resp 4: lower resp alterations

chest trauma types

blunt trauma and penetrating trauma

blunt

chest strikes or is struck by an object

blunt trauma severe

rib/sternal fractures can lacerate lung tissue

shearing can cause laceration and tearing of aorta

chest compression: contusion, crush injury, or organ rupture

penetrating trauma

foreign object impales organ tissues and creates open wound through pleural space

• eg knife, gunshots, etc

pneumothorax

• what is it

• what does it lead to/cause/detailed patho

air entering pleural cavity

normally, it is negative air pressure that reduces friction

air = positive pressure = partially or fully collapse

eventually causes dec lung volume

pneumothorax dx

cxr shows air or fluid in pleural space

pleural space = between the visceral pleura (covers the lungs) and the parietal pleura (lines the chest wall).

pneumothorax cms 3/4

small: Mild tachycardia and dyspnea

severe: respiratory distress

ausculation: Absent breath sounds over affected area

hyperresonance

classes/types of pneumothorax

spontaneous and iatrogenic

open and closed

tension

spontaneous pneumothorax

Rupture of blebs

• air filled sacs located on the surface of the lungs

• can be healthy or from resp concerns (copd, asthma, cf, pneumonia)

• smoking, male, tall and thin, family hx, prevois medical hx

iatrogenic

Caused by puncture during medical procedures

• eg biopsy, aspiration, tearing from ett, barotrauma from excess o2, etc

open vs closed pneumothorax

open: Air enters through an opening in the chest wall

• penetrating trauma

Closed: No external wound

• visceral lining is interrupted

tension pneumothorax affects what systems

affects both resp and cardiac systems

cms of tension pneumothorax 7/8

mediastinal shift and tracheal deviation

dyspnea + tachypnea

marked tachycardia

dec/abs lung sounds on the affected side

neck vein distention

cyanosis

diaphoresis

tension complication/tx

death from prolonged hypoxemia/cardiac insufficiency

URGENT: needle decompression and chest tube insertion

Hemothorax, Hemopneumothorax, Chylothorax

• def only

Hemothorax

• Blood in pleural space

Hemopneumothorax

• blood and air

Chylothorax

• Lymphatic fluid in pleural space

chylothorax tx

Treat conservatively (chest drainage, bowel rest, dietary mods)

with meds

surgery (thoracic duct ligation) or pleurodesis

Penetrating chest wound dressing

emergency: vent/occlusive dressing secured on 3 sides

prevents air from entering lungs during inhalation

during exhalation, allows some air to escape

object in place?

do not remove until hcp

stabilize with bulky dressing

Pneumothorax/pneumothorax procedures/mgt: 5

interprofessional 3

stable? 1

repeated? 1

Thoracentesis

Chest tubes with water-seal drainage system

Pleurodesis

if : stable with minimum air> no tx needed

Surgery may be indicated for repeated spontaneous pneumothorax

thoracentesis

• what is it

• purposes

• positioning

• how much

Aspiration of intrapleural fluid

dx and therapeutic purposes

Only 1000-1200mL fluid removed

why only that much 3

too much = risk for hypoxemia/hypotension

also re-expansion pulm edema

after procedure 2

Chest x-ray/ Ultrasound for puncture site after for complications

monitor vitals (bp, pulse ox, and signs of resp distress)

chest tubes

• role in pleural drainage

To remove air or fluid from pleural and/or mediastinal space

Reestablishes negative pressure = Lung re-expands

size

20 inches long

Various sizes (12F to 40F)

depends on pt condition and size

• large: 36-40 blood

• medium: 24-36: fluid

• small: 12-24: air

chest tube insertion 6/7

• where/locations

• where is it inserted

• pt position

• bed? and why

• after/during 2/3

usually in ER, OR, or pt bedside

arm above head of affected side

inserted in midaxillary area

elevate bed 30-60 deg to lower diaphragm and reduce injury

cxr after to confirm placement

monitor pt comfort and pain

chest tube drainage

-chambers

collection chamber (holds about 2l of water)

water seal

suction control/dry suction regulator

water seal 3

• what it means/does 2

• fill

corresponds w resp (tidaling)

allows air exit, not enter

fill with sterile water to 2 cm line

chest tube mgt 6

Prepare drainage unit as ordered

maintain patency of drainage system

observe tidaling

Observe for bubbling in water-seal chamber

Observe fluid levels in water-seal chamber

dressing care

drainage unit

wet suction: add sterile water to water-seal chamber (about 2 cm) and suction control chamber (20cm) as indicated or ordered

dry suction: add sterile water to fil line of air leak meter

maintain patency of drainage system

Keep tubing loosely coiled

Tape the connections for extra security

keep upright and below chest level at all times

tidaling

• what does it mean

• absent?

air fluctuations

• rise with inhalation

• fall with exhalation

absent?

• drainage system is not functioning

• lung is fully expanded

• attached to suction

  • disconnect briefly and observe tidaling

bubbling

air leak or pt (bronchopleural leak)

clamp the tube at pt’s chest level

if it stops: air is coming from pt

continues: the unit may need to be replaced

dressing care

sterile occlusive dressing change

remove old dressing carefully = prevent removing unattached items

cleanse site and maintain asepsis

petroleum gauze preferred, then dressing on top

assessments for patient with a chest tube 5

Vital signs

lung sounds

pain

Drainage amount and color

Drainage site infection: culture

education/encourage

shoulder stiffness prevention

Encourage deep breathing

range-of-motion exercises

incentive spirometry

Milking or Stripping Chest Tube

• yes or no

• why

• so what

Not recommended

Can increase intrapleural pressures and damage lungs

Position tubing so that drainage flows freely to negate need for milking or stripping

clamping

Never clamp routinely, only briefly for:

Changing drainage apparatus

Checking for air leaks

chest tube complications 3

Re-expansion pulmonary edema

Vasovagal response

Subcutaneous emphysema: air in tissue around insertion site

• cracking felt on palpation

report these to hcp 5

Drainage > 100 mL or 200 ml/hr

Subcutaneous emphysema

Respiratory distress

diminished/absent breath sounds

chest drainage site infection

drainage/collection full

Change when full: do not empty

Measure fluid level

unit overturned 2

return to upright position

have patient exhale and cough

unit disconnected

immediate priority, activate water-seal system

• immerse in 2 cm of sterile water

Do NOT EVER clamp (unless when removing)

• risk vs benefit

• atmospheric air in lungs vs air build up & tension pneumothorax

If accidentally removed

place occlusive dressing and secure with tape on 3 sides only.

removal or chest tube: when 3/4

• when 2

• what to do 1/2

When lungs re-expanded and drainage minimal

physician order

suction discontinued first

• gravity drain for about 24 hours

nsn care for removal 5

Pain meds 30–60 min prior.

Valsalva maneuver during removal (hold breath and bear down)

Apply occlusive dressing before inhalation

Chest x-ray is done (recurrence)

• check pneumothorax/effusion.

Monitor for respiratory distress (recurrence)