneumonectomy |
turn q2h; do NOT turn to UNAFFECTED side becausethat’s the only side that can breath. Soturn on affected side or back – switching between the two. Any side is fine with lobectomy |
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Howdo you know if pt has pulmo edema: |
crackling lungs, diminished breath sounds, JVD, tachycardia, PINK FROTHY SPUTUM, dyspnea |
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post-op complications |
- Respiratorydistress - Dysrhythmias - Pulmonaryinfections or effusions – preceded by atelectasis - Pnemothorax - Bronchopleuralfistula - rare - Hemorrhage and Shock - Pulmonaryedema |
