Respi Flashcards
Pathophysiology of hemo/pneumothorax
Blood or air has accumulated in the _____ space.
What has happened to the lung?
Pleural
Collapsed
Signs and symptoms of hemothorax/pneumothorax?
Discc L
Diminished breath sounds on affected side Increased HR SOB Cough Chest pain
Less movement on affected side
What will show up on the xray of hemo or pneumo thorax?
Air for pneumo
Blood for hemo
Subcutaneous emphysema is
Air trapped in the tissue usually in the neck face and chest
Treatment for pneumothorax and hemothorax
Thoracentesis
Chest tube
Daily chest x-ray
Tension pneumothorax
Causes TTTIC Trauma Too much Taping Insertion of Clamping
Patho
Trauma Too much PEEP Taping open pneumothorax on 4 sides w/o air valve Insertion of central venous line Clamping chest tube
Pressure built up in chest/pleural space and lungs will collapse. Which then the pressure pushes everything to the opposit side called mediastinal shift
S/S of tension pneumothorax
DA CARS Distend Assymetry Cya Absence Respi Subcutaneous
Distended neck veins Absence of breath sounds on one side Cyanosis Asymmetry of thorax Respiratory distress Subcutaneous emphysema
Tension pneumothorax can be fatal because
The pressure compresses vessels which decreases venous return thus decreases cardiac output
Treatment for tension pneumothorax
Large bore inserted by primary health care provider at 2nd intercostal space to allow air to escape
Treat the cause
Open pneumothorax
Treatment:
VTS
Opening through chest to allow air into pleural space. Also known as sucking chest wound.
Treatment:
Valsalva and hummm- increases thoracic pressure outside air cant get inside
Tape petroleum gauze on 3 sides 4th side acts like an airvent
Sit up to expand lungs. But Trauma clients stay flat for it to be evaluated for other injuries
Thoracentesis
To remove fluid or air from pleural space
Lung fluids are analyzed
Normally we have 20 ml of fluid in pleural space
Pre procedure of thoracentesis
Check Stop V/S Position: Sit Cant Sit
Check signed consent
Stop anticoagulant meds
Baseline V/S
Chest xray to assist surgeon in inserting needle
Position:
Sit on Edge of bed with feet supported and lean over bedside table (nurse is in front of client to prevent table from moving)
If cant sit up. Lie down on UNAFFECTED SIDE with HOB elevated to 45 degrees
During thoracentesis
Client must be very still, no coughing or deep breaths
As fluid is removed lung is expanding
Check V/S and compare to baseline and pain level
Post thoracentesis
Another chest xray to see if lungs re expand
V/S
Assess lungs for absent or reduced breath sounds on affected side
Check puncture site for bleeding
Monitor for complications such as infection, tension pneumothorax and subcutaneous emphysema
Turn cough and Deep breathe
Chest tube is needed because
Placement of chest tube
Can both be placed?
Other placement
Collapsed lung
Upper anterior chest or 2nd intercostal space for air
Laterally in lower chest or 8th or 9th intercostal space for fluid/drainage
Air rises and fluid or drainage settles. Chest tube is sutured to chest wall with an AIR TIGHT DRESSING.
Yes. With y connected and attached to closed CDU( chest drainage unit )
Mid axillary one tube for air while other for drainage. Anterior chest tube is not usually used because it requires prolonged healing
CDU means
Purpose of CDU
3 chambers of CDU
Chest drainage unit
Restore normal vacuum in pleural space by removing air and fluid in a one way system.
Drainage collection chamber
Water seal chamber
Suction control chamber
Drainage chamber
First chamber
The drainage is connected by a 6 foot tube to allow patient to move and turn around.
And if the chamber fills up, get another CDU but make sure to get one before it fills up. It usually holds 2000 mL of of fluid so it rarely gets full.
Water seal chamber
Promotes one way flow out of the pleural space which prevents air from going back to pleural space.
Small tube is connected to the first chamber that allows drainage to remain in first chamber while air goes to water seal chamber.
Contains 2 cm of water which acts as one way valve
Bubbling is normal when client is coughs,sneezes or exhales.
Tidaling is normal. It is the rise and fall of water. If it stops, the lung has re-expanded.
Suction Control Chamber
Third chamber.
When suction is needed, this chamber controls the amount of suction pressure applied
Sterile water is used and maintained at 20 cm.
Suction must be slow,gentle and continuous bubbling.
Pressure is not controlled by wall suction but is controlled by WATER LEVEL so always maintain prescribed water level.
If dry suction system is used
There is no water therfore no bubbling.
Dial is used to control suction not the wall suction even if the wall suction is increased.
Management priorities of closed chest drainage system
PEEP
Promote comfort
Ensure integrity of system
Ensure CT patency
Prevent complications
Assessment of CDU
Dressing Listen Oximetry Palpate for Record Notify DBE Wbc Daily
Assess dressing if it is intact and tight
Listen for breath sounds in both lungs. Compare good vs bad lungs.
Report anything <90% of pulse oximetry
Palpate chest tube site for subcutaneous emphysema, this could indicate poor tube placement
Record chest drainage every hour for 24 hours and then q8 hours
Notify physian if >200 ml in one hour and > 100 ml any hour after first hour. Change in color like yellow and bright red
Deep breathe cough and incentive spirometer
Infection should be monitored at insertion site so monitor wbc and fever
Dail chest x-ray for lung re expansion
Where would you obtain chest drainage for wbcs? Drainage collection chamber or chest tube?
Chest tube. Because the tube is self sealing.
Maintaining CDU
Level Straight Tape Dye Clamp
System must be below the chest. If too high, fluids or air will go back to pleural space. Gravity drainage is promoted.
Tubing should be straight and free of kinks and dependent loops.
Tape all systems, must be closed.
Monitor for water level in the system. Dye is done to make it easier to see.
Never clamp a chest tube without prescription. It could lead to tension pneumothorax.
When is bubbling a problem?
Fluctuations upon respiration stops?
If there is continuous bubbling in the water seal chamber then there is air leak. First check connection sites before calling primary health provider. May order you to clamp to determine air leak. Dont clamp for too long and dont leve client when clamping is done
If tidaling stops it means the lung has re expanded or there is a kink or clot (in hemothorax) in tubing or a dependent loop is present.
If tubing becomes disconnected?
If cdu falls over and leaks out or shifts to the drainage compartment?
If water is not present in water seal chamber?
Keep another sterile connector at bedside
Reconnect as fast as you can.
Re establish water seal.
Set cdu upright and check water levels. Fill water seal chamber to 2cm
Have client deep breathe or cough in case air went into pleaural space
Air can collapse the lung
What if chest tube is accidentally pulled out?
In removing chest tube…
Occlusive sterile dressing is placed or taped down on 3 sides. If occlusive dressing is not present, cover with your hand and call someone to bring you one, otherwise every time they take a breath they will pull air into pleural space.
Have client valsalva or hummmmm and place occlusive dressing.
Fractures of ribs and sternum
S/S
CRePS
Most common injuries in chest trauma, usually ribs 5 to 9 which are least protected by chest muscles.
Crepitus ( bones grating together )
Respiratory acidosis
Pain and tenderness
Shallow breathe
Treatment for fractures of ribs and sternum
Complications Incentive Immobilizing chest Non narcotic Nerve block Support area
Complications are observed such as hemo and pneumo thorax and flail chest
Incentive spirometry to preventrespirstory acidosis and pneumonia
Immobilizing chest is not recommended as it leads to shallow breathing and pneumonia
Non-narcotic analgesic just enough for client to cooperate
Nerve block to assist with productive cough
Support injured area with hands or pillow
Flail chest
S/S
SAD PIC
Occurs with multiple fractures
SEE-SAW chest. Paradoxical chest wall movement. Chest sucks inwardly on inspiration and outwardly on expiration.
Anxious and shortness of breath
Dyspnea
Pain
Increased pulse
Cyanosis
Treatment for flail chest
V SHIPP
Ventilate
Stabilize the area Humidified oxygen Intubate Pain management PEEP stabilizes the area and promotes lung expansion
2 types of PEEP
Invasive and non-invasive
Invasive PEEP
Ventilator Alveoli open Gas exchange Expands Classic for
Client is assisted with ventilator
At the end of expiration ventilator puts pressure on alveoli to keep it open
Improves gas exchange and decrease work of breathing
Expands and realigns ribs so they can start to grow back together
Used to treat classic ARDS, pulmonary edema and severe hypoxemia
Non-invasive PEEP has 2 types
Apply
Used for
CPAP and BiPAP
Continuous positive airway pressure
Bilateral Positive airway pressure
Pressure to the lungs and improve oxygenation and ventilation
Both are used for sleep apnea, ards, copd and pulmonary edema
Clients may be moved to these devices when they are weaned from the ventilator
CPAP
BiPAP
Priority assessment
Continuous pressure is delivered on expiration and inspiration. Used for obstructive sleep apnea and infants with underdeveloped lungs.
Pressure is applied on two different settings. One pressure on inhalation and a LOWER pressure upon expiration. Used on non-obstructive sleep apnea because it is tolerated better since they dont need to exhale against a high pressure
Anytime PEEP, CPAP BiPAP is used always assess for bilateral lung sounds every 2 hours. They could pop due to high pressure on lungs.
Pulmonary Embolism
Causes
BOCH DV - these things make blood thick or promote stasis
A thrombus or blood clot, can also be air, fat or amniotic fluid in maternity client
Birth control pills
Obesity
Clotting disorders
Heart arrythmias like A-Fib
Dehydration
Venous stasis from prolonged immobility or surgery
DVT
PE
VTE
Deep vein thrombosis is thrombosis in deep veins of the legs or arms
Pulmonary embolism is thrombosis that is broken off into lung artery
Venous thromboembolism that happens when you have both PE or DVT
S/S of PE
HH PaPePu CCRAPS Hypoxemia Hemoptysis Partial oxygen Petchiae Pulse Cyanosis Chest pain Restlessness Atelectasis HPN SOB
Hypoxemia is number 1 sign. Death can occur within an hour of hypoxemia.
Hemoptysis or coughing up blood
PaO2 is low
Petechiae over Chest
Pulse increased
Cyanosis Chest pain which is sharp and stabbing Restlessness Atelectasis on chest xray Pulmonary HPN or cor pulmonale Shortness of breath
Patho of PE
Priority assessment
Blood clot leads to no gas exchange and backed up blood increases blood pressure in lungs that results in pulmonary HPN aka cor pulmonale this affects the Right ventricle leading to Right sided HF
Check CVP
Diagnosis of PE
D-dimer
CTA
VQ scan
Angiography
D-dimer will be increased. This will tell clot anywhere in the body not just in the lungs
Computerized tomography angiogram is the most frequently used test to diagnose PE. Dye is used so check for renal function.
VQ scan is positive. This is done in radiology. Measures both airflow and blood flow to the lungs.
Pulmonary angiography is the most sensitive and specific test but is very expensive and invasive.
Prevention of PE
Position Stasis Walk Fluids Compression
Change position every 2 hrs
Prevent stasis by flexing and extending feet, hips and knees every 2 to 4 hrs
Walking is needed 4 to 6 times a day
Hydrate by forcing fluids
Pneumatic compression devices will not be used if DVT is suspected because it can lead to PE
Treatment for PE
Rest Oxygen and pain Anticoagulants Precautions Fibrinolytics Surgery
Bed rest and affected leg may be elevated to promote blood flow and prevent stasis
Administer oxygen according to ABGs and Decrease pain
Administer anticoagulants. It has 3 types.
1.Vitamin K antagonists like warfarin
2.Thrombin inhibitors like heparin, enoxaparin(Lovenox) or dabigatran (pradaxa)
3. Factor Xa inhibitors like rivaroxaban(xarelto) or fondaparinux (arixtra)
These drugs prevent clot from getting bigger. Limit green leafy vegetables while on warfarin(coumadin)
Bleeding precautions
Fibrinolytic agents to help dissolve embolus
Pulmonary embolectomy is done when fibrinolytic is not used.
Inferior vena cava filtration device is used to prevent clots from going into pulmonary system
Can a patient take warfarin and heparin at the same time?
Yes. Heparin is being tapered down while increasing warfarin.
Warfarin takes 48 to 72 hours to work and several more days to get to a therapeutic level
