2.1 Respiratory, Chest Trauma Flashcards
Describe and give example of a penetrating chest injury
Penetrating trauma:
Foreign object enters the body
-gunshot, stab wound, impalement
Common chest trauma injuries Hemothorax Pneumothorax Pulmonary or myocardial contusion Cardiac tamponade Esophageal and diaphragm injury Tracheal tear Great vessel tear
Describe and give example of a non-penetrating chest injury and types of force involved
Blunt trauma:
No communication between damaged tissue and the outside environment
-motor vehicle crash, fall, assault, sports injury
Type of force involved: Deceleration Acceleration Shearing Compression Crushing
Contrecoup trauma (think whiplash):
Blunt trauma caused by impact of body parts against another object. Injury occurs on side of impact and also on opposite side
*rib fraction is the most common chest injury
*fractions of scapula, sternum or first rib suggests massive force of injury
Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pneumothorax Spontaneous
Spontaneous pneumothorax:
Closed pneumothorax
Ruptured bleb on lung surface (most common)
Common with tall, thin, young men
S/S:
Sharp, pleuritic pain, worse with inspiration r/t air irritating the parietal pleura
Decreased breath sounds over affected area
Increase HR and resp, dyspnea, unequal chest expansion
TX:
Monitoring, supplemental O2, chest tube placement, surgery
Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pneumothorax Open
Open pneumothorax):
External wound, air enters the pleural space
Sucking chest wound- penetrating trauma (stab wound, gunshot wound, impalement)
S/S:
Pain
Decreased breath sounds over affected area
Increased HR and resp, dyspnea, unequal chest expansion
Audible air movement
TX:
Cover with sterile, occlusive, nonporous dressing
Tape 3 sides which allows air to escape
-inhalation sucks dressing to skin so outside air does not enter
-exhalation allows air to escape
Decreases risk of tension pneumothorax
Do not remove object in chest, stabilize with bulky dressing
Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pneumothorax Closed
Closed pneumothorax (negative pressure): No external wound, air in pleural space
2 Types:
Spontaneous
- ruptured bleb on lung surface (most common)
- common in tall, thin, young men
Traumatic -rib fractures Iatrogenic (medical procedure) -procedures such as central line placement (CVC) -mechanical ventilation
S/S:
Sharp, pleuritic pain, worse with inspiration r/t air irritating the parietal pleura
Decreased breath sounds over affected area
Increase HR and resp, dyspnea, unequal chest expansion
TX:
Monitoring, supplemental O2, chest tube placement, surgery
Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pneumothorax Tension
Tension pneumothorax:
Any cause (any type of pneumothorax), air overfills pleural space
Rapid accumulation of air with no escape
Open or closed
Pleural pressure becomes positive
Medical emergency!
Increased pressure on heart, great vessels, esophagus and trachea
S/S: Cyanosis Air hunger Agitation Tracheal deviation toward unaffected side Subcutaneous emphysema Neck vein distension Absent breath sounds on affected side Hyperresonance to percussion on affected side Tachypnea, tachycardia
TX:
Surgical emergency
Emergency decompression “band aid” until chest tube is placed. Insert large bore needle (14 g) in 2nd intercostal space, midclavicular line, to release air
Insertion of chest tube
Chest x-ray to confirm placement and re-expansion
Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Hemothorax
Hemothorax: Blood enters pleural space Causes: Blunt or penetrating trauma Surgery/procedure S/S: Dyspnea Decreased breath sounds Dullness to percussion Tachypnea, tachycardia Hypovolemia, shock TX: Chest tube Transfusion May require surgery
Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Rib Fracture
Rib fracture: Chest wall injury
Most common chest wall injury
-ribs 5-10 most common r/t least protected by chest muscles
-ribs 1-3, clavicle or scapula- suspect vascular injury
-ribs 7-10 suspect injury to liver (right side) or spleen (left side)
Rib fractures may injure pleura causing pneumothorax or hemothorax
S/S:
Pain with inspiration
Crepitus
Shallow tachypnea
Splinting
TX:
Analgesia, intercostal nerve block
Push pulmonary rehab- inspirex, cough and deep breathing, ambulate
Avoid binding or taping (leads to resp complications)
Imaging to exclude other injuries
Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Flail Chest
Flail chest wall injury:
Multiple adjacent rib fractures may produce a mobile fragment which moves paradoxically with respiration
Significant force required, often associated with other underlying injuries
S/S:
Paradoxical chest wall movement
Respiratory distress
Pain, dyspnea, crepitus, diminished breath sounds
Associated hemothorax, pneumothorax, pulmonary contusion (bruising of lung tissue)
TX:
Stabilize flail segment- occasionally need surgery/plating
Possible intubation and ventilator
Oxygen/PEEP
Aggressive analgesia
Treat other injuries
Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pulmonary Contusion
Pulmonary Contusion: Lung tissue (parenchyma) is fragile- shock wave of force causing alveoli and capillaries rupture leading to hemorrhage and inflammation Poor gas exchange S/S: May be delayed up to 24 hours Tachycardia, cyanosis, agitation Copious sputum- may be blood tinged TX: Supportive Ventilation and oxygenation Mechanical ventilation Bronchoscopy to clear secretions **Inflammation leads to vasodilation and capillary leaks
Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Cardiac Tamponade
Cardiac Tamponade: Fluid fills the pericardial sac around heart Compressed heart muscle cannot pump Medical emergency! Causes: Trauma Surgery Pericardial effusion Cardiac rupture or hemorrhage S/S: Pulses paradoxus (BP drops/pulse diminishes during inspiration) Beck's Triad- distended neck vein, muffled heart sounds, hypotension, tachycardia, tachypnea TX: Pericardiocentesis Surgery- pericardial window (piece of paracardial sac is cut out which allows fluid to continually drain) Volume resuscitation
Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pulsus Paradoxus
Pulsus Paradoxus:
Blood pressure drops
Pulse diminishes during inspiration
Hallmark to cardiac tamponade
Discuss why narcotics are administered cautiously to chest injured patients
Narcotics lower respiratory rate
Identify changes in ABGs that are expected in chest trauma patients
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Chest tubes
PNEUMOTHORAX (AIR)
Spontaneous: blebs, COPD
Traumatic: stabbing, gunshot, broken rigs, ventilator injury, procedural
Tension: life threatening progression of pneumothorax, shifts trachea and mediastinum to unaffected side
Chest tube PLEURAL EFFUSION (FLUID)
Transudate (clear, thin fluid): heart failure, cirrhosis, open heart surgery
Exudate (protein rich fluid): pneumonia, kidney disease, cancer, inflammatory disease
Other less common causes: autoimmune, TB
Hemothorax: blood drainage
Surgical drainage: fluid drainage
Chylothorax: lymph fluid in pleural space
Discuss types of airways: Oral
Oropharyngeal airway
Inserted through mouth
Measured corner of lip to mandibular angle
For unconscious patients only due to gag reflex
Discuss types of airways: Nasal
Nasopharyngeal airway Inserted through nose Measured nare to tragus of ear May be used for conscious patients Contraindicated with facial trauma Facilitates nasotracheal suctioning
Discuss types of airways: Esophageal
Esophageal tracheal airway (combitube): Temporary airway Easy to insert Common for stabilization in the field Not used with mechanical ventilation
Discuss airways: Tracheostomy, indications, advantages, complications
Tracheostomy:
Bedside or OR
Tube allows passage of air and removal of secretions
Indications:
Facilitate vent weaning
Manage secretions
Upper airway obstruction
Advantages:
Stable airway
Enables swallowing, speech, oral hygiene
Complications: Bleeding Infection Dislodgement Cuff necrosis
Discuss types of airways: Endotracheal
Endotracheal tube: More stable (days to weeks) Technically more difficult to insert Balloon inflated to prevent secretions from entering into lungs Anesthesia or respiratory failure
Review suctioning: Oral
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Review suctioning: Nasal
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Review suctioning: Trach
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Review suctioning: Endotracheal
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Review tracheostomy care
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Care of the patient post-thoracotomy
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Teaching:
Prevention of further complications???
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Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Cardiac Contusion
Cardiac Contusion: Cardiac tissue (myocardium) bruising damages contractile fibers, decreases strength of contraction and cardiac output S/S: Low BP may be delayed up to 24 hours Dysrhythmias Low cardiac output TX: Supportive Monitor for myocardial infarctions
Respiratory assessment
Decreased breath sounds on side of injury Dyspnea Hemoptysis Cyanosis Audible air from wound Frothy secretions Tracheal deviation
Pain assessment
Tachypnea= decreased ventilation= increased atelectasis
Diminished ability to cough= increased secretions= pneumonia
Hypercarbia, hypoxemia= respiratory failure results
Cardiovascular assessment
Rapid, weak pulse Decreased blood pressure Narrow pulse pressure- diff between systolic and diastolic Distended neck veins Chest pain Arrythmias
Chest trauma general treatment
Ensure airway Supplemental O2 IV access Removed clothing Semi fowlers Monitor vital signs Manage pain Labs and imaging
Chest tube propose and insertion
Purpose:
Remove fluid and/or air
Prevent fluid and/or air from returning
Restore negative pressure in the pleural space/re-expand lung
Insertion: Confirm consent Assist with positioning Administer medications Monitor patient Setup drainage system Label and send specimens
Chest tube complications and removal
Complications:
tube malposition
Re-expansion pulmonary edema (>1-1.5 liters removed)
Vasovagal response (brady, syncope)
Infection
Pain- decreased shoulder mobility, shallow respirations
Removal (requires special training):
Once lung re-expands and drainage is minimal
Discontinue suction prior to removal
Final check for air leak before removal
Cover site with airtight dressing for 24 hours
Chest drainage systems:
WET/DRY
Wet vs Dry suction
Regulation of suction
Wet: regulated by fluid level adjustment
Dry: regulated by a dial
Chest tube nursing care assessment
Assessment:
Respiratory rate, depth, effort, symmetry, pulse ox
Output amount, quality, color
Site/dressing, changed daily
Tube connection and patency
Verify order and suction settings (bellow should be out)
Presence of air leaks (bubbling in water seal chamber) or crepitus
Pain
Signs of distress: increased HR, JVD, tracheal deviation, anxiety
Chest tube maintenance
Keep system below insertion site
No clamping tubes, keep clamp at bedside
Maintain connections, correct kinks/depend loops
Tube dislodged, cover with occlusive, 3 sided dressing
Tube disconnected, place tube in sterile water until system can be reestablished
Chest tube drainage systems: NO WALL SUCTION
NO WALL suction chest tubes (water sealed):
Heimlich Valve: Small device, one way valve to release air No fluid collection chamber Often in emergency pneumothorax kits Can discharge home Can drip pleural fluid
PneumoStat: Small device, one way valve to release air 35mL collection chamber Can discharge home No pleural fluid drip
Mini500:
Medium size, one way valve to release air
500mL collection chamber
Can discharge home
Accordion Drain:
Medium size, one way valve to release air
500mL collection chamber
Compress accordion for suction, narrow tube
Can discharge home
Intubation indications and nursing care
Intubation indications: Upper airway obstruction apnea Decreased LOC Increased risk of aspiration Ineffective clearance of secretions Respiratory distress
Nasal vs Oral:
Oral preferred r/t easier insertion and can use larger tube for decreased work of breathing
Nursing care:
Maintain correct tube placement
Maintain proper cuff inflation
-collaborate with respiratory therapy
-high volume, low pressure cuffs prevent tracheal trauma
-check cuff pressure using MOV (min occluding volume) or MLT (min leak technique
Monitor oxygenation and ventilation
Maintain tube patency
Frequent oral care, suctioning, brushing teeth
Frequent repositioning and ROM, protect skin
Foster comfort and communication
Lung Surgery
What is it?
Post op care
Wedge resection: small section of lung removed for biopsy
Lobectomy: full lobe removal
Pneumonectomy: entire lung removed, space fills with fluid
Thoracotomy: incision through the chest wall
Thoracoscopy (VATS): small scope incision through the chest wall
Post op care: Monitor resp status, O2 Pain control Pulmonary rehab, IS, flutter, ambulate Chest tubes: usually start on suction, then water seal, air leaks are common Telemetry Encourage nutrition, increased protein
