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MED SURGE WINTER CLINICAL > w6 chest tubes > Flashcards

w6 chest tubes Flashcards

1
Q

what are the categories that traumatic chest injuries fall to?

A

1) blunt trauma

2) penetrating trauma

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2
Q

what is a blunt trauma?

A

occurs when the body is struck by a blunt object, such as a steering wheel.
-can cause severe, life-threatening internal injuries, such as a ruptured spleen

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3
Q

what is contrecoup trauma?

A

a type of blunt trauma, caused by the impact of body parts against other objects

  • differs from blunt trauma d/t the velocity of the impact
  • internal organs are rapidly forced back and forth w/in the bony structures that surround them so that internal injury is sustained not only on the side of the impact but also on the opposite side, where the organ or organs hit bony structures
  • if the velocity impact is great enough, organ and blood vessels can literally be torn from their points of origin
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4
Q

what is a compression injury?

A

occurs when the body cannot handle the degree of external pressure during blunt trauma, resulting in contusion, crush injuries, and organ rupture

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5
Q

what is penetrating trauma?

A

occurs when a foreign body impales or passes through the body tissues (e.g., gunshot wounds, stabbing)

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6
Q

what is pneumothorax?

A

air in the pleural space

  • can be a complete or partial collapse of the lungs d/t the accumulation of air
  • suspect this injury after any blunt trauma to the chest wall
  • can be closed or open pneumothorax
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7
Q

what is hemopneumothorax?

A

-pneumothorax associated w/ trauma may be accompanied by hemothorax

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8
Q

what is closed pneumothorax?

A

has no associated external wound

  • most common: a spontaneous pneumothorax, which is accumulation of air in the pleural space w/out an apparent antecedent event
  • caused by the rupture of small blebs (air-filled alveolar dilations <1cm in diameter on the edge of the lung at the apex of the upper lobe or superior segment of the lower lobe) on the visceral pleural space
  • cause of the bleb is unknown
  • common in underweight males- smokers between 20-40 years of age
  • common for this to recur
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9
Q

what are other causes of closed pneumothorax?

A
  • injury to the lungs d/t mechanical ventilation
  • injury to the lungs from insertion of subclavian catheter
  • perforation of the esophagus
  • injury to the lungs from broken ribs
  • ruptured blebs or bullae in a pt w/ COPD
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10
Q

what is open pneumothorax?

A

-when air enters the pleural space through an opening in the chest wall
-examples include stab, or gunshot wound, surgical thoracotomies
-must be covered w/ a vented dressing- allows air to escape from the vent and decrease the likelihood of tension pneumothorax developing
if the object is still in place- do not remove, instead stabilize it with a bulky dressing

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11
Q

what are the clinical manifestations of a pneumothorax?

A
  • dyspnea, decreased movement of involved chest wall, diminished or absent breath sounds on the affected side
  • hyper-resonance to percussion
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12
Q

what are the emergency management of pneumothorax?

A
  • chest tube insertion w/ chest drainage system: Heimlich (flutter) valve
  • if pt is stable and air/fluid in the intrapleural space is minimal, no treatment is needed- will resolve itself.
  • if fluid/air is minimal, the pleural space can be aspirated w/ a large-bore needle knowing as needle venting (life-saving method)
  • Heimlich valve can also be used to evacuate air from the pleural space
  • most common form of treatment for pneumothorax/hemothorax is chest tube that is connected to water-seal drainage
  • repeated spontaneous pneumothorax are treated surgically
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13
Q

what is hemothorax?

A

an accumulation of blood in the intrapleural space

-found in association w/ open pneumothorax and is then called hemo-pneumothorax

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14
Q

causes of hemothorax

A

chest trauma, lung malignancy, complications of anticoagulant therapy, pulmonary embolus, and tearing of pleural adhesions

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15
Q

what are the clinical manifestation of hemothorax?

A

dyspnea, diminished or absent breath sounds, dullness to percussion, shock

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16
Q

what is the emergency management of a hemothroax?

A

chest tube insertion w/ chest drainage system, autotransfusion of collected blood, treatment of hypovolemia as necessary

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17
Q

what is tension pneumothorax?

A

pneumothorax w/ rapid accumulation of air in the pleural space that does not escape.
-continued increase in amount of air shifts intrathoracic organs and increases intrathorcic pressure (can cause lungs to collapse- and cause the mediastinum shift towards the unaffected side)
can be d/t open or closed pneumothorax
-in an open chest wound, a flap may act as one-way valve, air can enter but cannot escape
-CO is also altered d/t decrease in venous return and compression of the vena cava or aorta
medical emergency!! d/t the effect of the respiratory and circulatory systems being affected

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18
Q

how can tension pneumothorax occur?

A

w/ mechanical ventilation and resuscitative efforts

-can also occur if chest tubes are clamped or become blocked in a pt w/ pneumothorax

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19
Q

clinical manifestation of tension pneumothorax?

A
  • medical emergency!!!
  • cyanosis, air hunger, violent agitation, tracheal deviation away from affected side, subcutaneous emphysema, neck vein distention, hyper-resonance to percussion
  • respirataotry distress, tachycardia, and hypotension
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20
Q

emergency management for tension pneumothorax

A

medical emergency: needle decompression followed by chest tube insertion with chest drainage system

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21
Q

what is a flail chest?

A

fracture of two or more adjacent ribs in two or more places with loss of chest wall-stability

  • during inspiration, the affected portion is sucked in, and during expiration, it bulges out
  • this paradoxical chest movement prevents adequate ventilation of the lungs in the injured area.
  • usually apparent on visual examination of the unconscious patient
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22
Q

what is the most common chest injury resulting from trauma?

A

fractured ribs- ribs 5-10 are the most commonly fractured bc they are least protected by chest muscles

23
Q

emergency management of flail chest

A
  • adequate ventilation, administration of humidified oxygen, careful administration of crystalloid IV solution and pain control
  • goal: re-expand the lungs and ensure adequate oxygenation
  • a short period of intubation and ventilation may be necessary until the diagnosis of the lung injury is complete
  • analgesic
24
Q

what are clinical manifestations of flail chest?

A

-paradoxical movement of chest wall, respiratory distress, associated hemothorax, pneumothrorax, and pulmonary contusion

25
Q

what is cardiac tamponade?

A

blood rapidly collects in pericardial sac, compresses myocardium b/c the pericardium does not stretch and prevents heart from pumping effectively

26
Q

what is the clinical manifestations of cardiac tamponade?

A

muffled, distant heart sound, hypotension, neck vein distention, increased central venous pressure

27
Q

what are the emergency management for cardiac tamponade?

A

medical emergency!!!! pericardiocentesis with surgical repair as appropriate.

28
Q

clinical manifestation if pneumothorax is small

A

mild tachycardia, dyspnea may be the only manifestations

29
Q

clinical manifestation if pneumothorax is large

A

respiratory distress, shallow rapid respirations, dyspnea, air hunger, and decreased oxygen

  • chest pain and a cough w/ or w/out hemotypsis may be present
  • on auscultation, there are no breath sound over the affected area, the hyper-resonance may be present
  • chest ct will show air or fluid in the pleural space
30
Q

what is mediastinal displacement?

A

occurs when the trachea shifts to the unaffected side

the pt is hemodynamically unstable

31
Q

what are the clinical manifestations of fractured ribs?

A

pain -esp on inspiration/ site of injury

  • the pt will splint the affected area and take shallow breaths to try and decrease the pain
  • pt is reluctant to take deep breaths, and decrease in ventilation may cause atelectasis to develop
32
Q

what is the purpose of a chest tube and pleural drainage?

A

to remove the air and fluid from the pleural space and to restore normal intrapleural pressure so that the lungs can re-expand

33
Q

where can chest tube be inserted?

A

in the emergency department, at the pt’s bedside, or in the operation room
surgery- tube is inserted via the thoracotomy incision
-bedside, pt is placed w/ affected side elevated, area is prep w/ antiseptic solution, local anaesthesia is given, and a small incision is made- one or two chest tubes are inserted into the pleural space (one catheter is placed anteriorly through the second intercostal space to remove air, the other is placed posteriorly though the 8th/9th intercostal space to drain fluid/blood)
-tubes are then sutures to chest wall, and puncture wound is covered w/ airtight dressing
-during insertion the tubes are kept clamped, but once it is in the pleural space they are connected to the drainage tubing and pleural drainage, and the clamp is removed!!!

34
Q

what are the three aspects to pleural drainage?

A
  1. collection chamber -receives fluid/air from chest cavity
  2. water-seal chamber - contains 2cm of water which acts as a one-way valve
    -incoming air enters the collection chamber and bubbles up through the water -water acts as a one-way valve to prevent back flow of air
    intermittent bubbling can also be seen during exhalation, coughing, or sneezing bc of an increase in pt’s intrathoracic pressure
    u should see fluctuations or “tidalling” the reflect the pressure in the pleural space- if this is not seen could be a kink/obstruction or lungs have re-expanded
  3. suction control chamber -controls suction to the chest drainage system -filled w/ 20cm of water
    -when the negative pressure generated by the suction exceeds 20 cm, the air from the atmosphere enters the chamber through a vent and begins bubbling up through the water =pressure is then relieved
35
Q

what are the two types of suction chambers?

A

wet and dry
wet- the traditional one with water. known as the ‘classic’ system’-bubbling is one way to tell if it is working
-u turn up the vacuum until gentle bubbling appears
-water will eventually evaporate, so water must be added periodically

36
Q

what is the dry suction control chamber?

A

contains no water
-it uses either a restrictive device or a regulator, internal to the chest drainage system, to dial the desired negative pressure
-dry system will have a visual alert that indicates if the suction is working- so no bubbling
the suction pressure is increased by turning the dial on the drainage system
-increasing the vacuum suction does not increase pressure

37
Q

heimlich valves

A
  • another device that can be used to evacuate air from the pleural space
  • a device that has a rubber flutter one-way valve w/in a rigid plastic tube. it is attached to the external end of the chest tube
  • vavle opens whenever the pressure is greater than the atmospheric pressure and closes when the reverse occurs
  • is acts like a water seal and is usually used for emergency transport or in home special care situations
38
Q

what is a small chest tube? “pigtail catheters”

A
  • used in selected group of pts
  • are less traumatic
  • drains may be straight catheters or pigtail (are less traumatic) like
  • if this is occluded, it can be irrigated by the physician
  • not suitable for trauma or for drainage of blood!!
  • bc of the small size it can be kinked, occluded, or dislodged more easily
  • small bore chest tubes, and Heimlich valves- to be used with caution in pts on mechanical ventilators b/c there is a potential for rapid accumulation of air and tension pneumothorax
39
Q

what is the issue with traditional practice of routine filing or striping of chest tubes to maintain patency?

A

no longer recommend b/c it can cause high dangerous intrapleural pressure and damage to the pleural tissue

40
Q

considerations of pt wi/ chest tube and water-seal drainage system

A

-keep all tube loosely coiled below the chest level- tube should drop straight from bed/chair to drainage unit
-keep all connection w/ tube tight
-observe for air fluctuations (tidalling) and bubbling in the water-seal chamber
-If no tidalling is observed (rising with inspiration and falling with expiration in the spontaneously
breathing patient), the drainage system is blocked, the lungs are re-expanded, or the system is attached
to suction.
-If bubbling increases, there may be an air leak in the drainage system or a leak from the patient
(bronchopleural leak)
-suspect a system leak when bubbling is continuous
-high fluid levels in the water seal indicates residual negative pressure

41
Q

what to do is u suspect a system leak when bubbling is continuous?

A

-To determine the source of the air leak, momentarily clamp the tubing successively from the chest tube insertion site to the drainage set, observing for the bubbling to cease. When bubbling ceases, the leak is above the clamp.
-Retape tubing connections.
-If leak continues, notify physician. It may be necessary to replace the drainage apparatus or to secure
the chest tube with an air-occlusive dressing.

42
Q

assess pt’s clinical status when having a chest tube

A
  1. Monitor the patient’s clinical status. Assess vital signs, lung sounds, pain.
  2. Assess for manifestations of reaccumulation of air and fluid in the chest (↓ or absent breath sounds),
    significant bleeding (>100 mL/hr), chest drainage site infection (drainage, erythema, fever, ↑ white blood cell count), or poor wound healing. Notify physician for management plan. Evaluate for subcutaneous emphysema at chest tube site.
  3. Encourage the patient to breathe deeply periodically to facilitate lung expansion, and encourage range-of- motion exercises to the shoulder on the affected side. Incentive spirometry every hour while awake may be necessary to prevent atelectasis or pneumonia.
  4. Chest tubes are not routinely clamped. A physician order is required. A physician may order clamping for 24 hours to evaluate for reaccumulation of fluid or air before discontinuing the chest tube
43
Q

chest drainage assessments

A

-never elevates the drainage system to the level of pts chest b/c fluid will drain back into lungs
-if the drainage chamber is full notify the physican and change the system
-report any change in quantity or characteristics of drainage e.g., clear yellow to bloody) to the MD
-notify MD is >100ml/hr drainage
-If the drainage system is overturned and the water seal is
disrupted, return it to an upright position and encourage the patient to take a few deep breaths, followed by
forced exhalations and cough manoeuvres.
-if the drainage system breaks, place the distal end of the chest tubing connection in a sterile water container
at a 2-cm level as an emergency water seal.
-do not strip chest tube it will dangerously increase intrapleural pressure

44
Q

how to manage a control chamber in wet suction system

A
  • keep the water at an appropriate level- add sterile water to replace the water loss d/t evaporation
  • keep the muffler covering the suction control chamber in place to prevent more rapid evaporation of water and to decrease the noise of the bubbling
  • connect tubing to the wall suction after filling
  • dial the wall suction until gentle bubbling is seen (generally 80-120mm Hg) -vigorous bubbling is not needed and will increase the rate of evaporation
  • If no bubbling is seen in the suction control chamber, (a) there is no suction, (b) the suction is not set high enough, or (c) the pleural air leak is so large that suction is not high enough to evacuate it
45
Q

how to manage a control chamber in dry suction system

A

After connecting patient to system, turn the dial on the chest drainage system to amount ordered (generally −20 cm pressure), connect suction tubing to wall suction source, and increase the suction until the correct amount of negative pressure is indicated. There will be a high negative-pressure release valve in the system

46
Q

chest tube dressing

A
  • not routinely change, if there is visible drainage notify MD
  • if order to change it- remove old dressing carefully to avoid removing unsecured chest tube- assess the site, and culture site as indicated
  • cleanse the site with sterile normal saline-apply sterile gauze and tape to secure the dressing
  • petroleum gauze may be ordered to prevent an air leak
47
Q

how to obtain a sample from the chest tube?

A
  • form a loop in the tubing in an area to get the most recently drained fluid
  • swab the sampling site of the tubing w/ antiseptic and allow to air-dry
  • aspirate form the sampling site with the syringe; cap syringe, label w/ pt name, date, time, and source of specimen
  • send to lab
48
Q

when can u clamp a chest tube?

A

can be momentarily clamped to change the drainage apparatus or to check for air leaks
clamping for more than a few moments is indicated only for assessing how the pt will tolerate the chest tube removal (typically done 4-6 hours before the tube is removed and pt is monitored closely)
clamping tube for transport is no longer advocated- can cause tension pneumothorax- small amount atmospheric air entering the pleural space is far less damaging

49
Q

what to do is chest tube becomes disconnected?

A

most important intervention is immediate re-established of water-seal system and attachment of a new drainage system ASAP
-in some hospitals, when disconnection occurs, the chest tube is immersed in sterile water (2cm) until the system is re-established

50
Q

what is the most complication r/t chest tube?

A

chest tube malposition

-nurse should observe for tidalling, listen for breath sounds and measure the amount of fluid drainage

51
Q

other complications of chest tube

A
  • infection at the skin site (use sterile technique)
  • pneumonia from not taking deep breaths (use incentive spirometer and use splinting on the affected side)
  • “frozen shoulder” from lack of ROM
  • re-expansion of pulmonary edema can occur after rapid expansion of a collapsed lung in pt w/ a pneumothorax or with an or with evacuation of large volumes of pleural fluid (>1 to 1.5 L)
  • a vasovagal response with symptomatic hypotension can occur from too rapid removal of fluid
52
Q

ches tube removal

A
  • removed when the lungs are re-expanded and fluid drainage has ceased
  • suction is discontinued, and pt is placed on gravity drainage for a period of time before the tube is removed
53
Q

how do u remove a chest tube?

A
  • by cutting the sutures; applying a sterile petroleum jelly gauze dressing; having the patient take a deep breath, exhale, and bear down (Valsalva manoeuvre); and then removing the tube
  • pain meds are given prior
  • site is covered with an airtight dressing, the pleura seals itself off, and the wound heals in several days. A chest radiograph is obtained after chest tube removal to evaluate for pneumothorax, reaccumulation of fluid, or both
  • wound should be observed for drainage and should be reinforced if necessary
  • observe for respiratory distress=may be recurrent/new pneumothorax

MED SURGE WINTER CLINICAL (8 decks)

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