QUIZ 2 Flashcards
Pathophysiology behind Tension Pneumothorax and be able to identify manifestations as well as complications that are associated with this:
Pathophysiology: life threatening condition that occurs when air builds up in the pleural space, putting pressure on the lungs and heart.
Manifestations: tracheal deviation, absent breath sounds on one side, distended neck veins, respiratory distress, asymmetry of chest, cyanosis.
Causes: sucking chest wounds, prolonged clamping of tubing (chest tubes), kinks or obstruction in the tubing, or mechanical vent with high PEEP
NOTIFY PROVIDER & RAPID RESPONSE STAT
Understand the physiology of an open pneumothorax:
Occurs when air accumulates between the chest wall and the lung as the result of an open chest wound or other physical defect. the larger the opening, the greater the degree of lung collapse and dyspnea.
Pathophysiology behind Pleural Effusion and understand assessment findings of pleuritic fluid following a thoracentesis:
Pleural effusion (fluid or air from the pleural space) thoracentesis is a surgical perforation of the chest wall and pleural space with a large bore needle. it’s performed to obtain specimens for diagnostic evaluation, instill meds into the pleural space, and remove fluid or air (pleural effusion) from the pleural space for therapeutic relief of pleural pressure.
Large amounts of fluid in the pleural space compress lung tissue and can cause pain, SOB, and cough.
assessment of the effusion area can reveal abnormal breath sounds, dull percussion sounds, and decreased chest wall expansion. pain can occur d/t inflammatory process. aspirated fluid is analyzed for general appearance, cell counts, protein and glucose content, the presence of enzymes such as lactate dehydrogenase (LDH), and amylase, abnormal cells, and culture.
color- > Bloody: trauma/hematoma, Milky: effusion present for a long time, Purulent: infection, Viscous: Mesothelioma, Clear straw colored: Normal
Understand the concept of flail chest, diagnostics, & abnormal findings associated w/ this.
Flail chest- condition occurring r/t trauma to the thorax when 3 or more ribs are broken in at least 2 places. broken rib segments move independently from the rest of the chest wall.
patho- chest wall stability disturbed (chest wall moves inward with inspiration as thorax expands out), severity dependent on 3 main factors (pleural pressure, extend of flail, movement of intercostal muscles with inspiration) may lead to hypoventilation with atelectasis and pulmonary contusion (edema and hemorrhage).
risk factors -> multiple rib fx from blunt chest trauma (often caused by motor vehicle crash or as a result of CPR on older adults)
diagnostics -> CXR, ABG, CT scan
Findings -> unequal chest expansion (the unaffected side will expand, while the affected side will appear to diminish in size or remain stationary), paradoxical chest wall movement (inward movement of segment during inspiration, outward movement of segment during expiration), tachycardia, hypotension, dyspnea, cyanosis, anxiety, chest pain
Interventions -> Maintain ABCs, pain management, monitor complications, nursing process
Identify why flail chest may be more prevalent with the older population:
older adult patients have decreased pulmonary reserves due to normal lung changes, including decreased lung elasticity and thickening alveoli.
Be able to explain what a pulmonary embolism is as well as the diagnostic tests and immediate and anticipated interventions. Identify concepts regarding patient education for a pulmonary embolism:
A PE occurs when a substance (solids, gas, or liquid) enters a venous circulation and forms a blockage in the pulmonary vasculature. Emboli originating from VTE are the most common cause. Other types of emboli include fat, air, septic (d/t bacterial invasion of a thrombus) and amniotic fluid.
Health promotion & diseas prevention -> promote smoking cessation, encourage maintenance of appropriate weight and heigh for body frame, healthy diet and physical activity, prevent DVT by encouraging leg exercices, wear compression stockings, avoid sitting for long periods of time
Manifestations -> dyspnea, chest pain, cough, shock, arrhythmia, syncope, chest pain, hemodynamic collapse
Diagnostics -> ABGs, troponin, D-dimer, ECG, US, CXR
Interventions -> Oxygen, thrombectomy, anticoagulation
Understand the concept of Oxygen Toxicity, associated complications regarding this, and measures to minimize/prevent oxygen toxicity:
Oxygen toxicity can result from high concentrations of oxygen typically above 50%, long durations of o2 therapy typically more than 24-48 hours, and the clients degree of lung disease
manifestations -> non productive cough, substernal pain, nasal stuffiness, n/v, fatigue, headache, sore throat, hypoventilation
interventions -> use the lowest o2 level necessary, monitor abgs, use an oxygen mask with CPAP or BIPAP if prescribed to help decrease the amount of o2 needed, use PEEP as prescribed while client is receiving mechanical vent to help decrease amount of oxygen needed.
Understand the concept of Airway, Breathing, Circulation:
Primary survey is a rapid assessment of life threatening conditions. the primary survey should be completed systemically so life threatening conditions arent missed. the ABCDE can be used to as a method of triage by the nurse to guide the primary survey.
Airway/cervical spine:
● assess for airway patency (if airway is partially obstructed speech could be potentially coarse or muffled)
● if a client is awake and responsive, the airway is open
● if client’s ability to maintain an airway is lost, its important to inspect for blood, broken teeth, vomit, or foreign materials in the airway that can cause obstruction.
● if the client is unresponsive without suspicion of trauma, the airway should be opened with a head tilt/chin lift maneuver. DON’T perform this technique on clients who have a potential cervical spine injury.
Breathing:
● once a patent airway is achieved, the nurse should assess for the presence and effectiveness of breathing
● assessment -> auscultate breath sounds, observation of chest expansion and respiratory effort, notation of rate and depth of respirations, identification of chest trauma, assessment of tracheal position, o2 level
Circulation:
● once adequate ventilation is accomplished, circulation is assessed
● assess HR, BP, peripheral pulses, cap refill for adequate perfusion
● check for bleeding, control bleeding if present
● consider cardiac arrest, myocardial dysfunction, and hemorrhage as precursors to shock leading to ineffective circulation
● shock can develop if circulation compromised. shock is the body’s response to inadequate tissue perfusion and oxygenation (tachycardia, hypotension = tissue ischemia, necrosis)
Have a general understanding of chest tubes and expected/unexpected findings:
Chest tube is a tube that’s inserted into the pleural space to remove excess air, fluid, or blood. This helps re-expand the lungs.
Nursing considerations -> always keep the drainage system below the patients chest, never milk the tubing, never clamp the tubing, report BRIGHT red bleeding (indicates active bleeding), monitor color & quantity of drainage every hour, lung sounds, insertion site, occlusive dressing integrity, and evidence of moisture.
If tube DISLODGED: cover insertion site with sterile dressing.
If tube DAMAGED: place tubing in sterile water while waiting for new system.
3 chambers:
1. Drainage- where fluid is collected from pt
2. Water seal chamber- allows air to be removed from the pleural space WITHOUT outside air entering the lungs (TIDALING- water rises & falls with each breath= GOOD, CONTINUOUS BUBBLING- BAD)
3. Suction control- wet suction (will have gentle bubbling) & dry suction (no bubbling)
