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nursing 272: final semester > Unit 2: Chest Trauma > Flashcards

Unit 2: Chest Trauma Flashcards

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1
Q

2 Types of Chest Trauma

A
  • blunt-force

- prenetrating trauma

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2
Q

Blunt Chest Trauma

A

the result of a blunt object hitting the chest or the chest striking a blunt surface such as the steering wheel

  • can be further characterized as acceleration or deceleration injuries
  • more diffuse than penetrating trauma
  • may cause injuries that may not be obvious at the time of initial assessment
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3
Q

Deceleration Injuries

A

the movement of the body is suddenly stopped but the internal organs remain in motion and collide with the chest wall
-body has been moving and comes to an abrupt stop

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4
Q

Accelerated Injuries

A
  • occurs when the body is abruptly set in motion (rear-end collisions) or when the body is hit by a rapidly moving object
  • sudden increase in speed
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5
Q

Penetrating Trauma

A

the result of sharp objects (knives, bullets) entering the chest and causing damage to internal structures or organs

  • other causes: objects that enter a motor vehicle during a collision (intrusion) or shrapnel from explosions
  • the depth, angle, and location of the penetration can differentiate whether the penetrating trauma is a superficial wound or is potentially life-threatening
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6
Q

Common Injuries occurring as a result of Chest Trauma

A
  • fractured ribs
  • pneumothorax
  • hemothorax
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7
Q

Common Injuries: Fractured ribs

A

most common injury associated w/ chest trauma

  • the integrity of the entire thorax and chest wall movement are compromised
  • patient cannot take deep, effective breaths, largely b/c of pain, effectively limiting the ability to maintain normal tidal volumes w/ each breath
  • there may be collateral penetrating damage to the organs and vessels located near the site of injury (ex: liver)
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8
Q

A Flail Chest

A

three or more adjacent ribs that have been fractured in two or more places as a result of blunt or crush chest trauma, resulting in a “free” segment of the ribs

  • “paradoxical” chest-wall movement is a hallmark sign
  • with each inhalation the damaged area moves inward; on exhalation, this section of the chest wall moves outward
  • chest wall movement is compromised largely b/c of pain; may result in respiratory insufficiency
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9
Q

Pneumothorax

A

the collection of air in the pleural space

  • there is a reduction in the negative thoracic pressure because of the presence of air in the pleural space; makes inspiration more difficult, and the lung cannot adequately expand
  • results in a reduction of gas exchange at the alveolar level, resulting in hypoxemia
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10
Q

Hemothorax

A

presence of blood in the pleural space
-occurs if there has been a laceration of the pulmonary vessel with blunt or penetrating trauma
-as blood fills the pleural space, the negative pressure is lost, limiting the lungs ability to expand
-the loss of blood from the vascular space mat result in hemodynamic compromise
>Drainage greater than 1500 mL = massive; may become hemodynamically unstable

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11
Q

Clinical Manifestations

A
  • decreased oxygenation and ventilation
  • gas exchange is compromised; decreased oxygenation
  • initially, hyperventilation occurs in an effort to increase oxygen availability to the tissues, but eventually as the patient tires, CO2 will begin to rise
  • Initial ABGs may = respiratory alkalosis d/t hyperventilation but respiratory acidosis will develop rapidly as CO2 is not exchanged
  • early sign of hypoxemia is agitation and anxiety, then qa decreased LOC
  • shortness of breath
  • subcutaneous emphysema (air in the tissues under the skin) may occur with blunt trauma and pneumothorax
  • pain; compromising chest wall expansion, thus oxygenation and ventilation
  • exhibit splinting, assuming a protective posture around the site of injury; further compromises lung expansion on the side of injury and pneumonia may result
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12
Q

To Diagnose: Imaging Studies

A
  • Chest x-ray
  • Ultrasonography
  • Chest CT
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13
Q

Chest X-Ray

A

to evaluate the skeletal features of the chest and to evaluate the integrity of the lungs

  • x-ray is viewed to look for fractures, lung expansion, or mediastinal damage
  • pneumothorax or hemothorax is visible on x-ray
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14
Q

Ultrasonography

A

focused assessment w/ sonography in trauma (FAST), is a valuable tool for a quick assessment in an emergency situation
-used to r/o cardiac tamponade (blood in the pericardium resulting in compression of the heart); life-threatening

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15
Q

Chest CT

A

performed upon a patient’s arrival to the ED in the case of high-impact thoracic trauma
-High-impact trauma: involves rapid deceleration and may result in chest wall deformities, multiple rib fractures, pneumothorax, or hemothorax

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16
Q

Laboratory Studies

A
  • ABGs
  • Serum lactate
  • Hemoglobin/Hematocrit
  • CBC and complete metabolic profile, coagulation studies, and a type and crossmatch in the event that the patient needs a blood transfusion
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17
Q

Laboratory Values: ABGs

A

arterial blood gases used to determine whether hypoxemia and abnormalities in the acid-base balance exist
-initially may indicate respiratory alkalosis d/t hyperventilation, but will quickly develop respiratory acidosis b/c of ineffective gas exchange and tiring

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18
Q

Laboratory Values: ABGs

A

arterial blood gases used to determine whether hypoxemia and abnormalities in the acid-base balance exist
-initially may indicate respiratory alkalosis d/t hyperventilation, but will quickly develop respiratory acidosis b/c of ineffective gas exchange and tiring

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19
Q

Laboratory Values: Serum Lactate Level

A

drawn to determine the adequacy of oxygen delivery to the tissues
-if the respiratory system is compromised, resulting in insufficient oxygen for cellular metabolism, anaerobic metabolism results
>this causes the production of lactic acids; rise in lactate levels within hours

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20
Q

Laboratory Values: Hemoglobin and Hematocrit

A

may be reduced if there is bleeding

-bleeding may be internal and not readily observable

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21
Q

Routine Labs Drawn in Any Trauma

A
  • Electrolyte panels
  • CBC
  • Coagulation studies
  • Patient specific tests
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22
Q

Treatment for Chest Trauma

A

ABCs!!

Airway, Breathing, Circulation

23
Q

Treatment: Airway

A

evaluate the airway

  • airway patent?
  • show any signs of respiratory compromise or obstruction?
  • partial or complete obstruction is a medical emergency
  • intubation may be necessary to provide an adequate airway
24
Q

Treatment: Breathing

A
  • Does the patient demonstrate the ability to breathe w/o any compromise in gas exchange?
  • Is there chest wall damage or other signs of respiratory compromise as indicated by abnormal ABGs, increased work of breathing, or signs of hypoxemia or hypercapnia?
  • intubation and assisted ventilation may be necessary
  • if not severe and able to protect the airway, use of supplemental oxygen
  • if pneumothorax or hemothorax is present, chest tube insertion may be required to facilitate breathing and adequate oxygenation
25
Q

Treatment: Circulation

A
  • Is circulation sufficient?
  • Does patient have adequate pulses and skin color?
  • Is the blood pressure WNL? if not, IV fluid resuscitation to maintain hemodynamic stability
  • if injury resulted in blood loss (hemothorax), blood transfusions may be indicated
26
Q

Safety Alert: If the chest tube becomes disconnected from the drainage system

A

immediately submerge the end of the chest tube in sterile water to preserve the water seal; this prevents air from entering through the disconnected chest tube and reaccumulating in the pleural space

  • as quickly as possible, reconnect to a new chest tube system
  • be aware of hospital policy
27
Q

Safety Alert: If the chest tube becomes dislodged from the chest

A
  • apply a Vaseline gauze dressing and notify provider immediately
  • prepare for insertion of new chest tube
28
Q

Indications for Chest Tube Placement

A

indicated if a pneumo- or hemothorax occurs as a result of chest trauma

  • In cases of a pneumothorax: b/c air rises, chest tube is placed high (2 ICS, midclavicular line)
  • For hemothorax, d/t effects of gravity, the chest tube is placed lower, in order to drain blood and fluid from the pleural space
29
Q

Chest Tube

A

placement allows for the expulsion of air and/or fluid while allowing the lung to re-expand
-chest tube connected to chest-drainage system

30
Q

Chest Tube Drainage System Components

A

> Collection chamber: allows for accumulation of blood and fluid
Water seal: acts like a one-way valve, allowing for the removal of the air/blood over time w/o the introduction of air back into the pleural space
Suction: applied to assist in re-expansion of the lung; D/C as the lung re-expands

31
Q

Medications Used for Chest Trauma

A

primarily analgesic

  • patient in extreme pain may not breathe deeply enough to avoid atelectasis
  • Initially, IV narcotic analgesia (morphine)
  • Regional block or epidural analgesia may be administered to reduce pain w/o the narcotic side effects; allows pt to breathe more effectively
  • in cases of penetrating trauma, prohpylatic broad-spectrum antibiotics to prevent infection
32
Q

Complications: Tension Pneumothorax

A

may occur if air or blood collects in the pleural space and is not removed

  • positive pressure in the pleural cavity increases, and affected lung collapses
  • as the positive pressure increases, it may cause a mediastinal shift toward the unaffected side; can result in compression of the heart, vena cava, aorta, and contralateral (unaffected) lung
  • Tracheal deviation toward the unaffected side is a hallmark sign of tension pneumothorax
  • in emergent cases, a needle decompression performed to remove the air from the pleural space, may be required; chest tube immediately after
33
Q

Complications: Cardiac Tamponade

A

caused by excessive air, fluid, or blood collecting in the pericardial sac

  • the heart cannot adequately fill or contract b/c of the compression of the ventricles
  • manifest as hypotension, muffled heart sounds, and distended neck veins (Beck’s Triad)
  • cardiac tamponade d/t fluid accumulation in the pericardial sac is treated w/ pericardiocentesis, the insertion of a large bore needed into the pericardial space to drain fluid
34
Q

Surgical Management: Thoracotomy

A

surgical excision to the chest wall

  • for patients w/ an unstable chest wall
  • for cases of severe flail chest for stabilization
  • indicated if the chest trauma has resulted in damaged organs or major vessels
35
Q

Connection Check 27.6:
You are caring for a client who sustained a chest injury following a motor vehicle collision, requiring a chest tube, and is receiving morphine via patient-controlled analgesia (PCA) for pain. Which of the following would alarm you and initiate a call to the primary care provider?
A. Somnolence
B. Restlessness and anxiety
C. Itching at the IV site
D. Minimal amounts of bloody chest tube drainage

A

B. Restlessness and Anxiety

36
Q

Nursing Management: Assessment and Analysis for Chest Trauma

A

Clinical manifestations of chest trauma are caused by damage to the chest wall and/or lungs causing problems with ventilation and oxygenation
>Tachypnea/hyperventilation
>Tachycardia
>Shortness of breath
>Decreased oxygenation
>Decreased LOC
>Decreased or absent lung sounds
>Asymmetrical chest excursion (in the case of a flail chest)
>Subcutaneous emphysema (air under a layer of the skin)

37
Q

Nursing Diagnoses

A
  • Impaired gas exchange r/t hypoventilation and pain
  • Acute pain r/t structural damage secondary to fractured ribs; presence of chest tube
  • Decreased cardiac output r/t hemorrhage and decreased circulating volume (hemothorax)
38
Q

Nursing Interventions: Assessments for Chest Trauma

A
  • Respiratory effort
  • Vital signs and pulse oximetry (SpO2)
  • Pain
  • LOC
  • ABGs
  • Chest Tube
  • Subcutaneous emphysema
39
Q

Assessments: Respiratory effort

A

increased work of breathing such as SOB, accessory muscle use, or nasal flaring may indicate a need for further evaluation and treatment of chest trauma or pneumothorax and/or a need for an advanced airway

40
Q

Assessment: Vital Signs and Pulse Oximetry (SpO2)

A
  • tachypnea and tachycardia may occur in response to decreased oxygen levels, increased oxygen demands, and/or pain
  • hypotension can indicate tension pneumothorax or cardiac tamponade d/t compression of the heart, vena cava, and aorta
  • hypotension can indicate excessive blood loss w/ hemothorax
  • decreased SpO2 (< 95%) may be present if there is ineffective respiration d/t pain or injury
  • continuous readings help evaluate response to treatment
41
Q

Assessments: Pain

A

severe pain d/t fractures may limit the patients ability to breathe deeply, which may result in decreased gas exchange

42
Q

Assessment: Level of Consciousness

A

agitation, anxiety, and eventually a decreased LOC may result from hypoxemia

43
Q

Assessment: ABGs

A
  • initial note a respiratory alkalosis d/t tachypnea and hyperventilation
  • a decreased PaO2 (normal: 80-95) may be present b/c of the impaired ventilatory effort and decreased surface area available for gas exchange in a collapsed lung
44
Q

Assessment: Chest Tube

A

> Amount of color and drainage:

  • red, free-flowing drainage in excess of 70 mL per hour indicates hemorrhage
  • cloudiness may = infection

> Water-seal chamber:

  • initially, there is bubbling on expiration, indicating air removal from the pleural space
  • Later, after the air has escaped from the pleural space, the water level fluctuates with respiratory effort (Tidaling)
  • When the pleural wall disruption is healed, the water fluctuation may no longer be present; evaluated for chest tube removal
  • continuous bubbling in the water-seal chamber = air leak
45
Q

Assessments: Subcutaneous Emphysema

A
  • produces a crackling feeling under the skin
  • not painful but may become uncomfortable if excessive
  • indicative of air from a chest injury escaping into the subcutaneous space, indicating potential chest trauma
  • subcutaneous emphysema of the head and neck could be life-threatening b/c the airway could be compromised
46
Q

Nursing Actions for Chest Trauma

A
  • Apply oxygen as ordered
  • Anticipate and prepare for intubation
  • Elevate HOB
  • Encourage deep breathing and coughing q 1 to 2 hours
  • Encourage ambulation ASAP
  • Chest tube management
  • Administer pain medications; encourage use of patient-controlled analgesia before ambulation and pulmonary toileting
47
Q

Chest Tube Management

A

> Maintain a closed system. Tape all connections, and secure the chest tube to the chest wall
-to prevent inadvertent tube removal or disruption of the systems integrity

> Keep collection device below the level of the chest; keep tubing free from kinks or loops

  • pleural fluid drains into the collection apparatus by gravity flow as well as low-level suction
  • kinks or loops can interfere w/ drainage

> NEVER CLAMP THE CHEST TUBE
-may result in increased air or fluid collection in the pleural space, worsening the pneumo- or hemothorax, and may result in a tension pneumothorax

> When chest tube is removed, immediately apply a sterile occlusive petroleum jelly dressing
-occlusive dressing prevents air from re-entering the pleural space through the chest wound

48
Q

Nursing Teachings for a Patient with Chest Trauma

A
  • Use of pain medications
  • Importance of coughing and deep breathing, ambulation, splinting w/ pillow while coughing
  • Motor vehicle safety; use seat belts, avoid distracted driving
49
Q

Evaluating Care Outcomes

A

a well-managed patient following chest trauma has unlabored respiratory effort, and ABGs within normal ranges

  • lung sounds are clear in all fields
  • pain is under control
  • if had a chest tube, skin integrity is intact
50
Q

Example of Deceleration

A

a motor vehicle traveling at 50 mph that hits a brick wall; causing the vehicle to come to a sudden stop
-all passengers inside the vehicle come to a sudden stop, typically against a hard surface in the car

51
Q

Example of Acceleration

A

pedestrian standing on the side of the road who is hit by a moving vehicle, causing the pedestrian to be thrown 20 feet
-deceleration forces are applied when the pedestrian hits the ground

52
Q

Compression injuries

A

organs or tissues compressed between two immovable surfaces such as bones or a steering wheel

53
Q

Shearing Injuries

A

occurs when skin or tissue slides in opposite but parallel directions

54
Q

Most Common Forms of Blunt Trauma

A
  • Motor vehicle crashes
  • Motorcycle crashes
  • Pedestrians struck
  • Bicycle injuries
  • Sports (football) injuries
  • Falls
  • Assaults

nursing 272: final semester (79 decks)

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