ADULT HEALTH EXAM (RESPIRATORY

ADULT HEALTH EXAM (RESPIRATORY) Adult Health Exam (Respiratory) Role of the respiratory system Oxygenation and tissue perfusion Patient history relating to the respiratory system - family and personal data - smoking and pack years - drug use - allergies - travel - nutritional status - cough, sputum production, chest pain, dyspnea, orthopnea Indicators of respiratory adequacy - clubbing - weight loss - unevenly developed muscles - skin and mucous membrane changes - general appearance - endurance Psychosocial assessment - stress may worsen some respiratory problems - chronic respiratory disease may cause changes in family roles, social isolation, financial problems due to unemployment or disability - discuss coping mechanisms, offer access to support systems Testing for respiratory - laboratory - function - non-invasive - invasive Lab Tests - blood (ABGs) - sputum - pertussis - viral Pulmonary function testing - noninvasive - spirometry (incentive spirometer) - evaluate lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, distribution of ventilation Capnometry and Capnography - noninvasive - measure amount of carbon dioxide present in exhaled air - normal pressure between 20 and 40 Non-invasive testing - standard chest x-rays and CT - ventilation and perfusion scan - pulse oximetry Invasive diagnostic testing - endoscopy - bronchoscopy - laryngoscopy - mediastinoscopy Thoracentesis - invasive diagnostic test - aspiration of pleural fluid or air from the pleural space - stinging sensation and feeling pressure - correct position (sitting down, bending forward, arms on table) - motionless patient - follow-up assessment for complications Lung biopsy - invasive diagnostic test - obtain tissue for histologic analysis, culture, cytologic examination - may be performed in patient's room Follow up care for invasive testing - assess vital signs - breath sounds at least every 4 hours for 24 hours - assess for respiratory distress - report reduced/absent breath sounds immediately - monitor for hemoptysis Why do we need oxygen? - essential for life and function of cells/tissues - respiratory, cardiovascular, hematologic systems work together, providing sufficient tissue perfusion to the body - oxygen therapy improves oxygenation and tissue perfusion Clinical manifestations of respiratory distress - dyspnea - nasal flaring - use of accessory muscles to breathe - pursed-lip or diaphragmatic breathing - decreased endurance - skin, mucous membrane changes (pallor, cyanosis) - chest pain Respiratory assessment - nose and sinus - pharynx, trachea, larynx - lungs and thorax (movement, symmetry, fremitus, resonance, breath sounds) - general appearance (muscle development) - skin and mucous membranes What is the best way to determine need for oxygen therapy? ABG analysis Purpose of oxygen therapy Relieves hypoxemia (low levels of oxygen in blood) Hypoxia Decreased tissue oxygenation Goal of oxygen therapy Use lowest fraction of inspired oxygen for acceptable blood oxygen level without causing harmful side effects Type of oxygen used depends on: - oxygen concentration required/achieved - importance of accuracy and control of oxygen concentration - patient comfort - importance of humidity - patient mobility What is the basic level of O2 given? 2L nasal cannula What happens when they need more oxygen than 2L? Put them on a non-rebreather mask at 15L What would you do if your patient is breathing 6x per minute and pulse ox is 60%? - use a bag valve mask - prepare to intubate Low-flow oxygen delivery systems Does not provide enough flow to meet total oxygen and air volume - nasal cannula - simple face mask - partial/non rebreather mask Nasal cannula - 1-6 liters - 24-44% - assess patency of nostrils - most people cannot handle a nasal cannula, so they use a simple face mask Simple facemask - minimum of 5 liters - delivers oxygen up to 40-60% - mask fits securely over the nose and mouth - monitor closely for risk of aspiration - face mask is more constricting Partial and non-rebreather masks - highest O2 level - can deliver 60-75% with flow rate of 6-11 liters - adjust flow rate to keep reservoir bag inflated - goal is to re-breathe carbon dioxide that you breathe out - use on a patient that is unstable and requires intubation Why do you need humidification with a nasal cannula and simple face mask? These masks will dry up your airway, and humidification makes sure your throat and nose stays moisturized High flow oxygen systems Can deliver 24-100% O2 at 8-15 liters - venturi mask - face tent - aerosol mask - tracheostomy collar - t-piece Venturi mask - adaptor located between bottom of mask and O2 sources - delivers precise O2 concentration - 8-15 liters at 24-100% - best source for chronic lung disease (COPD) - gives space for the oxygen to leak out as it goes into patient - switch to nasal cannula during meal times Non-invasive positive pressure ventilation (NPPV) - uses positive pressure to keep alveoli open, improve gas exchange without airway intubation - BiPAP -CPAP Continuous positive airway pressure (CPAP) - non stop - chronic - putting pressure on your lungs and pulling pressure out - always breathing for you - usually for patients with sleep apnea - if you hear leaking sounds, it means it's not doing its job Bi-level positive airway pressure (BiPAP) - very similar to CPAP - if you are breathing on your own, the machine does nothing - if you do not breathe, the machine senses it and breathes for you - used only when needed Tracheostomy - stoma (opening) that results from tracheotomy - may be temporary or permanent - breathes for you down your trachea - no longer breathing from your mouth - cannot talk or eat Priority patient problems - reduced oxygenation - inadequate communication - inadequate nutrition - potential for infection - damaged oral mucosa Other possible complications - penumothorax - subcutaneous emphysema - bleeding - INFECTION - tube obstruction/dislodgement What happens if a patient's trach comes out? - keep the hole open - if it is not a new track, stick the trach back in because that is their only way of breathing - need a bag valve mask (OVER THEIR TRACH, NOT THEIR MOUTH) Obturator - do not put the obturator in the trach - it will block the patient's breathing Air warming and humidification for a tracheostomy - tracheostomy tube bypasses nose and mouth, which normally humidify, warm and filter air - air must be humidified - maintain proper temperature - ensure adequate hydration Suctioning - maintains patient's airway, promotes gas exchange - assess the need in patients who cannot cough adequately - done through the nose or mouth - done when there are secretions or gurgling - apply suction only when withdrawing catheter (suction out) - mucus gets lodged and they cannot breathe without suctioning (drop in pulse ox) - NEVER SUCTION A PATIENT FOR MORE THAN 15 SECONDS Why should you pre-oxygenate a patient before you suction them? - you are not only suctioning their mucus, but also their oxygen - important to pre oxygenate so they have enough oxygen when suctioning Complications of suctioning - hypoxia - tissue (mucosal) trauma - infection (STERILE TECHNIQUE) - vagal stimulation, bronchospasm - cardiac dysrhythmias from induced hypoxia - have patient on a cardiac monitor and pulse ox Bronchial and oral hygiene - turn/reposition every 1-2 hours, support out of bed activities, encourage early ambulation (hospital acquired pneumonia) - coughing and deep breathing (incentive spirometer), chest percussion, vibration, and postural drainage promote pulmonary care - avoid glycerin swabs or mouthwash that contains alcohol for oral care - assess for ulcers, bacterial/fungal growth, infection Nutrition with trach - swallowing food can be a major problem - if balloon is inflated, can interfere with passage of food through the esophagus - elevate head of bed for at least 30 minutes after eating to prevent aspiration during swallowing - food=energy, and if you cannot breathe you have no energy to eat - huge aspiration risk Noninfectious upper respiratory problems? Not at risk for infection in the nose/throat down to the bottom of the clavicle (airway) Fracture of the nose - nose is a type of airway - if you have a fracture, you no longer have an airway (medical emergency) - brain sits behind your nose, so not much between your nose and brain - with this problem, we assume you punctured your brain until proven otherwise 3 types of nose fractures - closed reduction - rhinoplasty - nasoseptoplasty Closed reduction nose fracture Can punch back into place Rhinoplasty - need a splint/cast - have gauze/drip pad underneath (blood, mucus, CSF) - perform glucose lab to check if it is mucus or CSF (every 2 hours) - CSF has a halo around it - patient should be sitting up so they are not swallowing it, excessive swallowing is very bad - make sure they are on pulse ox Post-op care after rhinoplasty - stay in semi-fowler's position and change positions slowly - observe for edema and bleeding - check vital signs every 4 hours (BP - risk for losing blood) - change drip pad as needed - assess for CSF - DO NOT sniff upwards or blow nose Epistaxis - nosebleed - common problem - hold your nose for 1 HOUR and no peaking, or else it won't stop bleeding - nasal tamponade - cauterization of affected capillaries may be needed (burn capillaries off so they stop bleeding) - posterior nasal bleeding is an emergency (going towards lungs or stomach, do not know how much blood they are losing, CANNOT SQUEEZE BACK OF NOSE, must cauterize and monitor BP) - assess for respiratory distress - humidification, oxygen, bed rest, antibiotics, pain meds - #1 reason for nose bleeds is because it is dry, #2 is because you pick it, #3 is because you have high BP Nasal polyps - elderly people - benign, grapelike clusters of mucus membranes and connective tissue - large ones may obstruct airway - polypectomy will cut them out Cancer of the nose and sinuses - has to do with occupation or lifestyle mainly - very rare - smoking, working in industry - slow onse - manifestations resemble sinusitis Facial trauma - priority action is airway assessment - medical emergency - stridor (high pitch on inhalation) - SOB - anxiety/restlessness - hypoxia - decreased O2 sats - cyanosis, loss of consciousness - "battle signs," bleeding behind your ears or mastoid process (BRAIN IS BLEEDING, MED EMERGENCY) Le Fort Fracture - fractures of the maxillae - three broad categories - medical emergency - face and head is a fort to your brain Facial trauma interventions - airway assessment - anticipate need for emergency intubation - tracheotomy - cricothyroidectomy - debridement - inner maxillary fixation (wired shut) Cricothyroidectomy - pen through your throat - emergency situations - hope you hit the trachea and the patient can breathe - do not hit the hyoid bone - "cry for help" Obstructive sleep apnea - breathing disruption during sleep - 10 seconds for 5 times an hour - excessive daytime sleepiness, inability to concentrate, irritability are signs that you are not getting enough oxygenation at night - change in sleep position, weight loss - adenoidectomy, uvulectomy, etc. - CPAP mask Disorders of the larynx - vocal cord paralysis - vocal cord nodules and polyps - laryngeal trauma - vocal cords help you eat, breathe, swallow, and talk - if you have something wrong with your vocal cords, you cannot breathe or eat right Vocal cord paralysis - injury, trauma, or disease to the larynx, laryngeal nerves, or vagus nerve - can be caused by prolonged intubation or stroke - stridor - risk for aspiration (hold breath while swallowing) Vocal cord nodules Caused by enlarged, fibrous tissues caused by infectious processes or overuse of the voice Vocal cord polyps Edematous masses that occur most often in smokers and people with allergies Laryngeal trauma - occurs with a crushing or direct blow injury, fracture, or injury induced by prolonged endotracheal intubation - dyspnea, aphonia, hoarseness, bleeding - give oxygen - take vitals every 15 minutes - blood is going to our lungs Upper airway obstruction - interruption in airflow through nose, mouth, pharynx, or larynx - life-threatening emergency - heimlich maneuver (upward thrust underneath sternum) Most common thin for an adult to choke on? Steak Most common thing for a child to choke on? Hotdogs and grapes Interventions for upper airway obstruction - assess cause of obstruction - heimlich - maintenance of patent airway and ventilation (cricothyroidectomy, endotracheal intubation, tracheotomy) Neck trauma - may be caused by knife, gunshot, traumatic accident - priority is to assess and maintain an airway - assess for other injuries - assess carotid artery and esophagus - assess for cervical spine injuries, prevent excess neck movement by lying flat - obstruction can occur from initial injury or resultant swelling - may not be trauma that affects it, but the after effects of it Head and neck cancer - deadly - usually squamous cell carcinoma and slow growing - usually begins with mucous that is chronically irritated, becoming tougher and thicker - usually leukoplakia and erythroplakia lesions Physical assessment/clinical manifestations of head and neck cancer - lumps in mouth, throat, or neck - difficulty swallowing - change in taste in your mouth - color changes in mouth or tongue - persistant, unilateral ear pain - numbness of out, lips, or face - change in fit of dentures *** - burning sensation when drinking hot liquids or citrus - hoarseness or change in voice quality - SOB - anorexia and weight loss Head and neck cancer interventions - radiation - chemo - cordectomy - laryngectomy Laryngectomy postoperative care - first priorities are airway maintenance and ventilation - wound, flap, reconstructive tissue care - hemorrhage - speech and language rehab (cannot speak if balloon is pumped up, use white board to communicate) Electro-Larynx Generates speech after laryngectomy via vibrations Asthma - condition that occurs intermittently - occursin two ways: inflammation and airway hyper responsiveness leading to bronchoconstriction - treat with bronchodilation Patho of asthma - intermittent (comes and goes) and reversible airflow obstruction affecting airways only - NOT ALVEOLI Airway obstruction - inflammation - airway hyper-responsiveness Etiology of asthma - different types based on how attacks are triggered - caused by specific allergens, general irritants, microorganisms, aspirin - hyper-responsiveness caused by exercise, URI (upper respiratory infection), unknown reasons - some people only have asthma when they have a URI - asthma patients should avoid allergens if possible, but keep a diary to track and figure out what triggers your asthma Collaborative management of asthma - history - physical assessment and clinical manifestations - barrel chest (from getting air in but not getting it out) - inspiratory wheeze is worse because you are not getting air in - dry, barking cough - excretory muscles - cyanosis - low O2 in blood - put them on pulse ox Interventions for patients with asthma - diary - incentive spirometer - self management (if exercise induced asthma, take inhaler before exercise) - personal drug therapy plan What kind of inhaler is an albuterol? Rescue inhaler What kind of inhaler is an atriovant? Management, take every morning/day etc. Drug therapy for asthma - based on severity - preventative therapy - rescue drugs - bronchodilaters (beta 2 agonists, anticholinergics, etc.) - anti-inflammatory agents (corticosteroids, NSAIDS) *MUST BE TAPERED OFF OF STEROIDS Other treatments for asthma - exercise and activity to promote ventilation and perfusion - oxygen therapy via mask, nasal cannula, ET tube (acute asthma attack) - running is the best thing you can do because it opens up your lungs - try not to intubate Status asthmaticus - severe, life-threatening, acute episode of airway obstruction - intensifies once it begins, often does not respond to common therapy - patient can develop pneumothorax and cardiac/respiratory arrest - treatment is IV fluids, bronchodilaters, steroids, epi, oxygen - cyanotic - not producing enough O2 in their lungs - MUST GIVE 15 MG OF ALBUTEROL (2.5mg in one puff) Emphysema - lungs are stretched out and become hard - dyspnea - air trapping caused by loss of elastic recoil in alveolar walls - hyper-inflated, O2 is just sitting there and not doing anything - patient is going to want fresh and clean air, become air hungry Should you give an emphysema patient oxygen? NO ******* Chronic bronchitis - inflammation of the bronchi and bronchioles - usually from cigarette smoking - affects only airway, not alveoli - vasodilators everything and gives you inflammation and congestion - mucous in the lungs - coughing up thick mucous - risk for pneumonia, infections Chronic obstructive pulmonary disease (COPD) - must include emphysema and chronic bronchitis - bronchospasm and dyspnea - tissue damage not reversible - eventually lead to renal failure Bronchitis man - overweight because lack of exercise - smoking - hypertension (edema) - cyanotic because cannot breathe well enough - mucous coming out of mouth - overweight, edema, and cyanotic is because they go into right sided heart failure*** - extra fluid everywhere - very hard to deal with * blue bloater Emphysema man - older person - skinny and frail - very thin - cannot keep on weight because cannot keep air in or out, so energy is going down, and this causes weight loss - quiet chest - no cough - pink (because have O2 in, cannot get CO2 out) - purse lips (helps you get O2 in and push CO2 out) - tripod position (good) * pink puffer COPD man - will stay blue - little guy with tons of edema, lots of water weight, blue, and have sputum - they want oxygen so much, but we cannot give it because then they will need it the rest of their life * blue puffers Complications with COPD - hypoxemia - tissue anoxia - acidosis (ABGs) - thick mucous = infection - pneumonia - respiratory infections - cardiac failure - cardiac dysrhythmias - do not eat because they do not have the energy (high fat, high protein, high calorie, low sodium) How should COPD patients prevent infection? - incentive spirometer - deep breathe - mobility - patients do not have much energy to move, so stay with them the whole time to try to get them walking and let them sit down) COPD assessment - history (emphysema and bronchitis, ask about smoking/pack years) - sputum (color, consistency, how much) - ask how many pillows they sleep on - measure weight loss (same clothes, same time, etc.) - tripodding is good because they are getting air - cyanosis - deep breathing, pursed lips, using diaphragm - worry about diet with fatigue - very bad clubbing COPD interventions - improve oxygenation and reduce CO2 retention - prevent weight loss - minimize anxiety - improve activity tolerance - prevent respiration infection - diaphragmatic or abdominal breathing with pursed lips Drug therapy for COPD - beta adrenergic agents (albuterol) - anticholinergics - methylxanthines - corticosteroids - NSAIDS - mucolytics (Mucinex) COPD patients and oxygen - most COPD patients live around 85% oxygen level - they can only be allowed up to 4L of O2 - start at 2L, titrate up if needed - 2 liters is going to drop their pulse ox, so there is less room for new O2 to come in What would you do if a patient on 15 liters of oxygen is brought in by the medics and has a history of COPD? - ASSESS PATIENT - put on pulse ox - take off the oxygen Interstitial pulmonary diseases - affects alveoli, blood vessels, surrounding support lung tissue - restrictive disease - thickens lung tissue and reduces gas exchange - "stiff" lungs preventing good expansion and recoil - slow onset - ***dyspnea Sarcoidosis - granulomatous disorder of unknown cause - mostly affects lungs - autoimmune response - normally protective T cells increase and damage lung tissue - corticosteroids Idiopathic pulmonary fibrosis - fibrosis is scar tissue - hardening problem - common restrictive lung disease - highly lethal - extensive scarring - corticosteroids, other immunosuppressants used for therapy Occupational pulmonary disease - caused by job or environmental exposures - worsened by cigarette smoke - prevention through special respirators and adequate ventilation - coming from job/surroundings Lung Cancer - leading cause of cancer deaths world wide - cigarette smoking - number 1 place to metastasize - usually takes up to 6 months to diagnose, poor survival rate - can be mistaken for pneumonia because they look exactly the same - diagnose lung cancer with a biopsy Health promotion and maintenance of lung cancer - history (smoking) - pulmonary manifestations - nonpulmonary manifestations - psychosocial assessment - diagnostic assessment Non surgical management of lung cancer - chemotherapy - targeted therapy - radiation therapy - photodynamic therapy Surgical management of lung cancer - lobectomy - pneumonectomy - segmentectomy - wedge resection How many lobes of the lungs are there? 5 Lobectomy Removing a lobe of the lung out of 5 * Not the top lobe Pneumonectomy Removal of a whole lung Segmentectomy Remove a little piece/segment of the lung Wedge resection Taking a wedge (piece of pie) out of the lung; most common and most seen because you are leaving most of the lung Sinusitis - inflammation of sinus mucous membranes - usually caused by bacteria - pressure on the forehead (should not hurt when you press on their forehead) - see if there is consolidation in their sinuses (pen light) - treat with antibiotic if it is bacterial Sinusitis management - broad-spectrum antibiotics - analgesics - decongestants - steam humidification - hot/wet packs over sinus area - nasal saline irrigations - increased fluids - open up, have steam - steam thins it out and helps with dehydration (moisture coming out of your mouth, especially the faster you're breathing the sicker you are) - need to start fluids Tonsillitis - inflammation/infection of tonsils and lymphatic tissues - CONTAGIOUS, AIRBORN - usually bacterial - antibiotics 7-10 days (take full length) - very contagious - can get tonsils/adenoids out if they are causing too much pain (don't eat real food for 3-5 days, no solid food because will rip stitches out; watch for bleeding in the back of your mouth and signs of coughing/frequent swallowing) - make sure you eat and drink enough (dehydration) - cannot brush teeth - need suction and bed side and should be on pulse ox - NSS Rapid antigen tests (RAT) - strep test - tests for Strep A (lab for strep B) - take 3 drops of solution A, 3 drops of solution B, mix together - A is clear, B is pink, should get YELLOW when mixed together - swab the back of the tonsils with red stick that has two swabs on it - be careful not to puncture soft pallet (people gag when you put something down your throat, they'll jerk forward) - stick one of the swabs in the solution and move it around for 5 minutes, take it out and take the testing strip, and put the testing strip in the solution that you put the swab in - just a test line is inconclusive - just a control line is negative - two lines is positive for step A * other swab goes to the lab to test for strep B Peritonsillar abscess (PTA) - complication of acute tonsilitis - pus and infection in your tonsils - usually unilateral - difficulty breathing and bad breath - swollen lymph nodes - needle aspiration of the abscess - stick a long needle into throat and suck it out (no sedation) - done at bed side - put on antibiotics Laryngitis - inflammation of mucous membranes lining the larynx (vocal cords) - possible edema of vocal cords - acute hoarseness, dry cough, difficulty swallowing, temporary voice loss - doesn't need antibiotics but patient does not have a voice - give them a way to communicate - patient should not talk to voice can heal - steam helps Influenza - viral respiratory infection - severe headache, muscle ache, fever, chills, fatigue, weakness, anorexia - cannot cure with antibiotic - airborn/droplet precautions - vaccination is advisable (not if you are allergic to eggs) - people allergic to eggs can get mist - antiviral agents may be effective - tamiflu does not work and is a sugar pill - stomach bug Pandemic influenza - swine flu (H1N1) - mostly prevalent among animals and birds but can also become infectious to humans - highly contagious - strict isolation precautions (airborne/droplet) - antiviral drugs Pneumonia - excess fluid in lungs resulting from - inflammatory process - triggered by infectious organisms - acquired by different things - can go home with pneumonia unless you have trouble breathing/pulse ox is below 95% - otherwise, take antibiotics, increase fluid, and go home - do not lie down flat, sit up Nursing interventions with pneumonia - atelectasis - hypoxemia - history (smoking) - physical assessment (consolidation, raunchy, 99 tactile remits) Ventilator associated pneumonia (VAP) - huge problem in the hospital - if they have an NG tube, keep bed at 45 degrees for an hour after feeding What is a ventilator bundle? - hand hygiene - oral care (q2h) - head of bed elevated at least 30 degrees *reduces incidence of ventilator associated pneumonia Lab assessment for pneumonia - gram stain, culture and sensitivity of sputum (what bugs are growing) - CBC (WBC count) - ABGs (hypo or hyperventilating) - serum BUN (blood blood urea nitrogen) - electrolytes - creatinine Imaging and diagnostic assessment for pneumonia - chest x-ray (most definitive) - pulse ox - transtracheal aspiration - bronchoscopy Pneumonia interventions - antibiotics - oral care every 2 hours - oxygen - suction Who should get the pneumonia vaccine? - elderly - anyone with respiratory problems (asthma) - smokers - immunocomprimised Severe acute respiratory syndrome (SARS) - viral infection of respiratory tract cells, triggering inflammatory response - no known effective treatment - strict airborne isolation (private, negative pressure room) - must prevent spread of infection Pulmonary Tuberculosis - highly contagious - incidence increase related to onset HIV - private, negative pressure room Clinical manifestations of TB - progressive fatigue - lethargy - low grade fever - anorexia - night sweats - productive cough for 2 weeks - blood/rust color sputum Assessment of TB - HIV (important because immunocompromised) - travel history - physical assessment (tests) Diagnostic assessment for TB - PPD test - greater than 10 mm means they do not definitively have TB, but treat them like they do (5 mm for HIV patients) - take x-ray - sputum culture (definitive) - x-ray can say you do not have TB, but cannot definitely tell you that you do Interventions for TB patients - airborne droplet precautions - combination drug therapy with strict adherence - 3 negative sputum cultures = no longer infectious Lung abscess - localized area of lung destruction - pleuritic chest pain - acts like pneumonia - drain it out - give antibiotics - frequent mouth care (q2h) because mouth is exposed to what is in their lungs, so could get oral thrush Inhalation anthrax - bacterial infection caused by contaminated soil - 100% lethal if not caught within the first 2 days - only 50% survival rate if caught within the first 2 days - treat with lots and lots of antibiotics - airborne precautions - TB x1000 - full body suit Pulmonary empyema - collection of pus pleural space - most common cause is pulmonary infection, lung abscess, infected pleural effusion - drain it out - give antibiotics What 3 patients should be put on chest tubes? - pneumothorax - hemothorax - hemopneumothorax Pneumothorax - air in the pleural space; collapsing of the lung - cause by rib fracture, GSW/knife wound, thoracotomy, forceful coughing, line placement, bronchoscopy Hemothorax - blood and fluid in the pleural cavity - puncturing the lung - emphysema - open chest procedures - blunt/penetrating trauma Hemopneumothorax - air AND blood in the pleural space - air will be on top - fluid will be on the bottom - need 2 chest tubes - 1 for the air, 1 for the fluid Some other reasons we need a chest tube? - empyema - pleural effusion - after surgery or trauma of the chest resulting in pneumothorax or hemothorax - respiratory distress - lung problems at birth Where would you put a chest tube for a pneumothorax? 2-4th intercostal space at the axillary ling Where would you put a chest tube for a hemothorax? 8-9th intercostal space at the axillary line Insertion of chest tube contraindications - coagulopathy or platelet dysfunction (bleeding) - known or suspected mesothelioma (tumor) - TB (contagious, everyone in the room will die) How is a chest tube procedure done? - at bedside - make a slit with a knife and shove forceps in - pre-medicate patients and follow up Machines used with insertion of a chest tube - pleural evac - oasis (chest tube drainage, should be -20 vacuum, water seal should be filled up to zero) Insertion process of a chest tube - put patient on cardiac monitor and pulse ox - drainage device should be filled and ready to go - connect the long tube from the collection chamber to the patient's chest tube and connect the short tube to the suction source - get a chest x-ray to make sure it is in the right spot - immediately document the amount of fluid that came out (color, amount, consistency, etc.) - watch the patient's vitals Monitering patients with chest tubes - drainage devices should always be below the level of the chest - just like a foley catheter, but must always be below the patient - the system must stay up right - palpate the chest to make sure they do not have emphysema/air leaks Monitoring the drainage device for a chest tube - monitor it every 8 hours (every shift) - on inspiration, water should go up; on expiration, water should go down (titling) - always want to make sure the patient is titling when they're on a chest tube - however, continuous bubbling is the sign of an air leak See more