Week 8

Question 1

Thoracic problems

Answer 1

Infection:
Pleural Effusion
Empyema

Trauma:
Fractured ribs
Flail Chest
Sternal Fractures

Carcinoma

Question 2

The most common fractured ribs are

Answer 2

5-10 (least protected by chest muscles)

Question 3

Clinical manifestations of fractured ribs

Answer 3

pain at injury site particularly at inspiration
Shallow breathing
Atelectasis
Splinting

Question 4

Treatment for fractured ribs is

Answer 4

pain relief to allow for chest expansion

Question 5

Flail chest diagnosis

Answer 5

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.

Question 6

Initial therapy of flail chest

Answer 6

adequate ventilation, humidified oxygen, resuscitation fluids. May need mechanical ventilation

Question 7

Investigation of pleural effusion

Answer 7

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

Question 8

Empyema

Answer 8

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

Question 9

Malignant pleural effusions

Answer 9

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

Question 10

Carcinoma

Answer 10

Lung Ca
Medical management
Palliative care
Symptom control
Medication
Radiotherapy
Chemotherapy
Surgical Interventions:
LOBECTOMY
Pneumonectomy

Question 11

Thoracotomy

Answer 11

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

Question 12

Nursing management post thoracic surgery

Answer 12

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

Question 13

Chest drains

Answer 13

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

Question 14

The aim of chest drains are to

Answer 14

restore the usual negative pressure in the intra-pleural space
To re-gain apposition of the parietal and visceral pleura

Question 15

Why do we use chest drains?

Answer 15

Pneumothorax, tension pneumothorax
Haemothorax
Empyema
Malignant effusion
Trauma
Post-Operative

Question 16

Pneumothorax

Answer 16

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

Question 17

Clinical manifestations of pneumothorax

Answer 17

Increasing tachycardia
Increasing respiratory rate - tachypnoea
Dyspnoea
Respiratory distress 
Chest pain
Cough

Question 18

Assessment of patient and equipment of chest drains

Answer 18

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

Question 19

Chest drain management

Answer 19

Maintain sterility
NEVER raise chest drain bottle above site of insertion
Always remember to REMOVE clamps
Observe for signs of infection at insertion site

Question 20

Removal of chest drain

Answer 20

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

Question 21

Blood transfusion

Answer 21

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

Question 22

Blood transfusion alternatives

Answer 22

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

Question 23

Risks of autologous donation (patients own)

Answer 23

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

Question 24

Pre transfusion procedure

Answer 24

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

Question 25

Procedure when collecting blood pack

Answer 25

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

Question 26

Administering transfusion

Answer 26

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)

Question 27

During transfusion

Answer 27

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

Question 28

Febrile nonhaemolytic reaction (90% of all reactions)

Answer 28

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

Question 29

Acute haemolytic reaction

Answer 29

Potentially life threatening
Reaction between donor antigen/recipient antibody
Often rapid onset when infusion commenced
Usually due to mis-labelling/ID failure

Question 30

Other transfusion reactions

Answer 30

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

Question 31

Clinical manifestations of a transfusion reaction

Answer 31

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”