W8 Tutorial for W10 QUIZ (Patho + NP)

Question 1

Explain the pathophysiological basis of the pain experienced by the patient on breathing. (READ DESCRIPTION FOR CASE DETAILS!)

Answer 1

1. Direct trauma to the chest wall, forming a haematoma/bruise in the soft tissue or
   fracture of the ribs. The skin, ribs, intercostal muscles and parietal pleura are innervated
   by the intercostal nerves. Nociceptors are triggered
2. Breathing involves mainly contraction of the diaphragm and intercostal muscles. Injured
   structures cannot be immobilised during respiration, which leads to sensation of pain

Question 2

Identify and explain the
pathophysiological basis for
abnormalities observed in:
Respiratory rate

Answer 2

Sympathetic response to pain and anxiety. Unlikely to be triggered by the hypoxic drive. Lung function may be insufficient to support O2 supply and CO2 removal.

Question 3

Identify and explain the pathophysiological basis for abnormalities observed in: Percussion findings

Answer 3

Dull percussion at the base due to accumulation of fluid (blood) that gives off a dull note to
percussion. Dull note is usually heard over dense organ and tissue structures. In normal lungs, the expected percussion note should be resonant. In this case, the dull note could be due to the presence of fluid over the surface of percussion.

Question 4

Identify and explain the pathophysiological basis for abnormalities observed in: Auscultatory findings

Answer 4

Deceased breath sounds from the increased distance between skin surface and lung parenchyma where airflow occurs. Transmission of breath sounds diminished. Possible reasons:
● Air or fluid around the lungs
● Increased thickness of chest wall
● Over-inflation of part of the lungs
● Reduced airflow to part of the lungs

Question 5

Primary Survey: ABCDE - A

Answer 5

1. Airway maintenance-> what to check for?
   ◦ Head tilt chin lift/ jaw thrust
   ◦ Suctioning of secretions
   ◦ Baseline vital signs and cardiac rhythm
2. Immobilize C-spine-> why?

Question 6

Primary Survey: ABCDE - B

Answer 6

3. Breathing and ventilation-> What to inspect for?
   * IPPA
   * Inspect:
   ➢ Injuries on chest (lacerations, ‘seat belt’ sign)
   ➢ Paradoxical breathing in flail chest
   * Palpate:
   ➢ Trachea deviation
   ➢ Deformity
   * Percussion:
   ➢ Dullness-> indicative of?
   * Auscultate:
   ➢ Air entry?

Question 7

Primary Survey: ABCDE - C

Answer 7

4. Circulation and control haemorrhage
   * Direct pressure to bleeding sites (external) -> Control bleeding!
   * 2x IV plugs (Large bore) -> if difficult insertion?
   * Baseline blood values (e.g. FBC, RP, PT/INR, GXM)
   * Venous/ Arterial blood gas
   * ECG
   * LOC/ Skin colour/ Pulse

Question 8

eFAST areas

Answer 8

• Perihepatic
• Perisplenic
• Pelvic
• Pericardial
• Pneumothorax
• Pleural effusion

Question 9

Primary Survey: ABCDE - D

Answer 9

• Neurological assessment
  ➢ CLC assessment: PEARL, GCS, motor strength
  ➢ Decreased LOC
• Re-assess patient’s oxygenation, ventilation and perfusion status
  ➢Hypoglycaemia/ drug use/ alcohol intoxication

Question 10

Primary Survey: ABCDE - E

Answer 10

5. Exposure and environment
   * Fully expose patient for a thorough examination
   * Warming device to prevent hypothermia (e.g. bair hugger)

Question 11

Secondary Survey

Answer 11

1. History taking (AMPLE)
2. Physical examination (head-to-toe)
   ◦ Include posterior surfaces
3. Re-evaluate parameters
4. Pain control

Question 12

As SICU nurse, what to prepare to receive patient?

Answer 12

Preparation to receive the patient:
− Anticipate and prepare ahead (RTA - #, hemorrhage, internal
bleeding, need intubation to protect airway; KIV emergency operation/procedure)
− AVPU/ GCS (15 to 13 mild; 12 to 9 moderate; 8 to 3 severe)
− Trace investigations and diagnostic results (FBC/Renal Panel/GXM PT/PTT INR; correct fluid electrolytes imbalance; blood transfusion)
- Set up chest tube unit and prepare requisites for chest tube insertion
- Set up bed and equipment – infusion pump/s; ventilator in event need for intubation; I/A line; central line; IDC;
- NOK contact - in event patient deteriorated and unable to give consent; or patient collapsed
- Anticipate preparation for emergency operation (if any)

Question 13

Pt’s Hemothorax and SpO2 has worsened. Explain the physiological basis for the worsening of the: Haemothorax, SpO2

Answer 13

Defibrination of blood – impaired clot formation
Lysis of red blood cells – inflammatory response,
mechanical stress that damage RBCs, immune
response
Increased shunting – diversion of blood from
areas not properly ventilated

Question 14

What is increased shunting?

Answer 14

The shunt is a condition whereby
blood from the right side of the
heart enters the left side without
taking part in any gas exchange.

Shunt is the extreme degree of
V/Q mismatch where there is no
ventilation. Poor response to
oxygen therapy is the feature that
differentiates shunt from other
mechanisms of hypoxemia.

Question 15

As the SICU nurse, how do you manage Mr Joe’s deteriorating conditions (ABCDE - AIRWAY)

Answer 15

AIRWAY - * Raise HOB
* Lie patient laterally to drain out secretions (if not contraindicated)

Question 16

As the SICU nurse, how do you manage Mr Joe’s deteriorating conditions (ABCDE - BREATHING)

Answer 16

• O2 therapy; raise HOB 30 to 45 (contraindicated for
  spinal injury); prevent tension pneumothorax,
  control pain, intubate if required

Question 17

As the SICU nurse, how do you manage Mr Joe’s deteriorating conditions (ABCDE - CIRCULATION)

Answer 17

• IV cannula – large bore; IV fluid (isotonic;
  crystalloid/colloid);
• Insert IDC if necessary; strict I/O;
• 12 lead ECG

Question 18

As the SICU nurse, how do you manage Mr Joe’s deteriorating conditions (ABCDE - DISABILITY)

Answer 18

• GCS score
• Management of hypoglycemia (<4mmol/L) – follow
  hospital protocol – emergency: IV Dextrose 50%
  bolus)

Question 19

As the SICU nurse, how do you manage Mr Joe’s deteriorating conditions (ABCDE - EXPOSE/EXAMINE)

Answer 19

DDPP; POET; Analgesia; Allergy; Follow-up Inx results
(FBC, GXM, Renal panel; Coagulation profile; ABG etc)

Question 20

When to initiate / increase O2 therapy for Mr Joe?
A. if his SpO2 is below 90%.
B. after the doctor has ordered it.
C. with the aim of achieving SpO2 of more than 94%.
D. if his SpO2 indicates 93% and with the doctor’s prescription.

Answer 20

C. with the aim of achieving SpO2 of more than 94%.

Question 21

Chest drainage system - Collection chamber functions

Answer 21

Drain air & fluid from the
pleural space
Observe & record drainage

Question 22

Chest drainage system - Water seal functions

Answer 22

Act as one-way valve by
bubbling out air
Observe fluctuations in the
water level

Question 23

Chest drainage system - Suction control

Answer 23

Connected to suction wall
Remove air & fluid more
quickly

Question 24

Which 3 chambers are found in a closed chest drainage system?
A. Pressure, water seal, and gravity chambers
B. Water seal, pressure, and drainage collection chambers
C. Gravity, suction control, and drainage collection chambers
D. Water seal, suction control, and drainage collection chambers

Answer 24

D. Water seal, suction control, and drainage collection chambers

Question 25

The main purpose of the water seal chamber is to:
A. detect air leaks.
B. provide high negative pressure.
C. prevent air from going into his chest.
D. reflect the amount of drainage in the pleural space.

Answer 25

C. prevent air from going into his chest.

Question 26

What are the structures that will be traversed by the chest tube during its insertion?

What should you do to avoid damaging the neurovascular bundle during insertion of the chest tube?

Answer 26

• Intercostal neurovascular bundle lie in the costal groove along the inferior margin of the superior rib and pass in the plane between the inner two layers of muscles.
• So that ICD to be inserted along the superior surface of inferior rib.

Question 27

What are the consequences of unresolved
hemothorax?

Answer 27

Atelectasis

Other potential complications include :
* lung infection
* intrathoracic hematoma,
* wound infection,
* hemopneumothorax - coexist
* sepsis

Question 28

What Analgesic prior to Chest tube insertion? And why?

Answer 28

IV Fentanyl. Block pain + alter sensation of pain

➢Anesthetic Adjuvant
➢Strong opioid agonist 1
➢Strong μ agonists (no significant δ and κ
affinity).
➢High maximum analgesic efficacyHigh liability
for addiction/abuse

Question 29

Common Complications of Chest Tube Insertion

Answer 29

1. Allergic reaction
2. Bronchopleural fistula
3. Cardiac injury
4. Hemorrhage
5. Hepatic injury
6. Infection
7. Intercostal nerve, artery, or vein injury
8. Lung laceration
9. Re-expansion pulmonary edema
10. Splenic injury
    11.Subcutaneous emphysema

Question 30

Nursing role:
Prepare patient for insertion of Chest Tube
(Pre-insertion)

Answer 30

• Informed consent
• Administer pain
  medication
• Prepare equipment
• Set up drainage system
• Obtain baseline vital signs
• Position patient

Question 31

Nursing role: Insertion of Chest Tube
(Intra-Insertion)

Answer 31

• Assisting the doctor
• Positioning of patient
• Monitor/Observe patient
• Provide support
• Connection of chest tube to under water
  drainage
• Application of dressing
• Taping and securing of tubes

Question 32

Which of the following is the MOST appropriate position for the patient when preparing him for chest-tube insertion?

A. Prone position with head to the side
B. Lateral supine position with the legs bent
C. Upright seated position, leaning over a table
D. Semi-Fowler’s position with a pillow under the back

Answer 32

C. Upright seated position, leaning over a table

Question 33

Nursing role: Care of patient with Chest Tube (Post-insertion)

Answer 33

*Monitoring of patient
*Follow-up investigation
*Monitoring of chest tube drainage
Frequency
*Medication
*Observe for complications

Question 34

Documentation (chest tube insertion)

Answer 34

-Date, Time
-Site and Size of Chest Tube
-Name of Dr who performed the insertion
-Patient’s tolerance and parameter
-Any suction (if have the suction pressure) and
-Any CXR done to confirm placement

Question 35

Follow-up (chest tube insertion)

Answer 35

-Monitor & Maintain Respiration Function
-Safety (Emergency kit: x2 forceps, gauze in
Kidney Dish at bedside table)
-Taping – omental technique or safety pin (as per institution guidelines)

Question 36

Care of Patient with Chest-tube Drainage System in GENERAL WARD

Answer 36

1. Respiratory Function
   Monitor vital signs & SpO2
   Auscultate breath sounds
   Encourage deep breathing &
   coughing
   Encourage use of incentive
   spirometry
   Prop up patient
   Reposition patient
2. Check chest tube drainage system
   Check water seal
   - Level; Bubbling; Fluctuations/Tidaling
   Check suction pressure
   Assess drainage
   Ensure no dependent loop, kinking & clamping
   Connection taped securely
   Drainage bottle below level of patient’s chest
3. Assess insertion site
   - bleeding?
   - subcutaneous emphysema?

Question 37

Patient Education chest tube

Answer 37

*Deep breathing exercises
*Use of Incentive Spirometry
*Arm exercise ROM exercise
(refer PT/OT)
*Pain Management – to report to nurse
*Mobility (be careful of traction on chest tube)
*Placement of chest tube bottle (below chest
level)
*To keep chest tube bottle in stable position (on
the floor but away from feet movement)
*Dressing & elimination

Question 38

When palpating around the patient’s chest tube insertion site, you detect crepitation and tissue swelling, you suspect:

Answer 38

D. subcutaneous emphysema.

Question 39

The patient needs to be transported to the X-ray Department. A concern
during transport includes the assurance that:

A. the chest tube is clamped.
B. suction tubing is open to air.
C. the chest tube bottle is below the insertion site.
D. B & C

Answer 39

D. B & C

Question 40

At the X-ray Department, you notice that the drainage tubing was disconnected from the drain. Your first action is to:

A. re-establish connection.
B. notify the doctor immediately.
C. clamp the patient’s chest tube immediately.
D. send him back to the ward immediately and change another drainage system.

Answer 40

C. clamp the patient’s chest tube immediately.

Question 41

Which assessment data indicates that the chest tube has been effective
in treating the client with a right-sided haemothorax?

A. The client is able to deep breathe without any pain.
B. There is gentle bubbling in the suction compartment.
C. There is 250 mL of blood in the drainage compartment.
D. There is minimum drainage in the past 24hours.

Answer 41

D. There is minimum drainage in the past 24hours.

Question 42

Removal of Chest Tube (Indicators)

Answer 42

▪Little to no drainage
▪Fluctuations in under water seal stopped
▪Monitor respiratory status for normal breathing
▪Able to tolerate chest tube clamping (no signs of respiratory distress)
▪Chest X ray shows lung re-expansion with no residual air or fluid

Question 43

Removal of Chest Tube - nursing role

Answer 43

*Administer pain medication
*Prepare equipment
*Instruct patient to take deep breathe, exhale and bear down (as per
hospital practice) as the Dr removes the chest tube
*Coordinate with Dr on the closing of stoma
*Apply dressing
*Monitor respiratory status
*Arrange for chest X ray