resp 4b: lower resp alterations

rib fractures general info

• commonly where

• damages/results in

• usually caused by

Most common ribs 5 through 9

Can damage pleura, lungs, and internal organs

usually from blunt trauma

clinical manifestations 3

Pain at site of injury (esp with inhalation and coughting)

Splinting

Shallow respirations

potential complications

atelectasis

pneumonia

goal

dec pain for adequate breathing and decreased secretions

treatment

pain mgt: NSAIDs, opioids, thoracic nerve blocks

Patient teaching

pt education

Deep breathing and coughing

Incentive spirometry

Appropriate use of anaglesics

NO strapping or binding chest = more limitation = dec expansion = atelectasis

flail chest

• what is it/describe it

• can result in

fracture of several consecutive ribs in 2 or more places

unstable lung segment

• either sternum or consecutive ribs

pulmonary contusion can = hypoxemia

flail chest cm 4

paradoxical movement during breathing

• moves in opposite direction of intact portion

inc work of breathing

rapid shallow respirations

tachycardia

dx

visual inspection

palpation

• crepitus

CXR

nursing and medical interventions 4

Adequate airway and ventilation

Oxygen therapy

Analgesia/pain management

Surgical fixation

cardiac tamponade

blood collects in pericardial sac

does not allow pericardium to expand

prevents filling of ventricles

cms 4

BECK’s triad

• Muffled, distant heart sounds

• Hypotension

• Neck vein distention

Increased CVP- central venous pressure

mgt

Emergent pericardiocentesis

pleural effusion

• def and causes 4

Collection of fluid in pleura space

causes:

• Heart Failure

• TB

• infection

• Cancer

symptoms

sharp non-radiating chest pain(worse on inhalation)

decreased movement of chest

diminished breath sounds

dx

Chest x-ray

CT scan (reveal volume and location of effusion)

tx

Thoracentesis

Chemical Pleurodesis

Pain meds

pulmonary embolism (PE)

Blockage of one or more pulmonary arteries by a thrombus, fat or air embolus, or tumor tissue.

causes 4

DVT (from legs)

Atrial fibrillation

Post surgery

childbirth

risk factors

immobility

surgery (esp. pelvic/LE, past 3 months)

cancer

obesity

OCPs/HRT

smoking

pregnancy

HF

long air travel

clotting disorders.

clinical manifestations 6

Most common: Dyspnea

Hemoptysis

tachypnea

Chest pain (worse on inspiration)

Tachycardia

Crackles, wheezes

Hypoxemia

if severe: 4/9

5 ps

sudden mental status change

hypotension

feeling of impending doom

cardiac arrest

5 ps

pain

pulselessness

pallor

paresthesia

paralysis

dx 3

D Dimer Assay

High resolution multidetector CT angio has become preferred tool

Spiral (helical) CT scan—gold standard

PE prevention

Assess for risk of venous thromboembolism on admit

If at risk for bleeding use mechanical devices (SCDs)

Mobilization program

Prophylactic anticoagulant therapy

pe tx/mgt

ABCs; oxygen

Heparin

Thrombolytics (dissolve the clots); tPA most widely used

Surgical procedures

• Embolectomy (used rarely)

• Vena cava filters (prevention)

Bed rest, semi-Fowler’s position.

Lung Transplant: generally who gets it

therapy for patients with end stage lung disease

COPD, Idiopathic pulmonary fibrosis, cystic fibrosis

preop eval/absolute contraindications 7

malignancy/cancer within the last two years

chronic active hepatitis

hepatitis C

HIV

liver failure

renal failure

current smoker

Postoperative care 6

ventilatory support

fluid and hemodynamic management

nutritional support

immunosuppression

prevention of infection

monitor for signs of rejection

immunosuppression

Tacrolimus, Mycophenalate mofetil, and prednisone (steroid)

acute rejection

• when

• s/s 5

usually about 5-10 days

low grade fever

o2 desat

fatigue

dyspnea

dry cough

chronic

Bronchiolitis obliterans (BOS)

Bronchiolitis obliterans (BOS)

• what is it 2

• prevention 1

Progressive inflammation and lung scarring

airflow obstruction unresponsive to bronchodilators and corticosteroids

Prevention: reduce episodes of acute rejection

Discharge planning/Coordination of care

basic hygiene and ADLs

Self-care

medication management and timing

contacting transplant team

pulmonary hygiene

rehabilitation: improves endurance

teach/chat

Medication management, adherence, side effect monitoring

Pulmonary clearance: chest physiotherapy, deep breathing, coughing

Home spirometry to track lung function trends

Keep logs of meds, labs, spirometry results

test: The nurse identifies a flail chest in a trauma patient when:

A. multiple rib fractures are noted on x-ray.

B. a trachial deviation to the unaffected side is present.

C. paradoxical chest movement occurs during respiration.

D. there is decreased movement of the involved chest wall.

The correct answer is C.