Week 2 Flashcards
What are the three spaces found in the thorax?
The centrally located mediastinum
The right lung cavity
The left lung cavity
What is contained in the mediastinum?
Contains the heart, covered by the pericardium; the thymus gland; parts of the esophagus and trachea; and a network of nerves and blood vessels
What is the inner and outer membranes covering the lungs called?
Parietal pleura (outside) and visceral pleura (inside)
How much pleural fluid is produced in about 24 hours?
0.3mL/kg of body weight or 25mL in the average person
What is the pressure in the pleural space during inhalation and exhalation?
-8 cm H2O during inspiration and -4 cm H2O during expiration
Ventilation?
The mechanical act of moving air into and out of the lungs
Respiration
Gas exchange across the alveolar-capillary membrane
What is the name of the nerve that causes the diaphragm to contract?
The phrenic nerve
What are the characteristics of pleural pain?
SOB and pain
What are two common clinical conditions that require pleural drainage?
Rupture of the surface of the lung (such as a bleb) or tracheobronchial tree, allowing air and possibly serious or serosanguineous fluid into the pleural space while the chest wall remains intact
External penetration of the chest wall resulting from surgical intervention for trauma (eg gunshot) allowing air and blood or serosanguineous fluid from damaged tissues into the pleural space
What is a pneumothorax?
Air in the pleural space and negative pressure between the pleura vanishes
Open pneumothorax?
Wound from external that leaves the pleural space open to the air
Closed pneumothorax?
Enters space through rupture of the lung and visceral pleura but chest wall remains intact
Spontaneous pneumothorax?
Pneumothorax for no particular reason
What is a tension pneumothorax?
When air continues to leak into the pleural space with no means of escape there will be a rapid build-up of pressure in the pleural space
why is a tension pneumothorax dangerous?
If pressure becomes high enough, the lung can completely collapse and the pressure can then be transmitted to the mediastinum, pushing it away from the affected side, compressing great vessels and the heart itself (cardiac output decrease)
Signs and symptoms of a tension pneumothorax
Increases respiratory rate and effort
Dyspnea
Pleuritic chest pain
Decreased movement of the affected side of the chest
Decreased breath sounds on auscultation of the affected side
Falling BP
Rising pulse
Subcutaneous emphysema?
Feeling of crackling on chest palpitation
Hemothorax
Blood collection in the pleural space following thoracic surgery or certain chest injuries
Empyema
Accumulation of pus in the pleural space caused by pneumonia, lung abscess, or contamination of the pleural cavity
Chylothorax?
Accumulation of lymphatic fluid in the pleural space
Cardiac tamponade?
Blood collection in the mediastinal cavity following cardiac surgery or chest trauma, collecting between the pericardium and the heart and externally compressing the heart
How much extra air or fluid can a person usually tolerate in their pleural space (if they don’t have underlying lung disease)?
Less than 10%
What are the goals of chest drainage?
Remove the fluid and/or air as quick as possible
Prevent drained air and/or fluid from re-entering the chest cavity
Re-expand the lungs, restore normal negative intrapleural pressure
What should the nurse assess in regards to respirations?
Rate, regularity, depth and eas
Listen for breath sound changes (pay attention to symmetry of sounds)
Check drainage system is working
What could cause diminished breath sounds on the side that a client has a chest tube?
Re-accumulation of air or fluid in the pleural space
How should the nurse prevent pulmonary complications (e.g. pneumonia) in clients with chest tubes?
Every hour or two encourage deep breathing and coughing (explain this helps keep the lungs expanded and makes breathing easier)
How should a nurse teach a client to splint their incision?
By having the patient place a pillow over the incision and squeeze or hug the pillow close to the chest wall during coughing
Why is it so important to assess pain in a client with a chest drainage system?
Not assessing pain can put the client at risk for hypoventilation, increasing complications like atelectasis and pneumonia
What does it mean if the nurse finds that a client with a mediastinal chest tube has muffled heart sounds?
It is a sign of cardiac tamponade
Why is it so important to assess mobility in a client with a chest drainage system?
Mobility is shown to decrease stays and improve condition
What should the nurse teach clients about mobilizing after thoracic surgery?
Good for their recovery, lung expansion, fluid build up etc.
How can the nurse use positioning to enhance chest drainage while the client is in bed?
Changing it regularly by placing in high or semi fowlers to facilitate gravity drainage of pleural fluid
When are the only occasions when a nurse should clamp the tubing on a chest tube?
Locate an air leak
Stimulate chest tube removal (to assess patients tolerance)
Replace a drain
Connect or disconnect an in-line autotransfusion bag
What does a nurse need to assess about the chest tube site/dressing?
Dry and intact dressing
Sub emphysema
What should the nurse do if (1) subcutaneous emphysema develops, or (2) drainage eyelets are visible in the chest tube where it exits the chest?
Inspect site carefully and look for evidence of drainage eyelets, reposition tube, and notify physician, move the patient
If eyelets visible, get physician and fix the problem
What should the nurse do if a client accidentally pulls out the chest tube?
Clean ends with alcohol wipe and reconnect, asking patient to cough a few times to push any residual air out of the pleural space
What should a nurse assess in regards to tubing in a chest drainage system?
Working, no kinks, not pulled out anywhere, no pain etc
Why is essential to eliminate dependent loops in tubing (between the chest tube and the drainage system)?
They impede drainage from the chest
What should a nurse assess in regards to fluid that has drained from a chest tube?
Volume, rate, color, and characteristics
What does it mean if a chest tube suddenly has increased drainage when a postoperative client changes position?
The patient moved and gravity took hold of whatever fluid was building up (will have old colour)
What should a nurse assess regarding the water seal on a chest drainage system?
See that its filled to the appropriate level, and that the water level moves as the patient breathes (tidalling)
What could it mean if there is no tidaling in the water seal chamber?
Tubing is kinked, clamped, patient is lying on it, fluid-filled loop
How should a nurse check for an air leak in a chest drainage system?
Clamp the tube, if it stops its likely the lung/pleural space
Place the clamp on patient side of the connector between chest tube and tubing leading to chest drain, if stops, the leak is between patient and clamp
Between drain side of connector, leak could be from a hole or puncture
No bubbling stops? Could be cracked and may need to be replaced
How would a nurse assess for chest tube malposition?
Observing for tidalling water, listening for breath sounds over the lung fields, and measuring the amount of fluid drainage
What causes re-expansion pulmonary edema?
Occur after a rapid expansion of a collapsed lung in patients with a pneumothorax or large volumes of pleural fluid
What can cause a vasovagal response in a client with a chest tube?
Too rapid removal of fluid
What increases the risk of pneumonia in clients with chest tubes?
Not taking deep breaths, not using incentive spirometer, splinting on the affected side and shoulder disuse
What is a pleural effusion?
A collection of fluid in the pleural space
What conditions cause a transudative pleural effusion?
In noninflammatory conditions and accumulation of protein and cell-poor fluid
Increased hydrostatic pressure found in heart failure
Decreased oncotic pressure found in chronic liver or renal disease
What conditions cause an exudative pleural effusion?
In an area of inflammation
Occurs secondary to pulmonary malignancies, infections, embolization, and GI disease
What is a thoracentesis?
Procedure to remove fluid from pleural space
What is an empyema?
Pleural effusion that contains pus
What is a trapped lung?
When visceral pleura becomes encased with a fibrous peel or rind
What are the clinical manifestations of a pleural effusion?
Progressive dyspnea, decreased
What are the clinical manifestations of an empyema?
Pleural effusion ones and chest wall movement, night sweats, cough, and weight loss
What is a tracheostomy?
A surgical incision made into the trachea, creating a toma or hole through which the airway is managed
What are the 6 reasons that a tracheostomy may be performed?
Obstruction - acute or chronic
Mechanical ventilation
Aspiration pneumonia
Vocal cord paralysis or upper airway tumors
Secretion retention
Prevention of VAP (ventilator associated pneumonia)
When should a cuffed tracheostomy tube be used?
Short term mechanical ventilation, high flow oxygen and to prevention aspirations
When should a cuffed tracheostomy tube be used?
Short term mechanical ventilation, high flow oxygen and to prevention aspirations
When should an uncuffed tracheostomy tube be used?
Long term trach and during tube weaning process
What is the main disadvantage of an uncuffed tracheostomy tube?
Do not truly protect the lower airway from aspiration
Outer cannula
lies within incision
Inner cannula
fits inside outer cannula
Obturator
helps with insertion of tube
Cuff
Minimizes the passage of air or secretions around tube
Pilot Balloon
insertion of removal of air when inflating or deflating the cuff
Mucus plug cause/manage
Cause
Natural body humidification system
Management
Provide patient with humidity via a trach mask
Bleeding cause
Cause
Irritation, inflammation, insufficient humidity, vigorous suctioning, infection, excessive coughing
Infection cause/manage
Cause
Natural defenses for filtration being bypasses when a tracheostomy is present
Management
Continuous cleanliness whenever providing trach care
Tracheoesophageal fistula cause/manage
Cause
Necrosis allowing air to enter stomach and stomach contents may be aspirated
Management
Small NG tube
Tracheal stenosis cause/manage
Cause
Prolonged tracheal intubation resulting in scar tissue
Management
Appropriate sized tube, minimal cuff pressure, limiting tube movement, prevent infection
In a postop client with a new tracheostomy, what assessments must the nurse perform?
What precautions are recommended to prevent obstruction of the tracheostomy?
Avoid clothing or gowns that may cover trach
Do not use ointments of alves on site unless ordered
Check patency and cleanliness of inner cannula
What are the signs and symptoms of respiratory distress that may occur when the patient is being weaned from a tracheostomy tube?
Abnormal RR/pattern, accessory muscle use, abnormal pulse and BP, skin and mucous membrane color, abnormal ABG levels or O2 sat, inability to cough/clear secretions
In Interior Health facilities, how often should routine tracheostomy care be performed?
twice daily
What type of tracheostomies have non-disposable inner cannulas?
Cuffless trachs
What are the indications that a client’s tracheostomy requires suctioning?
Ineffective cough, depressed LOC, thick, tenacious, immobilized secretions
What precautions should be used when suctioning a client’s tracheostomy?
Iimit no more than 15 seconds
Appropriate size, bronchospasm post procedure
What precautions should be used when suctioning a client’s tracheostomy?
Iimit no more than 15 seconds
Appropriate size, bronchospasm post procedure
What are the indications for a tracheostomy?
Bypass obstruction, removal of secretions, mechanical long term ventilation, facilitate oral intake and speech in patient who requires long term ventilation
Abnormal bleeding cause/manage
Cause
Surgical intercention, erosion/rupture of blood vesske
Management
Monitor bleeding
Notify dr is excessive
Tube dislodgement cause/manage
Cause
Excessive manipulation or suctioning
Management
Ensure secure ties, keep obturator, hemostat and new trach tube at bedside
Obstructed tube cause/manage
Obstructed tube
Cause
Dried or excessive secretions
Management
Assess resp status, suction PRN, maintain humidity, perform trach carem hydration
Subcutaneous emphysema cause/manage
Cause
Air escapes from incision into tissue
Management
- monitor tissue, reassure patient and family
Tracheoesophageal fistula
Cause
Trach wall necrosis, leading to fistula formation
Management
Monitor cuff pressure, watch for coughing when eating or drinking
Tracheoesophageal fistula
Cause
Trach wall necrosis, leading to fistula formation
Management
Monitor cuff pressure, watch for coughing when eating or drinking
Tracheal stenosis
Cause
Narrowing of tracheal lumen owing to scarring caused by trach irritation
Management
Monitor cuff pressure, prompt infection treatment, ensure ties are secure
