Week 8

Question 1

Thoracic Problems

Answer 1

Infection
Pleural Effusion
Empyema

Trauma
Fractured ribs
Flail Chest
Sternal Fractures

Carcinoma

Question 2

Diagnosis Flail Chest

Answer 2

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

The affected (flail) area will move paradoxically to the intact portion .
-Prevents adequate ventilation

Question 3

Investigation of Pleural Effusion

Answer 3

-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 4

Empyema

Answer 4

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 5

Malignant Pleural Effusions

Answer 5

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 6

Carcinoma

Answer 6

Lung Cancer
Medical management
Palliative care
Symptom control
Medication
Radiotherapy
Chemotherapy
Surgical Interventions

Question 7

Surgical Intervention

Answer 7

LOBECTOMY

Pneumonectomy

Question 8

Thoracotomy

Answer 8

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 9

Video-assisted thorascopic surgery(VATS) PRO’s

Answer 9

Pros
Minimally invasive surgery (Keyhole)
Two – Three small incisions (5cm) in chest wall between ribs
Less intrusive
Smaller scars

Question 10

Video-assisted thorascopic surgery(VATS)

CON’s

Answer 10

Cons
Reduced visibility
Reduced access
May have to be converted to traditional thoracotomy
Only available in certain specialist centres
Not suitable for all patients

Question 11

Blood Transfusion

Answer 11

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 12

Pre-Transfusion procedure

Answer 12

Prior to collection of a red cell pack from a blood fridge or transfusion service provider, ensure that:
The prescription/order is complete
Informed consent is documented/charted
Full explanation to patient including potential reactions
Intravenous access (18-20G) is inserted and patent
Check if other IV medications are due
(Majority cannot be given with blood)
Baseline observations (TPR, BP, SpO2) & assessment
Be aware of reason for transfusion
Resuscitation equipment, including oxygen and adrenaline, are available and in working order
Know patient history/co-morbidities/previous transfusion history

Question 13

Procedure when collecting a blood pack

Answer 13

Fully completed and labelled request form
Self-access blood fridge/transfusion service provider

Check details carefully/sign register
Transport carefully - ? Esky/cold bag?

Direct to nurse requesting

Commence within 30 mins of release from cold storage

Unit must be infused within 4 hrs of release from storage

Store in blood fridges only
Vaccine fridges not suitable

Question 14

Transfusion (every bag)

Answer 14

Significant number of errors happen at administration

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 15

During transfusion (every bag)

Answer 15

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

Question 16

During transfusion (every bag) 2

Answer 16

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 17

Transfusion Reaction (2 main types)

Answer 17

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

Question 18

Transfusion reaction (other)

Answer 18

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 19

Clinical Manifestations of Transfusion Reaction

Answer 19

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”

Question 20

Pneumothorax – Tube Clamping

Answer 20

The tube may be clamped pre checking of lung inflammation chest x ray
A bubbling chest drain should never be clamped
Pt remain under strict nursing supervision while drain clamped
If patient deteriorates unclamp immediately and notify doctor (may be a sign of reaccumulation of pneumothorax)
Clamping following disconnection of tubing or during transport - not recommended.

Question 21

Chest Drain Management

Answer 21

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 22

Pneumothorax – When to remove ICC

Answer 22

Chest drain is swinging but not bubbling

Chest x-ray demonstrates complete expansion

Question 23

Removal of chest drain

Answer 23

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