Week 8 Flashcards
Thoracic problems
Infection:
Pleural Effusion
Empyema
Trauma:
Fractured ribs
Flail Chest
Sternal Fractures
Carcinoma
The most common fractured ribs are
5-10 (least protected by chest muscles)
Clinical manifestations of fractured ribs
pain at injury site particularly at inspiration
Shallow breathing
Atelectasis
Splinting
Treatment for fractured ribs is
pain relief to allow for chest expansion
Flail chest diagnosis
Fracture of two or more ribs, in two or more separate locations, causing an unstable segment, usually involves anterior (sternal separation) or lateral rib fractures.
Initial therapy of flail chest
adequate ventilation, humidified oxygen, resuscitation fluids. May need mechanical ventilation
Investigation of pleural effusion
Collection of fluid in the pleural space Clinical manifestations Progressive dyspnoea Decreased movement of chest wall Fever, Night sweats, cough and weight loss Diagnostic tap Nursing care during thoracentesis Role and responsibilities
Empyema
Pleural effusion that contains pus
If small bore drains are used then regular flushing may be required
If blocked then flush under aseptic techniques
Attention to nutrition
Safety of tube
Removed when pleural space is evacuated
Malignant pleural effusions
Small drain Suction not generally required Pleurodesis (Thoracentesis) Most successful when lung re-expanded Talc most successful (clamp for at least 1 hour) Pain management
Carcinoma
Lung Ca Medical management Palliative care Symptom control Medication Radiotherapy Chemotherapy Surgical Interventions: LOBECTOMY Pneumonectomy
Thoracotomy
Posterio-lateral thoracotomy most common
Incision lateral aspect of the chest (axillary) around and below the scapula
Incision approx. 15-25cm
Dissection down to intercostal muscles
Intercostal muscles separated either at upper part of the rib or lower aspect.
Rib space dependant on patient, surgeon and lobe to be removed
Nursing management post thoracic surgery
Preoperative education
Measurement of blood loss > 100 mls per hr significant
Observing for signs of re inflation of lung
Monitor vital signs
Care of wound site
Early ambulation
Encourage deep breathing and coughing
Adequate analgesia – surgical incision is extensive and severs muscles
Chest drains
Underwater sealed unit Drain air and fluid from the pleural cavity Allows the lung to fully expand Improves lung capacity and oxygen uptake Painfull Restrictive Held in place with purse string suture
The aim of chest drains are to
restore the usual negative pressure in the intra-pleural space
To re-gain apposition of the parietal and visceral pleura
Why do we use chest drains?
Pneumothorax, tension pneumothorax Haemothorax Empyema Malignant effusion Trauma Post-Operative
Pneumothorax
A pneumothorax is air in the pleural space
Results in partial or complete collapse of the lung
Spontaneous or as a result of trauma
Open pneumothorax, Tension pneumothorax,
Haemothorax
Clinical manifestations of pneumothorax
Increasing tachycardia Increasing respiratory rate - tachypnoea Dyspnoea Respiratory distress Chest pain Cough
Assessment of patient and equipment of chest drains
Ease of breathing Anxiety Chest discomfort, analgesia Entry site – Surgical emphysema Tubing Drainage Unit – underwater seal Safety May be connected to suction if air leak is persistent at 48 hours
Chest drain management
Maintain sterility
NEVER raise chest drain bottle above site of insertion
Always remember to REMOVE clamps
Observe for signs of infection at insertion site
Removal of chest drain
Clean area using aseptic technique
Wear sterile gloves for removal
Two person technique
One person removes drain
Second person hold purse string suture and rapidly closes wound on exit of drain
Clean wound post drain removal
Observe patient closely for signs of deterioration post drain removal
Blood transfusion
Transfuse only when benefits outweigh risks
Ascertain reason for anaemia
Decision to transfuse based not on Hb level
on a clinical assessment and documented as such
Therefore depends on individual clinical situation
clinical signs and symptoms
? still bleeding
? going for surgery
? immunosuppressed
? regular transfusions (chronic condition)
Is there an alternative to transfusion?
1unit packed cells ~ 250 mls ~ 10 g/dL The prescriber must Obtain informed consent (or refusal) Order blood/group & cross match/special requirements Daytime hrs unless emergency/urgent Generally 2 – 4 hrs (as tolerated) Older greater risk of overload 6 (7, 8 …) rights of medication administration Be aware of facility policy/procedure
Blood transfusion alternatives
Iron therapy (when caused by iron-deficiency anaemia)
Volume expanders (increase fluid volume but don’t treat anaemia)
Growth factors (slow replacement of Hb)
“Bloodless” surgery (erythropoietin/iron/technique)
“Cellsaver” blood salvage/replacement
Risks of autologous donation (patients own)
Severe reaction at time of collection
Pre-operative decrease in haemoglobin level which may make transfusion postop more likely
Blood may be lost, damaged or discarded, or expired if surgery cancelled
Bacterial contamination
Can still receive wrong blood
Still have transfusion associated cardiac overload (TACO)
Not currently in favour with The Red Cross
Pre transfusion procedure
Prior to collection of a red cell pack from a blood fridge or transfusion service provider, ensure that:
1.The prescription/order is complete
2.Informed consent is documented/charted
3.Full explanation to patient including potential reactions
4.Intravenous access (18-20G) is inserted and patent
5.Check if other IV medications are due
(Majority cannot be given with blood)
6.Baseline observations (TPR, BP, SpO2) & assessment
7.Be aware of reason for transfusion
8.Resuscitation equipment, including oxygen and adrenaline, are available and in working order
9.Know patient history/co-morbidities/previous transfusion history
Procedure when collecting blood pack
1.Fully completed and labelled request form
2.Self access blood fridge/transfusion service provider
Check details carefully/sign register
3.Transport carefully - ? Esky/cold bag?
4.Direct to nurse requesting
Commence within 30 mins of release from cold storage
5.Unit must be infused within 4 hrs of release from storage
6.Store in blood fridges only
Vaccine fridges not suitable
Administering transfusion
This check is completed with two staff at the patient side
Check correct patient ID/correct documentation/correct pack details (compatibility details) every time
With patient/blood bag/you & checker
Check blood bag for abnormalities (pickles, goldfish)
Special requirements (irradiated/CMV sero-negative)
ID band essential/still get patient to repeat details
Unless emergency
If in doubt don’t give it!
Don’t accept responsibility to commence transfusion unless involved in checking procedure
Prime with saline or the blood (though saline is easier)
During transfusion
Invert bag a few times/connect to IV Commence slowly via Standard 170-200 micron filter IV set Sign prescription form Fill out IV chart/FBC
Stay with patient & observe
Every bag
If no reaction increase to full infusion rate
Vital signs
Facility policy/stay with patient for first 15 mins
Baseline/at 15 mins/hourly/at conclusion – TPR, BP, SpO2 with patient assessment (depending on clinical condition)
Patient access to call bell
If repeat transfusion – ? flush (tradition) or not (research literature) with N/S between
Change line after completion of infusion or every 12 hrs
When complete
Time – FBC (& ? compatibility form)
Compatibility form into patient notes
Educate patient to advise of delayed reactions
If no adverse reaction dispose of empty blood bag
This changes frequently ? save ? facility dependent
Febrile nonhaemolytic reaction (90% of all reactions)
Caused by antibodies to donor leucocytes
More common if received multiple previous transfusions
Generally occurs within 2 hrs of transfusion initiation
Transfusion maybe cancelled or continued
Acute haemolytic reaction
Potentially life threatening
Reaction between donor antigen/recipient antibody
Often rapid onset when infusion commenced
Usually due to mis-labelling/ID failure
Other transfusion reactions
Allergic reaction
Possibly antihistamines and continue, if mild
Or can be severe life threatening anaphylaxis
Circulatory overload
If at risk may be prescribed a diuretic
Transfuse slowly
Bacterial contamination
Rare but potentially life threatening
Transfusion related acute lung injury (TRALI)
Cause unknown/life threatening
Delayed haemolytic reaction (up to 14 days post)
Mild symptoms/prone to severe reaction next time
Disease acquisition (Hep. B/C, HIV, CMV. CJD)
Extremely rare but possible
Clinical manifestations of a transfusion reaction
Fever (greater than 1°C rise in baseline T°/above 38°C) Rigors/chills Urticaria Tachycardia/hypotension (hypovolaemic shock) Dyspnoea/wheezing (overload) Nausea & Vomiting Backpain/chestpain Haemoglobinuria/oliguria Anxiety/”doom”
