Pneumothorax, Chest Trauma, Near Drowning Gas Exchange Pneumothorax, Chest Trauma, Near Drowning

Pneumothorax: What is it?? What is a Pneumothorax? Simple- Trauma- Tension- How would a client get a pneumothorax? Pneumothorax occurs when the parietal or visceral pleura is breached and the pleural space is exposed to positive atmospheric pressure.  Simple- air filled bleb on the surface of the lung ruptures allowing air to enter pleural space Trauma- when air escapes from a laceration in the lung itself and enters the pleural space or from a wound in the chest wall “sucking chest wound” A traumatic pneumothorax resulting from major injury to the chest is often accompanied by hemothorax (collection of blood in the pleural space resulting from torn intercostal vessels, lacerations of the great vessels, or lacerations of the lungs). Tension-  when air is drawn into the pleural space from a lacerated lung or through a small opening or wound in the chest wall; may be an effect of a different kind of pneumothorax. In contrast to open pneumothorax, the air that enters the chest cavity with each inspiration is trapped; it cannot be expelled during expiration through the air passages or the opening in the chest wall. In effect, a one-way valve or ball valve mechanism occurs where air enters the pleural space but cannot escape. The pressure compresses the heart and vessels and causes trachea to shift to the unaffected side. How depends on the kind. Simple bleb—from damaged lung tissue maybe from emphysema. Trauma is greater than 3cm stab, gunshot, MVA, etc. Tension can happen from ventilation, can be from small chest wound.

Pneumothorax: What is it?? What would you expect to assess on a client who is experiencing a pneumothorax? Depends on kind What are some diagnostic tests?? Assess:   In a simple pneumothorax, the trachea is midline, expansion of the chest is decreased, breath sounds may be diminished or absent, and percussion of the chest may reveal normal sounds or hyperresonance depending on the size of the pneumothorax. In a tension pneumothorax, the trachea is shifted away from the affected side, chest expansion may be decreased or fixed in a hyperexpansion state, breath sounds are diminished or absent, and percussion to the affected side is hyperresonant.  Both show signs of air hunger: SOB, cyanosis, hypotension, inc RR, inc HR, diaphoresis

Pneumothorax: How do we treat?? Medical Management Thoracentesis Chest Tube Thoracotomy Nursing Interventions? Thoracentesis- needle aspiration reduces the tension and restores sub atmospheric pressure Chest Tube- inserted into the second intercostal space into the PLEURAL SPACE to re-expand lung Thoracotomy-  As a rule of thumb, the chest wall is opened surgically (thoracotomy) if more than 1,500 mL of blood is aspirated initially by thoracentesis (or is the initial chest tube output) or if chest tube output continues at greater than 200 mL per hour. If you have A LOT of blood the DR needs to get in there and open the chest so we can make sure you’re not bleeding out from a secondary injury. Nurse Responsibilities: The patient with a possible tension pneumothorax should immediately be given a high concentration of supplemental oxygen to treat the hypoxemia, and pulse oximetry should be used to monitor oxygen saturation. (Monitor and maintain gas exchange and breathing, airway maintenance) Chest tubes to suction- nurse assesses the patency of the system

Chest Drainage System CHART 21-20 Chest Drainage System

Chest Drainage Systems Wet: Dry: Both systems can operate by gravity drainage, without a suction source Nursing Management of the chest tube? In wet suction systems, the amount of suction is determined by the amount of water instilled in the suction chamber. The amount of bubbling in the suction chamber indicates the strength of the suction. Wet systems use a water seal to prevent air from moving back into the chest on inspiration.  Dry systems use a one-way valve and may have a suction control dial in place of the water. Water is not needed for suction in these systems. Without the bubbling in the suction chamber, the machine is quieter. However, if the container is knocked over, the water seal may be lost. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent pneumothorax if the chest tube is inadvertently disconnected from the drainage system, a temporary water seal can be established by immersing the chest tube’s open end in a bottle of sterile water. Nurses: monitor drainage color, amount, patency of system, keep system below chest level

NCLEX Prep A client with a closed chest drainage system tries to get out of bed and disconnects the chest tube from the drainage system which falls on the floor. In what order of importance should the nurse perform the necessary actions when entering the client’s room? Submerge the tube in sterile water or saline. Set-up and attach ta new closed drainage system. Assess the client’s respiratory status. Check the client’s pulse and blood pressure. A, C, B, D. The priority action is to reestablish the water seal to prevent the client from sucking air into the chest tube (prevent pneumothorax). After establishing seal the nurse should assess the client for potential pneumothorax, then attach a new system. The last thing the nurse should do is assess the rest of the body systems.

NCLEX Prep The nurse is caring for a client with a closed chest drainage system. If the tubing becomes disconnected from the system, the nurse should: Instruct the client to perform the Valsalva maneuver Elevate the tubing above the client's chest level Decrease the amount of suction being applied Form a water seal and obtain a new connector D- The nurse should form a water seal, remove the contaminated end, and insert a new sterile connector. The Valsalva maneuver is used when the chest tube is being removed therefore Answer A is incorrect. Answer B is incorrect because the chest drainage system is maintained below the client's chest level. Answer C is incorrect because the nurse cannot alter the amount of suction being applied without a doctor's order.

NCLEX Prep The nurse is caring for a client with a pneumothorax who has had a chest tube inserted. The nurse notes continuous gentle bubbling in the suction control chamber. What action is appropriate? Immediately clamp the chest tube and notify the physician Do nothing, because this is an expected finding Check for an air leak because the bubbling should be intermittent Increase the suction pressure so that the bubbling becomes vigorous B- Continuous gentle bubbling should be noted in the suction control chamber. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Bubbling should be continuous and not intermittent, bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

NCLEX Prep The nurse is caring for the following clients. Which client would benefit most from an emergent thoracotomy? A 48 year old patient with gunshot wound to the back who lost vital signs upon arrival to the ED A 12 year old patient with traumatic asphyxia with CPR in progress for past 15 minutes upon arrival to the ED A 16 year old patient with traumatic amputation of arm with CPR in progress for 5 minutes A 19 year old patient with stab wound to chest who arrived with fixed and dilated pupils. A- this client is possibly bleeding out B wont live C lost too much blood D is already brain dead

NCLEX Prep One week after a thoracotomy, a client with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system. Which client assessment warrants follow-up nursing interventions? Water-seal chamber has 5 cm of water. No new drainage in collection chamber Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site C- If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

Chest Trauma: What is it?? Chest traumas account for 75% of all trauma deaths. Blunt Trauma- Penetrating Trauma- Blunt chest trauma results from sudden compression or positive pressure inflicted to the chest wall. chest wall fractures, dislocations, and barotraumas (including diaphragmatic injuries); injuries of the pleura, lungs, and aerodigestive tracts; and blunt injuries of the heart, great arteries, veins, and lymphatics  Penetrating trauma occurs when a foreign object penetrates the chest wall.

Chest Trauma- Blunt Trauma: What is it? Sternal/Rib fracture: Flail chest: Paradoxical movement: Pulmonary contusion: Ventilation issues!! Can be oxygenation if the alveoli collapse. Rib fx- manage symptoms, if severe can cause death. Fractures of the first three ribs are rare but can result in a high mortality rate because they are associated with laceration of the subclavian artery or vein. Fractures of the lower ribs are associated with injury to the spleen and liver, which may be lacerated by fragmented sections of the rib. Older adult patients with three or more rib fractures have been shown to have a fivefold increased mortality rate and a fourfold increased incidence of pneumonia Flail chest- ventilation issue because lung can not fully expand. Can lead to respiratory failure if severe. Frequently caused by steering wheel—3 or more adjacent ribs, fractured at 2 sites --Can’t fully exhale (lungs expand with insp and exp) This reluctance to move or breathe deeply results in diminished ventilation, atelectasis (collapse of unaerated alveoli), pneumonitis, and hypoxemia. Respiratory insufficiency and failure can be the outcomes of such a cycle. Pulmonary contusion- Damage to the lung tissue resulting in hemorrhage and edema, associated with trauma with rapid compression and decompression of chest wall and flail chest Abnormal accumulation of fluid in the interstitial and intra-alveolar spaces Injury to the lung tissue and capillary network results in leakage of serum protein and plasma; osmotic pressure enhances further loss from capillaries Blood, edema, and cellular debris accumulate in brochioles and alveoli; disrupting gas exchange

Chest Trauma-Penetrating Trauma Gunshot and stab wounds most common Classified by velocity Stab wounds: low-velocity weapon destroys a small area around wound Gunshot wounds: low, medium, or high velocity; extent of damage determined by distance, caliber of gun, and type of bullet The appearance of the penetrating wound can be deceptive; the extent of damage can be wide spread Can be ventilation or perfusion or both!

Chest Trauma- Complications Cardiac Tamponade: Cardiac Contusion: Increased Intrathoracic Pressure: Hypoxemia: Hypovolemia: Subcutaneous Emphysema: Hypoxemia from disruption of the airway; injury to the lung parenchyma, rib cage, and respiratory musculature; massive hemorrhage; collapsed lung; and pneumothorax Hypovolemia from massive fluid loss from the great vessels, cardiac rupture, or hemothorax Cardiac failure from cardiac tamponade, cardiac contusion, or increased intrathoracic pressure These pathologic states frequently result in impaired ventilation and perfusion leading to acute renal failure, hypovolemic shock, and death. Right ventricle is most affected because of anatomic position. What does the right ventricle do?  is the chamber within the heart that is responsible for pumping oxygen-depleted blood to the lungs. No blood to the lungs, what happens to the body? Subcutaneous emphysema: when the lung or the air passages are injured, air may enter the tissue planes and pass for some distance under the skin (e.g., neck, chest). The tissues give a crackling sensation when palpated, and the subcutaneous air produces an alarming appearance as the face, neck, body, and scrotum become misshapen by subcutaneous air.

Chest Trauma- Nursing Process Assessment: Diagnosis: Planning: Implementation: Evaluation: Assessment: obvious deformities, SOB, unequal chest expansion—labs? Diagnostic tests? (X-rays, ABGS) Diagnosis: pain, injury, ineffective breathing, ineffective coping, etc Planning: monitor for complications Implementation: all monitoring, cardiac monitoring, respiratory effort Evaluation: free from complications.

Near Drowning What is it? Who is most at risk? Medical and Nursing Management? Teaching? Nonfatal drowning is defined as survival for at least 24 hours after submersion that caused a respiratory arrest.  Drowning is the leading cause of unintentional death in boys 5 through 14 years of age and all children younger than 4 years.  For every one death there are usually four nonfatal drownings. Efforts to save the patient should not be abandoned prematurely. Successful resuscitation with full neurologic recovery has occurred in nonfatal drowning patients after prolonged submersion in cold water. This is possible because of a decrease in metabolic demands and/or the diving reflex. The nonfatal drowning process involves the onset of hypoxia, hypercapnia, bradycardia, and dysrhythmias.  manage the hypoxia, acidosis, and hypothermia. Prevention and management of hypoxia are accomplished by ensuring an adequate airway and respiration, thus improving ventilation (which helps correct respiratory acidosis) and oxygenation. Arterial blood gases are monitored to evaluate oxygen, carbon dioxide, bicarbonate levels, and pH. These parameters determine the type of ventilatory support needed. The use of endotracheal intubation with PEEP improves oxygenation, prevents aspiration, and corrects intrapulmonary shunting and ventilation–perfusion abnormalities (caused by aspiration of water). If the patient is breathing spontaneously, supplemental oxygen may be administered by mask. However, an endotracheal tube is necessary if the patient does not breathe spontaneously.

NCLEX Prep The nurse is assessing a client admitted with injuries sustained in a motor vehicle accident. Which of the following injuries poses the greatest risk to the client? Fractures of the ribs Contusions of the lower legs Fractures of the humerus Lacerations of the face A- Fractures of the ribs can result in a closed pneumothorax, a life-threatening emergency, that requires early detection and treatment. Answers B, C, and D are incorrect because they do not pose a risk to the life of the client.

NCLEX Prep The nurse is caring for a client with chest trauma. The nurse understands which one of the following findings is characteristic of a tension pneumothorax? Tracheal deviation toward the affected side Symmetry of the thorax and equal breath sounds Tracheal deviation toward the unaffected side Decreased heart rate and decreased respirations C- Assessment of the client with a tension pneumothorax reveals tracheal deviations towards the unaffected side. Answer A is incorrect because the deviation is toward the unaffected, not the affected side. Answer B is incorrect because the thorax is asymmetrical and breath sounds are absent on the affected side. Answer D is incorrect because the heart rate and respiratory rate are not decreased.

NCLEX Prep A nurse is caring for a client who sustained multiple rib fractures and severe facial trauma during a motor-vehicle crash. Which of the following findings should concern the nurse most? A. Increasing lethargy B. Shallow respirations C. Chest pain with positioning D. Bloody drainage from the nose A- because development of a fat embolus can cause disorientation or other CNS involvement. The rest are expected findings.