lOMoARcPSD| 63525276
MDC 4 FINAL EXAM GUIDE
Chest Injury and Respiratory Complex Disorders and Vents
● Pneumothorax S/S, nsg assessment, indications
○ Air enters the pleural space and causes a loss of negative pressure in the
chest cavity, leading to lung collapse. Air enters on inspiration and cant get out! ○
Risk factors: occlusion of chest tube, vent and rib fractures
○ S/S
■ Diminished breath sounds on the affected side, asymmetrical chest
expansion, deviated trachea to unaffected side, low CO2, low BP,
tachycardia, JVD, tachypnea, anxiety
○ Treatment
■ Simple: Occlusive dressing with chest tube insertion.
■ Tension: needle decompression thoracostomy
○ Assessment:
■ Vitals, labs, CO2 levels, cardiac, respiratory, ABG
● Rib Fracture S/S, assessment, clinical manifestations ○ From trauma, sports, GSW,
etc.
○ Problem is the trauma can cause punctured liver, spleen, lung contusion or
lacerations that can compromise blood and the vasculature from a small ink or
scratch.
■ Any trauma of chest can lead to hemothorax ○
Patient will have PAIN! Will need heavy pain
medication.
○ Teach patients how to splint when coughing.
○ Will need vitals, cardiac and respiratory assessments.
○ Watch for bruising!
○ Simple will need to heal on its own.
○ Prevent complications with exercise and breathing.
● Flail Chest S/S, assessment, tx on a vent, clinical manifestation
○ Will have 2-3 fractures of the ribs causing free floating segment
○ S/S
■ Paradoxical chest movements
■ Dyspnea
■ Cyanosis
■ Low BP
■ Elevated HR
○ Treatment: place patient on vent and intubate! PEEP to open alveoli.
○ Complication that must be monitored for: PNEUMOTHORAX
● Post Op complications of chest surgery and emergency treatment
○ Hemothorax: chest tube
○ Hypovolemic Shock or hypovolemia: fluids, blood and blood products,
, lOMoARcPSD| 63525276
○ Hemorrhage: pt goes to OR
● Tx of patients on a vent and troubleshooting measures, nursing interventions,
precautions for prevention of VAP/ ventilator acquired PN
○ While patient is on the Vent
■ Have ambu bag at bedside incase vent acts up- can alway bag valve them
if needed!
■ Assess respiratory function every 2 hrs
■ Monitor labs
■ Promote communication
■ Pain management
■ Turning every 2 hrs
■ Sterility when suctioning
■ Sputum color
■ Nutrition
■ Wash hands to prevent infection
■ Weights
○ VAP: from being on the vent for too long
■ Preventing VAP: HOB elevated 30 degrees, mouth care Q2hrs, suction
PRN, lung assessment constantly
● No petroleum with oral care! Give CHG oral rinse
○ Types of Vent modes
■ Continuous Mechanical Ventilation/ AC : full support for patient where
each breath is a vented breath. Patient is paralyzed.
■ Synchronized Intermittent: Partial support where patient takes breath
without assistance but can be turned down as needed for weaning.
○ Other Complications
■ Barotrauma from excess distention of alveoli
■ Increased ICP/ Hepatic congestion: reduce
PEEP ■ Ulcers: prevent with PPI or turning the
tube. ■ Irritation from the ET tube to throat.
● Indication of the need for a rapid response team on newly extubated patient
○ If the patient cannot maintain their own airways or are not meeting enough
oxygen demands by themselves ○ Any type of stridor or wheezing or SOB ○
Stay with patient entire time.
○ Remember to place them HOB elevated 30 degrees, o2, cardiac monitor, take
set vitals
○ ABGS, pulse ox, EKG, suction may be ordered or done
○ SEE THIS PATIENT FIRST BECAUSE IT LIFE THREATENING!
● Emergency care on a chest trauma in the ED, nursing responsibilities
○ ABCs
○ Oxygen
○ Intubation
○ Chest tube
○ Fluid resus
, lOMoARcPSD| 63525276
○ Assess constantly the lungs
○ Meds
● Pulmonary Embolism S/S, assessment.
○ PE is a clot that enters venous circulation and lodges in the pulmonary vessels,
causing obstruction, reduced gas exchange, tissue death and hypoxia.
○ Risk Factors: similar to DVT! Dehydration, immobility, traveling, IV catheters,
surgery, obesity, age, increased clotting, VTE, oral birth control use.
■ MOST COMMON CAUSE IS DVT THAT TRAVELS!
■ Ex: at risk populations: long distance drivers, ppl who go in airplanes,
COC use, pregnnacy, sitting at a desk for long time.
○ Patients with PE do not have classic manifestations and the variability often will
lead a PE to be overlooked.
○ Classic S/S: sudden onset dyspnea, sharp stabbing chest pain, apprehension,
restlessness, feeling of doom, cough, hemoptysis.
○ Other S/S: Tachypnea, crackles, pleural friction rub, tachycardia, S3/S4 sounds,
swearing, low grade fever, petechiae on chest and axilla, low saO2.
○ Assessments: Respiratory, Cardiac, Skin, Vitals.
○ Diagnosis
■ Labs: ABG, Metabolic panel, PTT, troponin, BNP, elevated D dimer d/t
fibrinolysis.
■ Imaging: Gold standard= pulmonary angiography, CT, CXR to R/O other
conditions, doppler studies.
○ Medications: fibrinolytic therapy, heparin.
■ Treatment: vena cava filter or thrombectomy of pulmonary artery
○ Interventions: raise HOB, O2, vitals and pulse oximeter must be placed and done
often, telemetry needed, IV access, assess for bleeding, prep for diagnostics.
■ With heparin we must be mindful to monitor bleeding
PTT 2-3 x normal (60-90 second range)
● Check heparin aPTT and warfarin PT/INR
○ INR SHOULD BE BETWEEN 2-3
● Remember to use bleeding precautions when on heparin or warfarin- no meds to
increase bleeding, soft tooth brush, electric razor! Need consistent intake vitamin K- too
much= med wont
work, too little- increased bleeding
■ May use TPA- 3-4.5 hrs from when clot diagnosed!
○ Patient Education
■ PREVENTION: early ambulation, wear Ted Hose or SCD, no pillows
under knees, take meds as prescribed, no smoking, hydration, change
positions frequently, no crossing legs.
■ D/C: anticoags needed for weeks to years, bleeding precaution education,
activities to reduce risk of recurrence, follow up care.
● Indications of Respiratory Distress
○ Mental status changes
○ Irritability
, lOMoARcPSD| 63525276
○ Anxiety
○ Dyspnea
○ SOB
○ Tachycardia
○ Tachypnea
○ Gasping
○ Stridor
○ Hemoptysis
○ Accessory muscle use
○ Cap refill is low cyanosis is late
● Nursing care of Sucking wound to the chest
○ Intubation
○ Airtight gauze needed
○ Then chest tube
● Nursing actions for low/high pressure alarm on Vent
○ Low Pressure: vent might be leaking as no pressure is reaching patient. Look for
disconnnections, leaks, poor connections.
○ High Pressure: look for obstruction, blocked airway, pneumo, edema,
bronchospasm, secretion, cough, kinks.
○ High respirations: patient is waking up, anxious or in pain.
■ S/S Anxiety on vent: tachycardia, dilated pupils,
● Acute Respiratory Distress Syndrome clinical manifestations
○ Occurs after lung injury- direct or indirect causing inflammation that increases
alveoli to allow entry of fluid.
○ Causes: shock, trauma, nervous system injury, emboli, infection, toxic gas
inhalation, aspiration, blood transfusions, bypass, near drowning incident,sepsis.
○ Trigger is systemic inflammatory responses
○ Often called non cardiac related pulmonary edema
○ S/S
■ Refractory hypoxemia
■ SOB,d dyspnea
■ Tachycardia
■ Cyanosis
■ Bilateral pulmonary edema
■ Crackles
■ Pink frothy sputum
■ X Ray with broken glass lung appearance
○ Treatment
■ Prone patient
■ PEEP needed on vent
● COMPLICATIONS: pneumo and low BP
■ Steroids and fluids
MDC 4 FINAL EXAM GUIDE
Chest Injury and Respiratory Complex Disorders and Vents
● Pneumothorax S/S, nsg assessment, indications
○ Air enters the pleural space and causes a loss of negative pressure in the
chest cavity, leading to lung collapse. Air enters on inspiration and cant get out! ○
Risk factors: occlusion of chest tube, vent and rib fractures
○ S/S
■ Diminished breath sounds on the affected side, asymmetrical chest
expansion, deviated trachea to unaffected side, low CO2, low BP,
tachycardia, JVD, tachypnea, anxiety
○ Treatment
■ Simple: Occlusive dressing with chest tube insertion.
■ Tension: needle decompression thoracostomy
○ Assessment:
■ Vitals, labs, CO2 levels, cardiac, respiratory, ABG
● Rib Fracture S/S, assessment, clinical manifestations ○ From trauma, sports, GSW,
etc.
○ Problem is the trauma can cause punctured liver, spleen, lung contusion or
lacerations that can compromise blood and the vasculature from a small ink or
scratch.
■ Any trauma of chest can lead to hemothorax ○
Patient will have PAIN! Will need heavy pain
medication.
○ Teach patients how to splint when coughing.
○ Will need vitals, cardiac and respiratory assessments.
○ Watch for bruising!
○ Simple will need to heal on its own.
○ Prevent complications with exercise and breathing.
● Flail Chest S/S, assessment, tx on a vent, clinical manifestation
○ Will have 2-3 fractures of the ribs causing free floating segment
○ S/S
■ Paradoxical chest movements
■ Dyspnea
■ Cyanosis
■ Low BP
■ Elevated HR
○ Treatment: place patient on vent and intubate! PEEP to open alveoli.
○ Complication that must be monitored for: PNEUMOTHORAX
● Post Op complications of chest surgery and emergency treatment
○ Hemothorax: chest tube
○ Hypovolemic Shock or hypovolemia: fluids, blood and blood products,
, lOMoARcPSD| 63525276
○ Hemorrhage: pt goes to OR
● Tx of patients on a vent and troubleshooting measures, nursing interventions,
precautions for prevention of VAP/ ventilator acquired PN
○ While patient is on the Vent
■ Have ambu bag at bedside incase vent acts up- can alway bag valve them
if needed!
■ Assess respiratory function every 2 hrs
■ Monitor labs
■ Promote communication
■ Pain management
■ Turning every 2 hrs
■ Sterility when suctioning
■ Sputum color
■ Nutrition
■ Wash hands to prevent infection
■ Weights
○ VAP: from being on the vent for too long
■ Preventing VAP: HOB elevated 30 degrees, mouth care Q2hrs, suction
PRN, lung assessment constantly
● No petroleum with oral care! Give CHG oral rinse
○ Types of Vent modes
■ Continuous Mechanical Ventilation/ AC : full support for patient where
each breath is a vented breath. Patient is paralyzed.
■ Synchronized Intermittent: Partial support where patient takes breath
without assistance but can be turned down as needed for weaning.
○ Other Complications
■ Barotrauma from excess distention of alveoli
■ Increased ICP/ Hepatic congestion: reduce
PEEP ■ Ulcers: prevent with PPI or turning the
tube. ■ Irritation from the ET tube to throat.
● Indication of the need for a rapid response team on newly extubated patient
○ If the patient cannot maintain their own airways or are not meeting enough
oxygen demands by themselves ○ Any type of stridor or wheezing or SOB ○
Stay with patient entire time.
○ Remember to place them HOB elevated 30 degrees, o2, cardiac monitor, take
set vitals
○ ABGS, pulse ox, EKG, suction may be ordered or done
○ SEE THIS PATIENT FIRST BECAUSE IT LIFE THREATENING!
● Emergency care on a chest trauma in the ED, nursing responsibilities
○ ABCs
○ Oxygen
○ Intubation
○ Chest tube
○ Fluid resus
, lOMoARcPSD| 63525276
○ Assess constantly the lungs
○ Meds
● Pulmonary Embolism S/S, assessment.
○ PE is a clot that enters venous circulation and lodges in the pulmonary vessels,
causing obstruction, reduced gas exchange, tissue death and hypoxia.
○ Risk Factors: similar to DVT! Dehydration, immobility, traveling, IV catheters,
surgery, obesity, age, increased clotting, VTE, oral birth control use.
■ MOST COMMON CAUSE IS DVT THAT TRAVELS!
■ Ex: at risk populations: long distance drivers, ppl who go in airplanes,
COC use, pregnnacy, sitting at a desk for long time.
○ Patients with PE do not have classic manifestations and the variability often will
lead a PE to be overlooked.
○ Classic S/S: sudden onset dyspnea, sharp stabbing chest pain, apprehension,
restlessness, feeling of doom, cough, hemoptysis.
○ Other S/S: Tachypnea, crackles, pleural friction rub, tachycardia, S3/S4 sounds,
swearing, low grade fever, petechiae on chest and axilla, low saO2.
○ Assessments: Respiratory, Cardiac, Skin, Vitals.
○ Diagnosis
■ Labs: ABG, Metabolic panel, PTT, troponin, BNP, elevated D dimer d/t
fibrinolysis.
■ Imaging: Gold standard= pulmonary angiography, CT, CXR to R/O other
conditions, doppler studies.
○ Medications: fibrinolytic therapy, heparin.
■ Treatment: vena cava filter or thrombectomy of pulmonary artery
○ Interventions: raise HOB, O2, vitals and pulse oximeter must be placed and done
often, telemetry needed, IV access, assess for bleeding, prep for diagnostics.
■ With heparin we must be mindful to monitor bleeding
PTT 2-3 x normal (60-90 second range)
● Check heparin aPTT and warfarin PT/INR
○ INR SHOULD BE BETWEEN 2-3
● Remember to use bleeding precautions when on heparin or warfarin- no meds to
increase bleeding, soft tooth brush, electric razor! Need consistent intake vitamin K- too
much= med wont
work, too little- increased bleeding
■ May use TPA- 3-4.5 hrs from when clot diagnosed!
○ Patient Education
■ PREVENTION: early ambulation, wear Ted Hose or SCD, no pillows
under knees, take meds as prescribed, no smoking, hydration, change
positions frequently, no crossing legs.
■ D/C: anticoags needed for weeks to years, bleeding precaution education,
activities to reduce risk of recurrence, follow up care.
● Indications of Respiratory Distress
○ Mental status changes
○ Irritability
, lOMoARcPSD| 63525276
○ Anxiety
○ Dyspnea
○ SOB
○ Tachycardia
○ Tachypnea
○ Gasping
○ Stridor
○ Hemoptysis
○ Accessory muscle use
○ Cap refill is low cyanosis is late
● Nursing care of Sucking wound to the chest
○ Intubation
○ Airtight gauze needed
○ Then chest tube
● Nursing actions for low/high pressure alarm on Vent
○ Low Pressure: vent might be leaking as no pressure is reaching patient. Look for
disconnnections, leaks, poor connections.
○ High Pressure: look for obstruction, blocked airway, pneumo, edema,
bronchospasm, secretion, cough, kinks.
○ High respirations: patient is waking up, anxious or in pain.
■ S/S Anxiety on vent: tachycardia, dilated pupils,
● Acute Respiratory Distress Syndrome clinical manifestations
○ Occurs after lung injury- direct or indirect causing inflammation that increases
alveoli to allow entry of fluid.
○ Causes: shock, trauma, nervous system injury, emboli, infection, toxic gas
inhalation, aspiration, blood transfusions, bypass, near drowning incident,sepsis.
○ Trigger is systemic inflammatory responses
○ Often called non cardiac related pulmonary edema
○ S/S
■ Refractory hypoxemia
■ SOB,d dyspnea
■ Tachycardia
■ Cyanosis
■ Bilateral pulmonary edema
■ Crackles
■ Pink frothy sputum
■ X Ray with broken glass lung appearance
○ Treatment
■ Prone patient
■ PEEP needed on vent
● COMPLICATIONS: pneumo and low BP
■ Steroids and fluids
