mdc4-exam-2-lecture-notes-5-9

Chest • Pneumothorax: air that suddenly enters the pleural space causing loss of negative pressure and reduction in vital capacity which can cause lung to collapse o Closed: air in the chest that has entered through a hole in the lung o Open: air in the chest that has entered through a hole in the chest wall o Spontaneous/iatrogenic pneumo: not associated with trauma, blebs, damaged tissue in the lungs (COPD) o Simple: air escapes from the injured lung into the pleural space, and negative intrapleural pressure is lost, resulting in partial or complete collapse of the lung o Tenison: air enters the intrapleural space but can’t escape of expiration; increased intrathoracic pressure causes the lung to collapse ▪ Pushes everything to the uninjured side including the heart; tracheal deviateion in present with a tension pneumo o Tension is worse than simple o S/S: sudden chest pain, minimal respiratory distress, tachypnea, central cyanosis, decreased chest expansion, breath sounds diminished/absent o assessment: respiratory/circulatory function, lung sounds, tracheal deviation o indications: o interventions: cover wound, immediate chest decompression, chest tube, monitor respiratory/circulatory, assess lung sounds, tracheal deviation, pain management • Rib Fracture: blunt trauma, increase risk of pulmonary contusion, pneumothorax, hemothorax o S/S: pain on movement/respiration, asymmetrical chest movement, splints chest defensively (reducing breathing depth/clearance of secretions) o Assessment: preexisting lung disease= greater risk for atelectasis/PNA; deep chest injury or poor prognosis= first and second rib, flail chest; 7 or more fractured ribs, expired volumes <15ml/kg o Interventions: uncomplicated fractures reunite spontaneously (usually not splinted), decrease pain to maintain gas exchange (intercostal nerve block for severe pain, analgesic that cause respiratory depression are avoided) • Flail Chest: 2 or more fractures of 3 or more adjacent ribs creating free floating fractured segment o S/S: paradoxical movement of chest wall, pain, dyspnea, cyanosis, tachycardia, hypotension o Assessment: paradoxical movement (segment goes in with chest expansion, out with exhalation), ineffective ventilation o tx on a vent ▪ if 100% O2 by non-rebreather face mask is not maintaining oxygen, intubation and ventilator will be required • early intubation and mechanical ventilation with PEEP is paramount in patients with refractory respiratory failure, severe hypoxemia and hypercarbia or other serious traumatic injuries ▪ pulmonary hygiene (CPAP, chest physiotherapy, facemask O2) ▪ treat underlying condition ▪ internal/external fixation • Post Op complications of chest surgery and emergency treatment o Complications of intubations ▪ Tube obstruction ▪ Dislodgement ▪ Pneumothorax ▪ Tracheal tears ▪ Bleeding ▪ Infection ▪ Trauma • Tx of patients on a vent o troubleshooting measures ▪ check the patient ▪ high pressure alarm: obstruction (cough- will reset, airway block- remove tubing and bag the patient, tension pneumothorax) • tube in R main bronchus, bronchospasm, mucous plugs, pneumothorax, air trapping, cough, biting, gagging, patient ventilator desynchrony, max is set too low, PEEP set too high ▪ low pressure alarm/low exhaled tidal volume alarm: vent didn’t reach the pressure it expected; air delivered was not exhaled back into tubing; look for disconnected tubing, leaks around ET tube cuff, poorly secured connections • ETT cuff deflated, Esophageal intubation, TV set too low, chest wounds/drains allowing air to escape, disconnection in ventilator circuit ▪ high respiratory rate alarm: heightened anxiety, awakening for sedation, pain ▪ apnea alarm o nursing interventions ▪ if it takes a while to find out what is wrong: remove the tube and start bagging the patient ▪ look at trouble shooting measures ▪ assess resp status/gas exchange ▪ monitor vitals Q4h ▪ assess pain level ▪ HOB 30 degrees ▪ Assess trach cuff for adequate inflation ▪ Empty ventilator tubing when moisture collects ▪ Move oral ET tube to the opposite side daily to prevent ulcers ▪ Assess GI distress, I&O, turn Q2h ▪ Assess sedation level ▪ Assess lingual swelling/ulceration ▪ Ophthalmic ointment ▪ Assess for muscle atrophy, pressure sores, and nerve damage ▪ Assess for possible early complications (rapid electrolyte changes, severe alkalosis, hypotension secondary to change in cardiac output) ▪ Monitor for signs of respiratory distress (restlessness, apprehension, irritability, increase heart rate) o Indications of weaning ▪ Resolution/marked improvement of illness ▪ Adequate nutritional status ▪ Normal electrolytes ▪ Hemodynamically stable ▪ Ventilatory muscle strength o Nursing care during weaning ▪ Assessment ▪ Psychological support ▪ Education o precautions for prevention of VAP/ ventilator acquired PN o medications to enhance compliance with ventilation: morphine, fentanyl, lorazepam, midazolam, propofol, haloperidol, (vecuronium, precede neuromuscular blocking agent; need narcotic or anxiolytic) • Indication of the need for a rapid response team on newly extubated patient o • Emergency care on a chest trauma in the ED, nursing responsibilities • Pulmonary Embolism: clot in the lungs o S/S: sudden onset of chest pain, sudden dyspnea, tachycardia, decreased tissue perfusion, pulmonary hypertension, reduced gas exchange, reduced oxygenation, hypoxia, tachypnea, chest pain, crackles, pleural friction rub, diaphoresis, hypotension, restless, apprehension, cough, S3 or S4 changes in T waves, petechiae over chest axillae ▪ Massive: dyspnea, syncope, hypotension, distended neck vein, cyanosis ▪ Small: pleuritic pain, cough, hemoptysis (coughing up blood) o Assessment: Labs: ABG, D Dimer, CTA, VQ scan, pulmonary angiogram o Risk factors: prolong immobility, central venous catheters, surgery, obesity, DVT, aging, history, heart failure, cancer, stroke, A Fib, long bone fractures, smoking, pregnancy, estrogen therapy, cancer, trauma o Interventions: ABC, oxygen, cardia monitor, IV large bore, anticoagulants, thrombolytics, catheter directed thrombolysis, surgical removal o Anticoagulants ▪ Heparin: aPTT 30-40, therapeutic range 1.5-2.5 times the controlled value (50-80 are average) antidote: protamine sulfate ▪ Warfarin: INR 0.8-1.1 normal, therapeutic range 2-3; antidote: vit k1 phytonadione, aquamephyton • Indications of Respiratory Distress o S/S ▪ Mental changes (confusion agitation) ▪ Dyspnea ▪ Tachypnea ▪ Gasping, wheezing, stridor, rhonchi ▪ Accessory muscle use ▪ Hypoxia- low oxygen le