NUR 303 EXAM 1

What is usually responsible for a pneumothorax in blunt chest trauma?

Rib fractures

This Photo by Unknown Author is licensed under CC BY-SA-NC

Mechanisms of Injury

Blunt

• Shearing and compression injuries of chest

structures

• External appearance may be minor but may

have severe internal organ damage

Penetrating

• Foreign object impales or passes through

body tissues creating an open wound

TRACHEAL DEVIATION –SIGN OF?

Tension Pneumothorax

Types

• Tension pneumothorax

• Accumulation of air in pleural space that

cannot escape results in increased

intrapleural pressure

• Causes mediastinal shift and

hemodynamic instability: reduced venous

return and reduced cardiac output

• Can occur with open or closed

pneumothorax

WHAT IS THE EMERGENCY TREATMENT NEEDED FOR TENSION PNEUMOTHORAX?

Needle Decompression

IMPALED OBJECTS IN THE CHEST (OR ANYWHERE) - LEAVE THEM OR REMOVE THEM?

Initial interventions:

• ABC’s

• Stabilize impaled object(s)

• Use a bulky dressing

• Assess for other significant injuries and treat appropriately

• Continue the respiratory assessment

• Place patient in a semi-Fowler’s position or on injured

side

• After ruling out cervical spine injury

• Administer analgesia

With an open sucking chest wound, why do we use a 3-sided dressing to cover it?

To prevent additional air from entering the pleural cavity during inhalation and allow trapped air to escape from the untaped edge during exhalation.

If patient develops respiratory distress, check 3-sided dressing to ensure air is escaping from beneath dressing.

IF YOUR PATIENT WITH CHEST TRAUMA IS STABLE, WHAT DIAGNOSTIC TEST WOULD BE DONE FIRST TO CONFIRM PNEUMOTHORAX?

Chest X-Ray or Chest Imaging

Which type of pneumothorax is due to laceration or puncture of the lung during a medical procedure or treatment?

Types

• Spontaneous—rupture of blebs

• Can occur in healthy or

chronically ill persons (COPD,

asthma, cystic fibrosis,

pneumonia)

• Risk factors: Tall, thin, male,

family history, or previous

spontaneous pneumothorax

• Iatrogenic —medical procedures

• Biopsies, subclavian catheter

insertion, ventilator, esophageal

trauma

AFTER THE CHEST TUBE IS

INSERTED, WHAT IS IT

CONNECTED TO?

WHAT ARE THE TWO BASIC

TYPES?

AND WHAT ARE THE

CHAMBERS??

Pleural Drainage

Wet chest drainage unit.

This unit has 3 chambers: (1)

collection chamber; (2) water-seal

chamber; and (3) suction control

chamber.

Suction control chamber requires a

connection to a wall suction source

that is dialed up higher than the

prescribed suction for the suction to

work. In the water suction unit, the

suction control chamber controls the

wall suction pressure.

Pleural Drainage DRY

Pleural Drainage

Dry chest drainage unit.

This unit has 3 chambers: (1)

collection chamber; (2) water-seal

chamber; and (3) suction control

chamber.

Suction control chamber requires a

connection to a wall suction source

that is dialed up higher than the

prescribed suction for the suction to

work. In the dry suction unit the wall

suction is controlled by using a

regulator control dial.

What is SQ air?

Subcutaneous emphysema or SQ

air (also known as crepitus) can

develop after chest trauma or

after chest tube insertion and

should be monitored & evaluated

especially if patient’s airway /

neck area are involved.

(feels like Rice Krispies crunching

under the skin)

What to do if your chest tube or pleural drainage system is accidentally knocked over on its side?

If chest drainage unit is accidentally knocked

over onto its side and tubing remains intact

without change in patient – sit it upright and

assess the system and patient

Having patient perform Valsalva maneuver (also

during chest tube removal will stop air from

entering the body

Is system is broken - place chest tube end in 2 cm

of sterile water until new drainage system is set up

What is Tidaling?

• Tidaling is normal fluctuation of the

water within the water-seal chamber

with respirations

• If tidaling stops suddenly or

unexpected and there are noticed

changes in patient condition (increased

dyspnea, decreased oxygen saturation,

and increasing anxiety in – check that

there are no ‘kinks’ or obstruction of the

tubing

Why do we not “milk” or clamp chest tubes?

This can cause

increased

intrathoracic

pressure - or a

tension

pneumothorax

Who’s at greatest risk for a pulmonary embolism (PE)?

Immobility or reduced mobility

Surgery within 3 months (especially pelvic and lower extremity)

History of VTE

Cancer

Obesity

Oral contraceptives/ hormone therapy

Smoking

Prolonged air travel

Heart failure

Pregnancy

Clotting disorders

Which test is used to confirm PE?

CT Scan with contrast

V/Q Scan if allergic to CT contrast or in renal failure

D-dimer tests are often ordered but

are not sensitive or specific for PE,

they simply indicate clot degradation

What class of medication is used to treat pulmonary embolism?

Give an example from that class

Anticoagulants

Arterial clots treated with antiplatelets such as patients

at risk for stroke related to atrial fibrilation

• Aspirin (acetylsalicylic acid), Plavix (clopidogrel)

Venous clots treated with anticoagulants

• Lovenox (enoxaparin), Heparin, Coumadin (warfarin)

*Don’t forget the importance of encouraging early

ambulation and use of prescribed intermittent

pneumatic compression devices

What is an inferior vena cava (IVC) filter?

a small metal device placed inside the body's largest vein to catch blood clots before they reach the lungs

What is the first thing assessed and first thing addressed on any patient?

Airway

Breathing

Circulation

Don’t forget your basic life

support (BLS) and

cardiopulmonary

resuscitation or CPR

Tonicity

• Tonicity is related to the osmotic pressure

of a solution – how much it influences the

movement of water

• In Healthcare, tonicity refers to how

'osmotically' similar a solution is to our

intravascular fluid (or plasma)

• Isotonic

• Concentration of stuff ‘equal’ to

intravascular plasma

• 0.9% saline, lactated Ringer's, D5W*

• Hypotonic

• Concentration of stuff less than plasma

• 0.45% saline

• Fluid would move out of the vascular

space

• Hypertonic

• Concentration of stuff more than

plasma

• 3% saline, D5W + 0.9% saline

• Fluid would move into the vascular

space

Which IV fluid is an example of hypotonic solution?

0.45% Normal Saline

or ½ Normal Saline

Isotonic fluids like 0.9% Normal

Saline (NS) or Lactated Ringers (LR)

are isotonic fluids used for resuscitation

What happens to the electrolyte sodium with increased free water intake?

Hyponatremia – which can cause cerebral edema,

especially when it develops rapidly (acute

hyponatremia)

Manifestations:

Headache

Nausea and vomiting

Confusion

Seizures

Decreased consciousness - change in mental status

Coma

Respiratory arrest in severe cases

Hyperkalemia Causes

• Shift from ICF to ECF

• Acid-base abnormality

• Hydrogen ions [H+] move INTO the cells to correct an abnormally low pH (acidosis)

• K+ shifts in the opposite direction – out of the cells - to maintain electrical neutrality

• When the pH is fixed, the H+ and K+ will go back to where they started

• Cation with Succinylcholine administration. Can cause worsening HyperK: 0.5-1.0mEq/L.

• Decreased output (most common)

o Kidney failure

o Massive cell injury: crush injury or muscle damage, K+ released on cell death.

• Increase K+ intake

o Dietary or medically.

Hypokalemia: Causes

Potassium loss

• Decreased PO intake.

• GI tract:

• Stool output

• Kidneys

• Normal loss or diuresis

• Shift from ICF to ECF

• Acid-base abnormality

• Hydrogen ions [H+] move INTO the cells to correct an abnormally low

pH (acidosis)

• K+ shifts in the opposite direction – out of the cells - to maintain

electrical neutrality

• When the pH is fixed, the H+ and K+ will go back to where they started

Hypomagnesemia Causes:

Decreased intake

• Malnutrition

• Alcohol abuse

Decreased absorption

• Celiac disease

• Crohn's disease

Increased need:

pregnancy

Hypocalcemia: Causes

Trousseau = Tourniquet → Hand spasm (muscle cramping & tingling)

→ Think hypocalcemia

Decreased Intake:

Decreased amount in diet

Alcohol abuse

Poor absorption • Crohn's disease

Hypoalbuminemia – calcium binds to albumin

Increased Loss

Hypoparathyroidism

Renal failure

Hyperphosphatemia

Pancreatitis

Laxatives and diarrhea

ABG Interpretation Steps

Diagnosis in six steps:

1. Evaluate pH

2. Analyze PaCO2

3. Analyze HCO3–

4. Determine if CO2 or HCO3– matches

the alteration

5. Decide if the body is attempting to

compensate

Acid-Base Mnemonic - ROME

Respiratory

Opposite

• Alkalosis ↑ pH ↓ PaCO2

• Acidosis ↓ pH ↑ PaCO2

Metabolic

Equal

• Acidosis ↓ pH ↓ HCO3

• Alkalosis ↑ pH ↑ HCO3

Blood Gas Values

Arterial blood gas (ABG) values provide information

about

• Acid-base status (CO2 and HCO3)

• Underlying cause of imbalance

• Body's ability to regulate pH

• Overall oxygen status

• PaO2

• If low, does patient need oxygen and / or pulmonary toilet (TCDB)

What is Acid-Base Regulation?

• The body’s metabolic processes produce

acids that must be neutralized and excreted

• Regulatory mechanisms:

• Buffers (fastest)

• Respiratory system

• Renal system (slowest)

Manifestations of metabolic acidosis

Headache

Decreased BP

Hyperkalemia

Muscle twitching

Warm, flushed skin

N,V,D

Changes in LOC

Kussmaul Resp.

CAUSES:

DKA

Severe diarrhea

Renal failure

shock

Manifestations of respiratory acidosis

Hypoventilation→ hypoxia

rapid, shallow breaths

decreased BP with vasodilation

dyspnea

headache

hyperkalemia

dysrhythmias (increased K)

drowsiness, dizziness, disorientation

muscle weakness, hyperreflexia

CAUSES:

decreased resp. stimuli

(Anesthesia, drug overdose)
COPD

Pneumonia

Atelectasis

Manifestations of respiratory alkalosis

seizures

deep, rapid breathing

hyperventilation

tachycardia

decreased or normal BP

hypokalemia

numbness or tingling of extremities

lethargy and confusion

light headedness

N,V

CAUSES:

hyperventilation

(anxiety, PE, fear)

mechanical ventilation

Manifestations of metabolic alkalosis

restlessness followed by lethargy

dysrhythmias (tachycardia)

compensatory hypoventilation

confusion (decreased LOC, dizzy, irritable)

N,V,D

tremors, muscle cramps, tingling of fingers and toes

hypokalemia

CAUSES:

severe vomiting

excessive GI suctioning

diuretics

excessive bicarbonate